Bioethics Discussion Blog: Patient Modesty: Volume 46

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Tuesday, December 20, 2011

Patient Modesty: Volume 46



Continuing on with the discussion regarding issues of physical modesty in the context of medical care, there continues to be debate throughout these Volumes as to who is responsible for the contested inequalities in attention to these issues and what is necessary for the resolution of these issues.  Is there a conflict between the male and female gender, working apart, in attaining their own individual modesty goals or should both genders look to each other's physical modesty needs and desires and stand and work together to change the medical care system to meet all their goals? I suspect the latter is the wisest.  Perhaps the best suggestion for both genders to become active to the same cause and to get together on a website to develop tools for advocacy.  I would suggest checking in at Suzy's site where the goal is to do just that.  Here is her description of the Mission Statement and Goals:

MISSION STATEMENT:
We believe that each patient is an individual and as such has specific preferences and needs including what accommodations they require to maximize comfort when their modesty must be compromised in the medical experience. Our mission it to act as a liaison between patients and providers in establishing, understanding, and executing the policies and procedures essential to that end. When appropriate we will act as advocates for patients to achieve that goal through interaction, education, and referrals to both patients and providers.

GOALS: Our goal is to help patients achieve dignified and respectful healthcare through education and information. Everyone has different needs and expectations of their healthcare providers, and we provide choices and options in obtaining those needs. We understand that modesty, privacy, and respect are primary needs when facing procedures and we promote educating providers in the sensitivity of those needs.

ADDENDUM (12-23-2011)


 On 12-23-2011, Belinda wrote the following comment : Going back the the "Naked" article, it would seem that now is the time to write protocols for exams with dignity at the forefront with equal accessibility as needed for any kind of exam making draping practices uniform. It would give patients and idea of what to expect and do as much to relieve the awkwardness of such an exam. Any thoughts on this?

I responded with the following:
Belinda, an EXCELLENT suggestion! In fact, to make the suggestion even more productive.. how about the visitors here (even you PT) together create a final consensus list, a series of suggested protocols for attending to all the patient modesty issues experienced in medical care. The development of the list can written to this blog or Dr. Sherman/Doug Capra's or on Suzy's blog.

But not just writing this protocol list to our blogs.. the final consensus list should be sent to Dr. Atui Gawande who wrote the article "Naked" in the New England Journal of Medicine and which was the basis for our entire series of Volumes on patient modesty. As some of you may know, Dr.Gawande is now a very well respected individual for his analysis and writings about a host of important medical issues that need fixing or change. By this project on our part, this may be the most direct way, through Dr.Gawande, to get something moving rather than repeated moaning and yearning on our blogs. How is that for an idea? Again, thanks Belinda for a suggestion to get us all "off our butts" (so to speak). 




..Maurice.
Graphic: "Man and Woman Apart and Together"-Classic icons modified by me with ArtRage.


NOTICE: AS OF TODAY JANUARY 11, 2012 "PATIENT MODESTY: VOLUME 46" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 47

151 Comments:

At Tuesday, December 20, 2011 10:41:00 AM, Anonymous Anonymous said...

Jean, My male doctor and the two female nurses were all at fault.

I have had wonderful female influences in my life and was quite ready to expect respectful treatment. The smiling grin and stare of the first nurse and the sitting down to stare at my genitals of the second nurse changed it to being naked and humiliated by opposite gender nurses. So I am not ok with the nurses.

The doctor left me so totally naked in front of the two nurses. I didn't even have a blanket or sheet. Just a gown that was pulled up to my navel. So I am not ok with my male doctor.

The ability for mixed gender treatment to be perceived by the patient as naked humiliation is high and the consequence is devastating. I think provider gender choice for all intimate procedures must be provided.

Mark

 
At Tuesday, December 20, 2011 2:25:00 PM, Anonymous Anonymous said...

Thank you Dr. Bernstein for referencing our site. alan penned the Mission Statement, I penned the Goals, and further down the road people will see that Doug (then Mer) and Hexanchus penned statements and valuable resoureses. It seems men and women really can work together for a common goal!

Thank you Gail. Hope to see you at the site.

Perhaps we all have different issues that brought us to this table. Motives may differ as well. But respecting each other is what will service change.

Suzy

 
At Tuesday, December 20, 2011 8:04:00 PM, Anonymous Anonymous said...

Mark

Do you now see the mentality at work here,
regarding jean's comments blaming you because you
are a male. Blaming your physician for the behavior
of the nurses,because he is male.

What does that suppose to mean? Does it mean
Mark that everything bad or wrong that happens to you
is your fault.

Men pay more health insurance dollars than women
in that men carry the primary health insurance for the
family. Women consume more health care dollars than
men. It is correct now to say that women are at fault
for all complaints forwarded to the joint commission.
Because women constitute the majority of hospital
staff and are responsible for the vast majority of hospital
acquired infections among their patients. Known fact that
women carry more bacteria on their hands then men, yet
nursing staff are the cause an estimated 100,000 deaths each year,all the more reason to get more males into nursing.

PT
year

 
At Tuesday, December 20, 2011 10:01:00 PM, Anonymous Anonymous said...

I have been a nurse for more than 25 years, in surgical nursing as well as the emergency dept. Nurses male and female are professionals. There is nothing sexual about doing medical procedures like catheterization or assisting with bathing, peri-care etc. Often there is only one "sex" of staff available, sometimes they are male nurses, not female.
I am not quite sure what the answer is. I can imagine that it is very difficult for patients. When I am a patient I don't like having exams or procedures that require disrobing; but it is part of receiving care. What I really care about is receiving good care from a technical perspective. Trust me you want someone who knows what they are doing and will also listen to you.
Terry

 
At Tuesday, December 20, 2011 11:01:00 PM, Blogger Maurice Bernstein, M.D. said...

Golly, I agree with Terry in terms of the sexual neutrality of what I do as a physician examining and treating patients. I also agree with Terry with the comments in the second paragraph with regard to my views about how I personally feel about an examination or procedure on myself as the patient. To me and perhaps similarly to a number of patients, I don't look at whatever physical modesty I may have as a reaction to any sexual implications but more that I haven't been conditioned over the years to expose myself to others beyond my wife. And I, too, would be more concerned with the technical care I will receive than simply the bodily exposure.

These are my personal thoughts. Of course, since I am interested in reading and having presented on my blog all views, I am not using my personal views to be part of my moderation of the blog.

..Maurice

 
At Tuesday, December 20, 2011 11:28:00 PM, Blogger Doug Capra said...

Terry: Thanks for joining us. I don't think anyone on these blogs, (maybe a few on the extreme end of this debate) believe caregivers see sexuality in what they do. I think most will tell you that, for them, that's not the point. But I did quote a study above that strongly suggested than some males may have sexual feelings during genital exams. And guess what? Nobody on this blog even responded to that study. It's near the end of the last volume. What are your responses to it?

You and Dr. Bernstein are looking at this primarily from your point of view. That's fine, even necessary. You've got to do you jobs. Some of us are trying to look at this primarily from the patient's point of view. That's valid, too. Both positons are valid. And both positions need to be considered when dealing with patients and given equal value.

What most on these blogs are against are modesty violations against either gender by caregivers of either gender -- carelessness, blindness, indifference, the "I've seen it all attitude." You write: "Often there is only one "sex" of staff available, sometimes they are male nurses, not female." Agreed. But, be honest, what are the odds of a male patient having a male nurse available as compared with a female patient having a female nurse available? That's another aspect to this debate. The double standard and the almost complete unavailability of male cna's, patient techs, and medical assistants.
But, I'd like to hear your reaction to Mark's story on the last volume of this blog. What's your take on that?
And I do welcome you to this blog and hope you stay and are willing to discuss this. You'll get some strong reaction. I don't agree with some of the extreme positions I read here. But I've heard enough personal stories from people I know and trust (not on blogs, but in person), soem from doctors and nurses whose modesty has been violated when they were patients -- to convince me that there are just too many modesty violations in medicine today, that too may caregivers forget how traumatic careless exposure is for patients, that too may caregivers become desensitized and don't even "see" these violations anymore -- that this issue is rarely an open topic between caregiver and patient, but the one of the elephants in the room of medicine.
You say you don't know what the answer is. It's not that difficult. There are plenty of possible answers in some of the suggestions and cited research on this blog and the one I co-moderate with Dr. Joel Sherman. The answers are out there. The question is whether the medical profession has the will to deal wit this.
You talk about receiving good care from a technical perspective -- good care, as I'm sure you know and agree -- is about the whole person: the body, mind and spirit. You can't really separate the technical care from that. Not really. It's all part of the same care.

 
At Wednesday, December 21, 2011 5:41:00 AM, Anonymous Anonymous said...

No study has been done on why patients feel the way they do about modesty. I cannot speak for anyone else on this blog, but I have posted before and said that prior to a horrific experience in the hospital, I was gender neutral when it came to who cared for me no matter the level of intimacy. My mother was an RN and helped shape a positive outlook toward medicine, caregivers, etc. as a child. I took those values with me as I grew, and all was well with the world until THAT day. It changed who I am and how I feel.

Now I am hearing that my positions are extreme. Are they? Who is anyone to judge what they do not know?

Burned in a house fire, scarred for life? Come on over, we'll light some candles and have some wine for a relaxing evening. Do you think? That illustration shows that perception and life experience can alter any situation.

Welcome Terry. Great to have you and other medical professionals. It's time that everyone who works in the field think about the life experience of those they care for.

Current attitudes just make more of us who have strong feelings about this issue. Until respect and dignity are given as high a priority as medical care, the cycle will keep repeating itself as in abuse.

Until there is a study done to show the relationship to humiliation, anger, loss of trust, will we know the actual damage that these practices (some of which are included in standard of care) are detrimental to mental health.

The medical community has decided to throw all the social norms to the wind, strip people publicly without telling them what to expect may not seem like abuse but it is, if a patient wasn't told and the end result was against their will even if there is no intent on the part of the caregiver.
belinda

 
At Wednesday, December 21, 2011 6:06:00 AM, Anonymous Anonymous said...

To me, I find modesty issues in medical care tangled with control issues. For me, the lack of patient control and power is the bigger issue. If that were solved, it would be easier to solve modesty issues.
An ER nurse once told me "We're all control freaks". Now of course, I'm not saying everyone is. But I do see a fairly common thread of medical providers trying to maintain control.
Control over medical records
Control over requiring intimate exams in order to get birth control
Control over who sees the patient disrobed, perhaps despite their preference - for ex. requiring a chaperone, even if it makes the patient uncomfortable, or what staff is in the OR. Or staff just bursting into the room.
Control a uncooperative patient by putting them in a gown, and thus in a subservient position (supposedly still taught in some medical schools)
Control over who cares for you in a hospital - almost impossible to fire one doctor and find another
Control over being able to leave a hospital - if you leave AMA, your insurance may not pay for future care for that condition. You can, in effect, be trapped.
To me (I understand probably not everyone else) it isn't so much of an issue of someone seeing me disrobed, as my lack of a choice as to who sees or touches me.
Sure, you always have a choice. But, if you don't "submit", you may be denied access to birth control, necessary surgical procedures, etc. If you leave a hospital without "permission", there may be grave financial consequences. So in practicality, at times the patient doesn't really have much of a choice.
If patients had more control (and it is their lives and their bodies after all), they would have more chance of their modesty desires beieng met.
I do, of course, understand the practicalities of the limited numbere of male nurses, OR staff, etc. However, if it were necessary, perhaps organizations would find a way to change their staffing.
TAM

 
At Wednesday, December 21, 2011 6:08:00 AM, Anonymous Anonymous said...

PT:
You obviouly misinterpreted my comments. I NEVER blamed Mark for what happened to him. I merely pointed out that it is not only female (nurses) but can also be male (doctors and/or nurses) that disregard patients' modesty, as in the instance of Mark's doctor not having a problem with the nurses behavior. I did not say, either, that it was the doctor's "fault", just that he did nothing to help the situation. It may have been the nurses behaviors that brought Mark to this blog but many females on this blog are here because of male caregivers' actions. So the situation works both ways.
I also can appreciate the comments by Terry. She, as a nurse, has at least acknowledged that care involving exposure is surely difficult for patients and she stated that it is difficult for herself, also, to have exams that require disrobing. But she is probably more representative of the majority of people: that they will accept this loss of modesty to receive care. That has been my point all along. That a system wide change will probably not occur as long as the majority of people feel this way. I think a lot of us on this blog either are on the extreme end of the modesty spectrum or else, like a lot here, have had a blatantly disrespectful experience that has brought them here and perhaps changed them forever about accepting opposite gender care. Jean

 
At Wednesday, December 21, 2011 8:03:00 AM, Anonymous Anonymous said...

Terry, thanks for joining the conversation.

Terry and Maurice, I have two issues here.
1)You both view the modesty issue from an “ER” point of view. I agree, if I have been hit by a truck or something I want someone to save my life. At lot of procedures, and what most people on the blog are talking about, are planned procedures. These procedures are scheduled and consideration for a patient should be possible. My prostate procedure was scheduled 9 weeks in advanced at a hospital that does thousands of these.

2)May goal is only to have male patients have equal respect to woman. It isn't hard or expensive. For woman, respect of her modesty is in the front of providers minds. For men it is in the back of their minds or not at all. Terry, if you were getting a schedule pelvic exam, you would expect and receive attempts to cover you and keep you from feeling vulnerable even though you were getting a very personal exam. Most women would demand female staff. There are many considerations that woman get as normal respect that men are not even considered for. In my exam I didn't even get a sheet. Most of the medical system does not respect men's modesty. I have tried to ask Maurice if they teach equal modesty at his school but he hasn't really weighed in. If Maurice's doesn't teach it, who does? The hospital I went to doesn't hire men for the Oncology department because of woman modesty concerns.

Mark

 
At Wednesday, December 21, 2011 8:38:00 AM, Blogger Doug Capra said...

"Now I am hearing that my positions are extreme. Are they? Who is anyone to judge what they do not know?"

I can't know what you "heard," belinda. But I do know what I wrote to Terry: "You'll get some strong reaction. I don't agree with some of the extreme positions I read here." I can't help it if you see yourself in that sentence. I certainly didn't mention you or belittle your experiences. I'm making a very valid statement, i.e. I don't agree with all positions on this blog. Obvious, you don't either.
This blog is what -- 46 volumes? I've been on here almost since the beginning and I've read every volume. There's a continuum in the attitudes people have here. People who won't expose themselves for to any reason under any circumstances to medical staff, even if treated respectfully and with dignity -- people who would rather die (and some do) than get medical care -- those people have stated such on this blog and represent an extreme position. As I stated many times, it's not so much about nakedness, it's about respect and dignity. Most people, IMO, will accept and can deal psychologically with opposite gender care, and do every day, if they are treated with respect and dignity. Embedded in that statement is the idea that they're not forced or intimidated into the kind of treatment they don't feel comfortable with. On the other end are people who demand a particular gender to care for them for unhealthy reasons. They represent an extreme position, too. Some people lean toward one end of the other. Most of us are in what I might call a "Zone of Tolerance" in the middle, depending upon how we're treated.

 
At Wednesday, December 21, 2011 10:23:00 AM, Blogger Maurice Bernstein, M.D. said...

Mark, I am not sure that I understand what you mean by "teach equal modesty". On teaching physical examination to first and second year medical students, we teach general and gender specific concerns for physical modesty. We teach that uncovering any patient of any gender is done with the patient's consent unless unconscious. All uncovering of either a conscious and unconscious patient is for a clinically essential reason. The same goes for "the laying on of hands" (touching the patient) as we call palpation and percussion or even auscultation. As I previously mentioned, anything short of that permission could be interpreted as assault or battery. (We have enough concern about malpractice charges brought to us so we don't need the added burden of criminal charges!)

With that said, yes there are some gender differences in the application of concern for patient modesty. As I had written here previously, we find from experience and so assume that a male patient will have less concern about exposing his anterior chest than a women exposing hers. Responses to the abdominal exam are similar for both genders. The modesty issues are a bit different with regard to male and female pelvic/rectal exams which I have noted previously where the words the students are taught to express to the patient are different and also the use of chaperons may be different.

Again, as I have previously noted, what we teach in the first and second year may "go out the window" and to various extents discarded as the students move into their later school years and beyond and start experiencing the malignant "hidden curriculum" where disregard or "assumption" regarding patient modesty issues are unintentionally or intentionally done because of limitations of time, considered "urgency" of procedures or consideration by attending physicians that the value of a clinical teaching experience on a patient for the students trumps any concern for patient modesty.

So there you have it. Any questions? ..Maurice.

 
At Wednesday, December 21, 2011 11:34:00 AM, Anonymous Anonymous said...

Dr. Bernstein:
You have always been very clear on certain issues, so I only have one question (sort of)....do your students ever bring up their own gender regarding opposite gender care? Do male students ask what to do if females refuse their care or vise-versa? Would you encourage them to seek out the preferred gender or try to console the patient with the "clinical" aspect.
If you have previously answered that directly, then I am sorry I missed it.

Suzy

 
At Wednesday, December 21, 2011 12:59:00 PM, Anonymous Anonymous said...

Maurice, sorry you have answered this before. I guess my problem is I am not sure I can apply the answer. So let me give you an apples to apples question. You have a male and a female patient. Both are in for the same rectal exam. It requires the patient to be in stirrups and have a cath inserted. The rectal exam is then started. Will your instruction have patients be drapped the same?

Thanks,

Mark

 
At Wednesday, December 21, 2011 1:45:00 PM, Blogger Maurice Bernstein, M.D. said...

Suzy, I may have noted this previously but the 2nd year students are, if anything, shy about imposing requests for the patient to expose their bodies even to the extent of having the patient remove stockings to properly evaluate the skin, nails, color,pulses, sensation and so on in the feet. I have had repeatedly to remind them to request and, if necessary, help the patient to remove the socks.

What I am about to write deals with hospitalized patients (not ambulatory clinic) about which I am mainly experienced. All students are told to introduce themselves to the patient, explain the student's obligations and what the student intends to do and what the role of the patient is in the student's education. If the patient accepts, notwithstanding the gender of the student or gender of the patient, the learning exercise begins. During the physical exam procedure, the student again irrespective of gender, explains to the patient what is to come next and awaits a sign that the patient agrees. I have not heard from a student nor have I witnessed an occurrence where the student or a patient rejected the other only based on gender. Once a student wanted to switch patients when her male patient became almost physically aggressive towards her and frightened her. Virtually all patients regardless of gender similarities or differences cooperate with the exercise and the reason that the examination may be terminated prematurely is because of yet unrelieved pain, restlessness or fatigue. Sometimes the student on first entering the room finds the patient asleep and desires another patient. I often go with the student to the sleeping patient, touch the patient lightly, the patient awakens and irrespective of gender accepts the invitation for a history and physical. Please consider that in an inpatient hospital situation, with degrees of boredom as a bed-patient, all the reactions of the patient with regard to student gender or other issues may be different than in an outpatient clinic. ..Maurice.

Are there any other questions about the education of medical students. There shouldn't be any secrets. ..Maurice.

 
At Wednesday, December 21, 2011 1:47:00 PM, Anonymous Anonymous said...

Terry, I am very grateful to have you here, we desperatly need providers and especially nurses to wiegh in and give us the other side of this issue. I would ask and hope you are not offended by some of the responses here. Some people come off as confrontational and aggressive, it is an emotional issue. I hope you will be able to wade through them and stay with us and help us understand your side.

I appreciate that you were candid enough to admit you understand this must be difficult from the patients side. For many people we feel they the attitude is we as providers feel this is no big deal so you should as well. Your acknowledgement that while it isn't a big deal for you, you understand it is for the paitient is huge. I think if more providers acknowledged this, it would lessen the anomosity some feel toward them. Thank you for that.

I am one that finds it very uncomfortable to be exposed to females even in the medical setting. Strange as it may sound that has been the worst part of anything I have had done in a medical procedure (none of mine have been life threatening). What really bothers me is not the can't accomodate, it is the fact that often there are options but providers don't ask. I think this is because it is more efficient if the patients accept what is provided vs asking and having to accomodate. I have related here I had to have a scrotal sonogram, it was done by a female tech my age. She was very nice, very professional, did a great job but it was very embarassing. When I was leaving I heard the same female tech tell a female patient she was going on break and the only tech available was male so if she would feel more comfortable with a female she could wait and she would be back in 15 minutes. I learned a little from that episode, when I was going to have a vasectomy I asked the MD if he could do it without the nurse, just he and I, he said no problem. A friend of mine had it done same MD and talked about how humiliating it was with the nurse he knew personally in there. These are incidents that could have been avoided but no one cared enough to ask.

Would you please give me some thoughts on these questions, and please don't take them as condemning. I really do not doubt the process is not sexual for you, but I struggle with this part. Even though it is not sexual, do you feel exactly the same, think the exact same thoughts when the naked patient is a 350 lbs man, a female, or a very attractive well built male? I understand that it isn't sexual, but is it the same?

Also, from your experience do you feel male and female modesty is addressed the same way? Is it given the same importance. It doesn't seem to me that it is, I think historically it has been held men don't care as much or at all, and given the gender dispairity its hard to provide for males.

Great to have you here, I hope you will stay with us awhile or longer if you please and can tolerate a little attitude from time to time...last thought, it seems often providers act as if quality care and accomodating modesty are mutually exclusive of each other...do you see this thought often?...thanks for being here...alan

 
At Wednesday, December 21, 2011 1:49:00 PM, Anonymous Anonymous said...

Doug, I didn't take any of your comments personally. It was Maurice who once commented on his views about emergencies to that I commented, I'd rather be dead and would refuse the emergency care because my mental health is more important to me than my physical health.

Tam, power can only exist if it is given. For example, a patient may want to leave the hospital and they can if they know how to do it. Stay and refuse everything they want to do. You will be kicked out so fast you won't know what happened to you. Everyone has the right who is competent to make those decisions especially with support from mental health experts who agree with your position based on what one has experienced. The medical community has an obligation to protect those who need it, to honor the gender request as best they can and then it's up to the patient.

It is also one thing to say you would refuse opposite gender care even in an emergency and another thing to actually do so if the situation presented itself. I have wondered about that.

One thing one cannot be is shy or disrespectful to the medical team who is attempting to care for you. I have found if you explain yourself clearly and what you need to get through you will have options.

Men do have a tougher time when it comes to nursing staff but then there is the option of asking the doctor to do what he has to without any nurses and you might be able to assist or...go shopping and then tell your doctor how much you like him but that another practice can accommodate your needs and if you can't be accommodated you will have no choice but to change.

You can say anything to anyone as long as you are respectful and appreciate what they are trying to do.

One of the most eye opening experiences for me is that a doctor totally messed up with the aim of helping me. This was years ago and it took a long time to realize that they just don't know what to do. There is much work to be done and I have been working diligently for many years first analyzing what happened to me (by dissecting the various elements), why I felt the way that I did, and finally with writing my own protocol for what I need and then on how to get it.
belinda

 
At Wednesday, December 21, 2011 5:12:00 PM, Anonymous Anonymous said...

Belinda, you say power only exists if it is given. I agree with you somewhat, in principle anyway. But in practicality, it can really be a battle - one the patient may have a hard time winning. The patient may be at a very vulnerable timee.
Think of a teeneager who wants birth control, who gets told that they MUST have pelvic exam first. Are they going to have the strength and resources to fight that battle?
I remember an old lady friend who was "trapped" at what I consider to be a bad hospital. We were not able to arrange a transfer. Refuse everything? She would have died. They had the leverage there. I did eventually get a new attending, but what I had to go through to do it was impressive. She was very ill, she could never have managed.
That same lady had some privacy violations also - she wasked a male resident to not be in the room while she was completely exposed - he refused, stating "I'm a doctor, I've seen them before". I got him out, eventually - but it wasn't easy.
I understand all of these patient rights, but in practice, it's not always that easy - especially if you're quite ill and/or vulnerable.
Those rights really should belong to the patients, without having to battle for them. Privacy being one of them, of course.
TAM

 
At Wednesday, December 21, 2011 8:23:00 PM, Anonymous Anonymous said...

Well Golly Maurice


I too want to receive the best technical as well
as professional care. But then this Is not a perfect
world then is it.

Terry

Certainly,you don't know what the answer is
do you. May I suggest you read over the volumes
and some other choice blogs. What does 25 years
experience have to do with anything? I actually have
you beat by a decade,dosen't mean anything.

You say that male and female nurses are
professionals. What is that supposed to mean?That
all of them are professional, or just some of them,or
are you just one of those nurses from allnurses who happens to be ashamed of the comments your cohorts
make.


PT

 
At Wednesday, December 21, 2011 9:07:00 PM, Blogger Maurice Bernstein, M.D. said...

Mark 12:59pm today wrote: "You have a male and a female patient. Both are in for the same rectal exam. It requires the patient to be in stirrups and have a cath inserted. The rectal exam is then started. Will your instruction have patients be drapped the same?" Approaches to examinations of genitalia and rectum are presented to students by both the instructors and the male and female teacher-subjects.

If you want the details of the procedures, here they are:
If only a rectal exam is to be performed, it can be performed similarly in the case of either a male or female. The patient lies on a table on the patient's side fully covered except for the anal area exposed. The anal area is inspected, the anal sphincter tone is evaluated by initial insertion of the physician's finger and then the finger is inserted fully and the rectal ampulla is palpated..all taking just seconds. No Foley catheter is needed to be inserted in either male or female for a solitary rectal exam. In the ambulatory male, the custom is simply to have the man bend over a table with only the anal area exposed. This positioning has not been considered acceptable for a woman thus lying on one side would be the positioning. An isolated rectal exam is more rarely performed in a female. It is usually part of the pelvic exam in which the lithotomy position is the accepted positioning for the best pelvic/rectal examination and the draping is to cover the body except to bare the external genitalia/rectal area. I hope this description helps to answer your question. ..Maurice.

 
At Wednesday, December 21, 2011 9:30:00 PM, Blogger Maurice Bernstein, M.D. said...

Speaking of the 46 Volumes on this thread developing over a 6 1/2 year period, it might be interesting if someone would take the time to review all these volumes and tell us whether there has been some sort of metamorphosis in the commentary from simply descriptions to constructive ideas. Or is there only repetitions but no advancements in thoughts? In other words, in summary, what are we learning as we progress through all of these volumes? I have my own view but I would like to read what others find. Will continuing on to more and more Volumes provide benefit? ..Maurice.

p.s.- For those unaware, this thread was divided into progressive Volumes of 120-140 or so comments because of my experienced loss of commentaries by the Blogger.com early on when I allowed hundreds of commentaries to be posted in one volume.

 
At Wednesday, December 21, 2011 10:50:00 PM, Anonymous Anonymous said...

Wow, there is quite a bit going on here emotionally. I am impressed with the passionate voices in these posts. For the record, I believe that having a deep and abiding respect for each person is really important.
Patients are in a vulnerable position and should have more control over care. In this country my anecdotal observation is that nurses, predominantly female, are seen as "gender neutral" when it comes to giving care that requires disrobing, but males are not, whether the provider is a nurse or a doctors.
I have seen more "care and attention" paid to female
patients who are Muslim or come from other countries where modesty standards are different. I do not agree with
that approach & think every patient deserves appropriate
draping and respect.
I am not familiar with the allnurse posts, and don't post
there.
I agree with Dr. B's comments about licensed personnel
and think patients should be concerned and that there is
work to be done there.
In nursing training there is a great emphasis on "cultural
competence." in my opinion, it would be impossible for me
to be entirely "culturally aware" in our emerging global
world; but I can employ the same standards of respect for
each individual and family and seek to meet their needs.
I don't have time to read all of this blog, but I am sure
there are many important points, & I encourage those
contributors who are doing so to engage the "system"
through legislative and other methods. Currently there are
a lot of resources being used in hospitals to transform
them into being "patient centered," but most of the care
given in terms of med administration times, exam times,
etc. are not. So at this stage there is a lot of training and acronyms, but little actual change. I believe only patients
will be able to shift care by demanding change.
I agree with a previous poster, that much is about "control" when you enter the system and it is good to have an advocate with you if possible and to verbalized your preferences. You do have the right as a patient to refuse care. There is a patient's bill of rights that is in that pile of
admission papers. You should respectfully and in a kind way ask many questions like, what is that medication for, why am I having that test etc. What are the risks. If you want only male or female caregivers ask. If you know staff and having them give you care would be embarrassing please speak up. Many of your caregivers are just running to keep up with all that is demanded in a shift.
And for the record, I have asked other nurses to circulate OR cases or do invasive procedures on patients I knew. It doesn't happen often, but it does happen.
Most (yes some are just looking for a job or a paycheck) healthcare professionals really do go into healthcare because they want to help others.
I probably won't be able to stick around on this board, due to work and school. I came across this doing a web search about provider/patient relationships. I think there is a great study here and applaud each contributor.
Keep up the good work & keep questioning the system.
Terry

 
At Thursday, December 22, 2011 5:47:00 AM, Anonymous Anonymous said...

Tam, I agree with you in a perfect world.

I've been struggling with this book I'm writing and now realize there needs to be two books. One book to discuss how I got to my positions in the first place, the analysis etc. and the second book protocols for getting what you want. Using myself as my own guinea pig I've been "playing" with different techniques until I got it right.

You are also right that we should not have to be put into the position we are with regard to modesty.

I've recently written to a congressman and there is a congresswoman in NY that I'm currently putting a package together to send. What bothers me about this is that the laws were put into place by the Patient Bill of Rights and totally ignored, so we need to figure a way to enforce those laws. I believe (due to my extensive work experience in a couple of pertinent fields) that I've found a way to do that.

This struggle reminds me in some ways of the Civil Rights Movement in that very early on, egregious behaviors weren't recognized by the perpetrators. It is the same here. The professionals only looking at their point of view, justifying it, without accountability or responsibility for the damage they inflict every day. Sometimes the damage is worse than the illness that brought one to the hospital.

Some say my positions are aggressive and extreme. I will agree that to some they may feel extreme. Once something terrible happens, you can either "trust a system that is undeserving, or...protect your autonomy. Frankly, the only healthy thing to do is understand who you are, what you need and to make sure you get it. Anything less than that, is compromising yourself and putting yourself in a situation where you do not feel safe.

My positions don't need to be justified by anyone, only explained.

You are only going to get what you need by sweat and hard work while you are well. If all that is in place, then, you won't need to do it when you are sick.
belinda

 
At Thursday, December 22, 2011 6:18:00 AM, Anonymous Anonymous said...

Maurice, the blog editing of my question misses the point. I was asking a hypothetical question about identical procedures on a man and a woman and would you teach identical modesty or drapping. Perhaps the problem is the procedure was hypothetical. I wasn't really interested in the rectal exam. Although it is interesting the male "assume the position" rectal exam is taught to be inappropriate for a woman.

Mark

 
At Thursday, December 22, 2011 9:01:00 AM, Anonymous Anonymous said...

Alan, I haven't read back through the blog about your experience. It must have been upsetting to have this embarrassing sonogram and on the way out to hear if you were a woman you could have had preferential treatment. In your case there was a male tech but she didn't consider offering the consideration to you. This is my complaint, males should be offered the same consideration as women. Did you write or complain to anyone?

Mark

 
At Thursday, December 22, 2011 9:23:00 AM, Anonymous Anonymous said...

Alan, Geez the more I think about your sonogram the more upset I am. How much more could you be up in a guy's privates?! Yet no consideration when there was a male tech there. COME ON!

Mark

 
At Thursday, December 22, 2011 2:42:00 PM, Blogger Doug Capra said...

"Or is there only repetitions but no advancements in thoughts? In other words,"

That's my assessment, Maurice. But I'm not suggesting you stop thread. New people come on and the same discussions get recycled, perhaps with a little different slant, but not much. Occasionally, but not often, a new idea shows up. I find myself trying to search out older volumes to find something I posted so I don't have to rewrite it. But it's usually so time consuming to search that I just try to rewrite an old post from memory. I really don't have time to do that, but it's frustrating not providing new people with some of the information they want and may need that's already been on the older threads. I'm running out of steam.

 
At Thursday, December 22, 2011 3:07:00 PM, Blogger Maurice Bernstein, M.D. said...

Doug, I can't find a universal search mechanism for all the Comments on my blog. In the upper left corner of all pages, there is a Search field. It will find you all terms or expressions which are present in any blog thread's first page but not within the Comments. However, if you go to the Comments page of any Volume, you could use your browser's Find mechanism to find all terms and expressions in throughout the Volume page. You might have to search a number of Volumes to find what you want but it should be fairly rapid if your search term is more specific than broad. I have used the Find mechanism on Google Chrome browser.

With regard to your impression.. hmmn..should we have expected anything more than a migration of visitors in and out and simply repetition in and out? Probably not.
..Maurice.

 
At Thursday, December 22, 2011 4:08:00 PM, Anonymous StayingFit said...

Doug, you can use Google to do the searches, and you can limit the universe searched by specifying this site. Here is an example of what you would type into Google's search field:

chaperone site:bioethicsdiscussion.blogspot.com

Here, I am searching for the term "chaperone", and the search is limited to Dr. Bernstein's blog. I hope that this helps.

 
At Thursday, December 22, 2011 4:09:00 PM, Anonymous Anonymous said...

Doug, you reported a hospital that allowed an ER show to humiliate a male patient. Have you identified the hospital or drafted a letter? I think it would be worth being active. This or Suzie's site could lead activism not just blogging.

Marl

 
At Thursday, December 22, 2011 4:56:00 PM, Blogger Doug Capra said...

Maurice: No, I agree with you -- what's happening is normal. New people come on who haven't read previous threads, etc., but one sees this happen on all kinds of blogs. I notice it happens on allnurses.com all the time. But there posters are then referred to a specific thread about a specific topic -- like on Joel Sherman's original blog. I'll try your suggestion for searches to see how it works. If it does, when new posters arrive on the blog, maybe we can refer them to a particular volume, maybe even a date. But the problem is that, on this blog, the topics are really scattered over all the volumes. So you may find a relevant discussion covering several posts on one particular volume, but there'll be several other volumes that will have similar stretches of discussion about the same topic. I don't know the answer.

 
At Thursday, December 22, 2011 5:08:00 PM, Blogger Maurice Bernstein, M.D. said...

StayingFit, thank you so much for bringing to our attention how to solve the issue that Doug brought up regarding isolating specific topics written in the Comments section of my blog threads. ..Maurice.

 
At Thursday, December 22, 2011 5:27:00 PM, Anonymous Anonymous said...

Terry, I understand you may not be able to stay with the blog long, but I would ask you to consider bringing the blog to other nurses attention and ask the to visit. I would also hope that you would consider coming back as often as you can, whatever that may be. I would like to tell you, this is a great place to get information on provider/patient relationships. Personally I think most people here would agree with me when I say almost without exception the vast majority of nurses I have encountered as a patient and as I went though end of life with my parents were simply some of the most exceptional people I have ever met. The care and compassion I experienced is hard to discribe, which is why this issue seems to be at odds with that. I hope you or some of your coworkers can help us gain some insight into that.

You have already given several things to think about, in your 1st post you acknowledged it must be difficult for patients, you have no idea how big that was. In your second you confirmed male providers are not seen as gender nuetral but females are. Tie that to Dr. Bernstein's comment that for the same procedure asking a male to assume a position that would not be acceptable for females begins to form a pattern that many men have complained about but doesn't seem to be an issue for providers. Thia is on its face, discrimination, but in reality, acceptable discrimination. I believe nurses are not the cause, they are part of the system that is the cause. I hope you will find a way to help here either by sending coworkers or partcipating yourself.

 
At Thursday, December 22, 2011 5:34:00 PM, Blogger Maurice Bernstein, M.D. said...

I think we all would be interested for the last anonymous writer to give us a pseudonym for identification. Thanks. ..Maurice.

 
At Thursday, December 22, 2011 6:18:00 PM, Anonymous Anonymous said...

Mark, I got the point of your post, I often wonder if providers don't understand the question or if they simply don't want to answer it. It was pretty obvious the question was when a procedure requires exposure are men and women treated the same, in his case draping. In Mark's case, why would he be left undraped for the procedure but women are draped for pelvic exams. Indirectly the question was answered by indicating it was fine to have a male bend over a table but not a female.

Mark, I was furious, I was mad at them, I was mad at myself, in fact, the first thing I did when I walked out of the hospital was buy a pack of cigarettes and had my first smoke in almost 20 years. It ate on me for months until I stumbled across this thread and realized I wasn't a freak, others felt the same way. I did contact them, first I sent an email to the patient advocate, when i did not get a reply I went again to the CEO, to the patient liason, to the general mail. I got a flurry of calls from the patient advocate, from the head of the imaging dept., from the patient liason. They were very understanding and sympathic. They promised they were changing protocol. Now I can not tell you that I verified they did, but I believe they did. I also must say when I wrote them I was respectful and pointed out the benefit to them in offering a choice better patient relationships and experiences, a competitive edge over facilities that can't offer the same, etc. I believe I made a positive impact on the faclity and it did a great deal for me, I have applied what I learned several times since, I find providers are willing to accomodate if we ask, while I feel they should ask, one step at a time. What you are doing will empower you, challenge the status quo, you will be amazed what it does for you.

And that Doug and Dr. Bernstein is one of the values of this thread. Rehash, yes sometimes it is, but while the core is the same at this point, there are others who come and go. AND, it has and continues to make a difference. Dr. Bernstein, Suzy posted a link to a site where we are trying to form a group to start with a website and then to take it to a proactive involved group. If you would consider posting a link on the side where we could continually direct people to the site to get them involved it would be appreciated and might help move this beyond discussion.

Side note, Dr. Sherman was qouted on a blog for patient advocates on Trisha Torrey's blog. Keep spreading it folks....alan

 
At Thursday, December 22, 2011 7:24:00 PM, Blogger Maurice Bernstein, M.D. said...

I have included a link to the patient modesty advocacy blog in the LINK section of the right hand column of this blog. ..Maurice.

 
At Thursday, December 22, 2011 7:28:00 PM, Anonymous Anonymous said...

I want to thank Terry so much for weighing in. That’s really what I think this blog needs is perspective from female nurses. I also want to thank Dr. Bernstein for trying so hard to instill the importance of modesty to his students.

After reading thousands of posts over the months and having my own positive and negative experiences in health care I have concluded the following:

No matter who they are, whether it’s me, you, the Pope, the nice nurse, the chaperone, the surgeon, and yes, even Dr. Bernstein, when a patient is naked, the health care provider will likely at least peak at their private areas. There are a hundred reasons why from innocent curiosity to perversion, but admit it, probubly everybody takes a quick look. So if it bothers you, take preemptive measures and of course, speak up! If there is no accommodation, then if you can, leave and tell them why and go find someone who will accommodate you.

Regarding being completely exposed while the nurses stare at you, bring a sterile cloth and cover your genitals yourself before the gown is removed and tell them that you will absolutely not consent to it being removed. If the procedure calls for complete exposure, delay the procedure repeatedly asking why the opposite gender staff have to be there and contesting their response. Stand up for yourself. It’s your best chance. If nothing else, at least you can aggravate them.

I do want to say that I believe that there are female and male nurses who care for patients because they love people and do what they can to protect your modesty. God bless and keep them.

In closing, I want to share something a friend suggested. He said that perhaps some of us should consider that the best course of action may not be to change the system but rather, if at all possible, change your viewpoint. He suggested at least trying to condition ourself not to care. Now there’s the real freedom he said. Imagine if you could care less that technicians had to view and or touch your naked body. Better yet, if you admired their profession and viewed them as great examples of humanitarians whose sole purpose was to selflessly care for you in the most compassionate manner. Now I agree that such an approach would be freedom from this unhealthy fear and loathing that we all seem to share. Remember, he said, it’s true, if you believe it.

Just a thought
but I still hate ‘em,
Warmouth

 
At Thursday, December 22, 2011 7:38:00 PM, Anonymous Anonymous said...

Terry


I agree with you,don't spend to long at this site. It's
just that I don't see you contributing much. You are
typical of the nursing visitor here,making your opinions
without reading into the cause of the problem.

You say all nurses are professional.I want people
to stop using that word. Professional only means you
get paid for what you do and has nothing to do with
how respectful,advocating or what you actually think.

It has nothing to do with how trustful you are,that's
why they created angieslist.com. I see many young
nurses who think they are professional,driving an 11
year old BMW and barely making the 450 dollar a month
payment to the used car lot. These people's lives are
more screwed up than Lindsey Lohan, funny they all
say how caring they are.

Ever see how fast they pull out of the hospital
parking lot,almost taking out that family of four. Even
more interesting is when there are safety concerns for
the patient and the first comment out of their mouth
is concern for their license,not the well being of the
patient.

A survey of across the nation nursing students
asked these potential nurses why they chose nursing
and their response was, "a good paying job. I'm willing
to bet that if you ask these same nurses whose physical
privacy is more important, a 79 year old man or an 18
year old female,the responses would essentially be
mutual.


PT

 
At Friday, December 23, 2011 5:29:00 AM, Anonymous Anonymous said...

It is interesting that the same exam, with body parts in the same place is conducted two different ways depending on one's gender.

It is probable that nobody took into account dignity within the context of a psychologically uncomfortable exam.


Laying on one's side for a rectal exam, draped, offers as much dignity for several reasons, one of which is that the patient's experience is that of a covered person, whereas a patient bending over a table with their pants down brings focus to the patient that they are unclothed.

Labor and Delivery could benefit as well by offering leg coverings to women (they used to), or a tent, to lessen the experience of being exposed.

Some exams are not afforded these luxuries of options and same gender care will often lessen that feeling of vulnerability in those patients that need it.

Going back the the "Naked" article, it would seem that now is the time to write protocols for exams with dignity at the forefront with equal accessibility as needed for any kind of exam making draping practices uniform. It would give patients and idea of what to expect and do as much to relieve the awkwardness of such an exam. Any thoughts on this?
belinda

 
At Friday, December 23, 2011 9:04:00 AM, Blogger Maurice Bernstein, M.D. said...

Belinda, an EXCELLENT suggestion! In fact, to make the suggestion even more productive.. how about the visitors here (even you PT) together create a final consensus list, a series of suggested protocols for attending to all the patient modesty issues experienced in medical care. The development of the list can written to this blog or Dr. Sherman/Doug Capra's or on Suzy's blog.

But not just writing this protocol list to our blogs.. the final consensus list should be sent to Dr. Atui Gawande who wrote the article "Naked" in the New England Journal of Medicine and which was the basis for our entire series of Volumes on patient modesty. As some of you may know, Dr.Gawande is now a very well respected individual for his analysis and writings about a host of important medical issues that need fixing or change. By this project on our part, this may be the most direct way, through Dr.Gawande, to get something moving rather than repeated moaning and yearning on our blogs. How is that for an idea? Again, thanks Belinda for a suggestion to get us all "off our butts" (so to speak). ..Maurice.

 
At Friday, December 23, 2011 10:33:00 AM, Blogger Doug Capra said...

Warmouth:
Here are some areas where we disagree: You write: "when a patient is naked, the health care provider will likely at least peak at their private areas." I don't necessarily believe that. For most, their work does become routine and they don't "see" certain things anymore. I wrote about this idea, how we're socialized to "see" and not "see" certain things depending upon our culture and training. I'm not saying it doesn't happen. But your use of the term "likely," IMO, is not accurate. That doesn't mean some don't. You also write: "There are a hundred reasons why from innocent curiosity to perversion, but admit it, probubly everybody takes a quick look." I don't agree. Most don't pay any attention to patient genitals unless there's a need to for medical reasons. My opinion.
You write: "Imagine if you could care less that technicians had to view and or touch your naked body." Ironically, I think many people on this blog originally felt this way, and then they had their modesty violated. I'll say it again, and again. It's not about being naked as much as is about how you're approached and treated. Most people would go along with your last paragraph if they felt their dignity was being respected.
You also write: "Now I agree that such an approach would be freedom from this unhealthy fear and loathing that we all seem to share." If someone has been mistreated by the medical culture, I don't think that their misgivings, fear and loathing is necessarily unhealthy. In fact, it may be quite healthy to be proactive. Patients who haven't been mistreated know the "possibilities," what could happen. When those possibilites then happen to unsuspecting patients, the patients then lose trust. There's nothing unhealthy about taking more control of your life and health.
Also, you write that "we all seem to fear" this. I don't, and perhaps some others on this blog don't have this fear and loathing about exposing my body to opposite gender caregivers as long as I perceive that I'm being treated with dignity and respect.
I do agree with you that people need to stand up for themselves and speak up. Patients need to communicate and let caregivers know how they feel and what they expect.

 
At Friday, December 23, 2011 12:16:00 PM, Anonymous Anonymous said...

Warmouth:
I have no idea if your friend was chiding you, being sarcastic, or actually trying to help.But this is what I heard: "He said that perhaps some of us should consider that the best course of action may not be to change the system but rather, if at all possible, change your viewpoint."
What I heard: If you see something that is unfair and unjust, then you need to rethink your own opinion about what is fair and just. Eventually you will see things their way.

"He suggested at least trying to condition ourself not to care."

What I heard. If your ethical, moral, and social values make you uncomfortable in any situation, it's best to get rid of those values than to stand up for them.

"Now there’s the real freedom he said."
Yes, there is freedom in not caring about anything or fighting for your own beliefs. Freedom to be a passive participant while everyone else (good or bad) does whatever they want.Just step back...smile...and if you see something bad happening to someone: turn away. If you pretend it does not exist, then it doesn't.

"Remember, he said, it’s true, if you believe it."
Yes, but denial isn't truth.And conditioning isn't true belief. And changing your viewpoint when someone disagrees with you is just giving up.

Suzy

 
At Friday, December 23, 2011 6:03:00 PM, Anonymous Anonymous said...

Maurice


What is the point of a protocol list? It won't
change anything besides, those kinds of guidance
and instructional tools already exist. One type are
the core values of an institution and we all know most
can't recite them nor even know of their existence.

I believe that over the number of years that
I have been posting to this thread, we have all made
the points clear. Solutions to many math problems won't
exist for a very long time and one more website isn't going
to solve this one. This particular problem will be solved
most likely in the legal arena. Just in the last several months legal rulings have been made regarding strip
searches involving male inmates.

You frequently mention the continual examples
you teach your medical students, yet I really don't see
the problem as physician based. Moreover, if it were,
I'm suggesting that the examples would be short lived
in that once people graduate from the Dr Maurice Bernstein
school of thought they simply get comfortable with what
they want to do.

Realize Dr. M that I am giving you a lot of credit
however, female nurses start their programs with the same
mentality they leave with. Hipaa is a perfect example of
this thread and if the Internet existed in the 70's, you can
be sure there would be blogs with the same concerns.

How did Hipaa come to be? With people making
their concerns known and certainly hospitals and medical
facilities never took the initiative, they just stood by until
the federal government passed laws. The shortcomings
of this blog are that the nursing problem is not addressed.

The students you teach represent a small core in
the big picture and certainly won't make any difference,
although this blog does empower some. I'll even suggest
that once nursing reaches equilibrium the problem will
still remain only to be solved finally in the courts. Over
and over I see visitors to this blog who really don't get
it.

The first problem with this blog is it's title,
modesty. It never will or can address problems such
as sexual misconduct among hospital staff in that this
revolving door seems to suggest that the patient has
some type of hangup.

Anyone in healthcare knows that sexual impropriety
is an unspoken word and can have severe financial
Implications for a medical facility. Laws in many states
only have recently required medical facilities to report
sexual assaults within their facilities in 24 hours. Why,
because patients were told,it's the medication, you
have imagined it. Who told these patients this,nursing
staff. Ever wonder why intensive care units are now
locked down. In other words you have to be let in by
picking up a phone on the wall and calling to be let
in if you are a visitor. There is a reason for that.

This blog simply fails to address many of these
issues for a number of reasons and for that Maurice
perhaps it is time that you end this topic.


PT

 
At Saturday, December 24, 2011 10:07:00 AM, Anonymous Anonymous said...

PT, For once, I agree with you and I've been talking about the abuse issue for a long time perpertrated by both genders to patients of both genders.

The reason it's important to establish draping protocols are two fold. First, it promotes the dignity of every individual and second, it would allow patients to know when inappropriate procedures were being used for the sole purpose of exposing their bodies needlessly (thereby erradicating abuse when procedures are standardized).

Maurice, thank you for the suggestion, however, that was just a little piece from my research and experience...more to come.

Happy Holidays everyone!
belinda

 
At Saturday, December 24, 2011 10:48:00 AM, Blogger Maurice Bernstein, M.D. said...

I have a suggestion about clarifying discussions by a separation of issues. Perhaps "patient modesty" which is being written about on this thread is really an anticipation of suspected or to be observed unwanted sexual behavior on the part of the healthcare provider. In other words, it is not simply the concern of "baring one's privates" but regarding what such baring might lead to as a sexual response by the provider or even on the part of the patient. The modesty would therefore be an anticipatory mechanism rather than a reaction to an event in progress. Therefore, such patient modesty on the part of the patient could be either imagined or based on the emotional reaction to a past experience.

If the above definition is correct, then it is patient generated and could be, in reality, unrelated to the specific behavior of any particular healthcare provider. Thus, patient physical modesty being discussed on this thread represents a patient fear and a discussion should be oriented about how to mitigate that fear.

Sexual behavior on the part of the provider,on the other hand, it's frequency and extent and how to control would be a separate thread for discussion.

Do you find that such separation is a reasonable consideration to discussion? ..Maurice.

 
At Saturday, December 24, 2011 11:46:00 AM, Anonymous Anonymous said...

Maurice, on your last post you wrote, "Perhaps "patient modesty" which is being written about on this thread is really an anticipation of suspected or to be observed unwanted sexual behavior on the part of the healthcare provider...it is not simply the concern of "baring one's privates"

I do not accept this definition of patient modesty. For me, and I'm believe for many others,"baring our privates" in the presence of the opposite gender is exactly what humiliates and embarrasses us.

As a large and powerful man, I have absolutely no anticipation of unwanted sexual behavior on the part of a healthcare provider because I believe it's clear to them that any such behavior on their part would put them in immediate danger of a violent response on my part.

Perhaps your definition of "patient modesty" may have some truth for some women, the frail and the elderly but for most males who are quite capable of protecting themselves from any inappropriate actions I believe it is simply incorrect.

MG

 
At Saturday, December 24, 2011 11:48:00 AM, Blogger Doug Capra said...

"Sexual behavior on the part of the provider,on the other hand, it's frequency and extent and how to control would be a separate thread for discussion."

I agree. I've never seen sexual behavior or sexual abuse as a significant part of the modesty discussion -- at least from the male point of view. I would grant that some women might see it differently, and for good justifiable reasons.
The importance of protocols, as I see it, would be to let people know what to expect. I would want to see them set up so that the patient and caregiver could negotiate the protocols if the both agree -- but that would involve open communication. For example, both might feel comfortable with less restrictive draping methods.
But part of the big issue here, as I see it, is the lack of information available to the patient. Ironically, many healthcare providers think they are giving sufficient information. Many patients feel they haven't gotten enough information, esp. after the fact when some feel they have been "ambushed," i.e. Mark's experience as related on the last volume.
This is why I would be in favor of clear, published protocols regarding not just draping, but also use of chaperones, and other issues specifically related to patient privacy, dignity and modesty.
PROVIDER -- "Have you read the protocols for this procedure?"
PATIENT -- "Yes."
PROVIDOR -- "How do you feel about what's going to happen? Are you comfortable"
PATIENT -- "I feel okay." OR "I'm not comfortable with some of them."
PROVIDER -- "What are you not comfortable with?"
PATIENT -- The patient relates, etc.

This basic dialogue protocol should be part of every exam, visit, procedure, etc. Will it take more time? Perhaps. But it clearly demonstrates that the provider cares about the patient's feelings. And I believe it will make a difference, even with patients who don't particularly care about their modesty.

 
At Saturday, December 24, 2011 12:33:00 PM, Anonymous Anonymous said...

Suzy you are right on the money. I and others have compared this to the struggle for racial & gender equality. The similarities are many, the perpetrators were mixed with those relatively few who drove the issue, and supported by the vast majority on that side going along even if they recognized it was wrong and didn;t agree. On the victims side, a relatively small minority stood up and built a fire under those who had previously disagreed with the eprsecution. How many women accepted the position that a womans place was in the home and the man was the head of the household. If women had accepted the suggestion change yourself to accept this...where would they and society be, remember at one time this was accepted by the vast majority, men and women.

PT, there are two issues, modesty violations and abuse. I believe modesty is violated more frequently due to SAP and the desire to cut costs than intent. Abuse has a element of intent to harm, violations of modesty doesn't always or in my opinion often have that. It is more self serving than malcious. I would agree they are two different threads. My modesty violations were carried out by very nice people whom I feel really did have my health in mind. Perhaps you would be better on one that deals with abuse as you feel it is all malicious.

Doug, Dr. Bernstein I disagree. I would feel more comfortable with a snotty jerk of a male nurse with no bedside manner than a nice respectful female when it comes to exposure. That is just me. While approach can lessen can make it more tolerable, doesn;t change it. Your arguement plays more to the "we are professionals" solution than what many here are actually asking for, accomodation like they want it.

I hope you will leave this thread run as given the length and continued use, it would seem to indicate it is an issue. Dr. Bernstein, have any of your other threads even approached this. I would ask everyone to view the link and come to the blog Suzy has built, we are using it to gather thoughts to build an advocacy site. Please help.....alan

 
At Saturday, December 24, 2011 2:52:00 PM, Blogger Doug Capra said...

alan: I don't think it's a question of disagreeing, unless it's about numbers, i.e. how many people feel this way or that way. I respect your right to the care you feel most comfortable with. We don't disagree about that. But I do believe that most people are somewhere in the middle on this issue and can go either way, and I believe the way they go depends on whether they feel safe and respected. I don't think most people would feel safe and respected with"a snotty jerk of a male nurse with no bedside manner," or a nurse of either gender with that attitude.
But, we do need more research on this, don't we?

 
At Saturday, December 24, 2011 4:44:00 PM, Anonymous Anonymous said...

Belinda


Draping protocols are already in effect in that
they essentially only apply to female patients. It is
considered sexual misconduct under state nursing board
rules to deliberately leave a patient uncovered,ie exposing
their genitals.

How are your draping protocols going to help,
benefit an unconscious and intubated patient. A patient,
perhaps young with a head injury and placed in a barb
coma. In a private room in a neuro icu, with curtains
closed and total care. In 24 hours numerous staff,lab,
respiratory,radiology,etc are in and out of that room.
Will the nursing staff insure your privacy,don't
be so sure. Despite you being unconscious,do you think
you are safe?


Alan


Many modesty violations fall under more
serious privacy violations and the two are closely
related. You said "your modesty violations were carried
out with very nice people who had your health in mind."
Was it nice when they offered a female patient
an option for a female tech, but not a male tech for you,
and actually said that in front of you.
Sorry, I don't see that as nice and certainly
not being a real advocate for you. If they are not
advocating for all their patients,then no they don't have
your health in mind.

PT

 
At Sunday, December 25, 2011 4:47:00 PM, Anonymous Anonymous said...

I recently reread Amy Kapczynski’s Same-Sex Privacy and the Limits of Antidiscrimination Law (mentioned in one of the older volumes) and noticed something I think is relevant to the discussions here. On page 17 she writes “Courts may be more likely to resist the automatic sexing of the privacy norm where the privacy of men is at stake because men’s bodies are seen as inherently less private than women’s—an issue to which we will return shortly.” The reason for this is found on page 18 “the same-sex privacy BFOQ is a concession to the way people experience cross-sex bodily exposure as a threat or risk.” And on page 22 “The differential distribution of risk of assault between women and men would then help explain why same-sex privacy rules are generally not applied to men.”

http://www.medekspert.az/es/chapter13/resources/275.pdf

So women are afforded greater bodily privacy because of women’s fear of sexual assault and most sexual assaults on women are committed by men. Society and the medical profession thinks women are simply incapable of sexually assaulting men therefore exposure of men to the opposite sex is OK. We see this in court rulings involving strip searches at prisons, reporters in locker rooms, male nurses needing chaperones but not female nurses.

So if this fear of sexual assault gets women what they want, then men could and should use the same argument. Now its true, your average women is not going to over power your average man, but they can sexually assault men in other ways as Marc found out.

Alex

 
At Sunday, December 25, 2011 6:15:00 PM, Anonymous Anonymous said...

Alan said

"I would feel more comfortable with a snotty
jerk of a male nurse with no bedside manner than a
nice respectful female with respect to exposure."

I agree with you Alan,however, your chances
of getting a snotty female are much greater than a snotty
male. I have heard female nurses say

" if I ever come in here please cover me up."
" if I ever need a foley, it needs to be done by a female."

I know you are just making an analogy and I
agree with you 100 percent,but there is no such thing
as a nice respectful female when it comes to exposure.
If she were respectful she would find you a male and
let's for a moment reverse the roles. If you were her
nurse do you think she would view you as a nice
respectful male when it comes to exposure, I doubt
she would allow you.

The fact that 95 percent of nurses are female
coupled with the attitude that mens privacy is irrelevant
opens unique cases of abuse towards male patients.
This problem presents itself not only in nursing,
but ultrasound,radiology and radiation oncology. These
departments have only aligned themselves with the
Fem Nazi nurse instructors. It's ok to make fun of male
patients and their genitalia. It's ok to admit that they look
and it's ok to offer female patients a higher level of
respect than male patients.

PT

 
At Monday, December 26, 2011 12:03:00 PM, Anonymous Anonymous said...

I agree that there are 2 different issues going on in this blog: 1. medical modesty as related to the humiliation and embarrassment of being exposed, especially to opposite gender but not necessarily sexually charged and 2. medical modesty as realted to sexual abuse/misconduct. I got the impression early on that this blog was more dedicated to the concerns as stated in #1. I think the issue of misconduct/abuse should actually be addressed on another blog. I realize that misconduct of a sexual nature can and does occur (although I do not believe it is common) when a patient is exposed and in a vulnerable position but IMO most on this blog are here because they just felt "ambushed" and experienced a (probably unnecessary) humiliation. I am not in any way trying to diminish those who have had an abusive experience in the medical arena but I think that those incidences would be better addressed legally whereas the general modesty issue may be better addressed through some of the suggested advocacy means or by each individual patient. And just to weigh in on the standarized draping, etc. protocols, I think that would be very beneficial. If the patient knew exactly what to expect, what was going to occur, who would be involved, etc., they would be better prepared to either accept the exam/procedure or negotiate changes to help them. If it is a time constraint to present this information to a patient, why can't there be printed materials for patients to review (those who wanted) before they consent to anything? At least given the chance to have detailed information could possibly help the patient feel more involved and informed and give them an opportunity to ask more in depth questions instead of feeling surprised when things happen, sometimes all to quickly. Jean

 
At Tuesday, December 27, 2011 2:35:00 PM, Blogger abc said...

I would like to add a point that I have not seen yet. (Although, I have not read all 46 installments of the Modesty topic).

I am a male and I felt violated at 12 years old by a male doctor. I was away from home and needed to be taken to a doctor for serious cold/infection symptoms and I was taken to the local respected pediatrician.

During the exam, he "undressed me" without explanation, request, or words of comfort. I think the worst part was that he lowered my pants and underwear. My regular doctor had us in only underwear for annual physicals- and that was not a problem (but still dreaded)-- I knew what was coming.

What this doctor did, just felt violating...I'm still thinking about it 30 years later. Some say "It was a form of covert sexual abuse"...some say things were different back then. I may never know what the doctors intentions are...but the outcomes has left me confused.
Feedback and comments are welcome and appreciated.
Jim

 
At Tuesday, December 27, 2011 7:44:00 PM, Blogger Doug Capra said...

Jim: Thanks for your story. Yours is the kind of story every medical professional needs to read. On this blog, we're often talking about opposite gender violations -- but your experience demonstrates that it's not necessarily the gender but (1) lack of empathy; (2) lack of communication; (3) lack of respect for patient dignity. That can come from either gender. Providers need to learn how what seem to be little stories like yours can live with a patient for the rest of his life. Research into memory tell us that when embarrassing/emotional events like that happen to us, a drug is released in our brain that tends to set that memory in solid. With a 12-year-old, I can completely understand the confusion in your mind. This is also the "elephant in the room" syndrom. Your 12-year-old emotions, embarrassment, and confusion, probably filled the room. That, combined with the doctor, as an adult, who didn't acknowledge what was happening to you -- added to your confusion. You knew something wasn't right about the situation. You sensed that elephant. But because it wasn't acknowledged it made you wonder whether there was something wrong with you. This is also the whole issue of denial that we sometimes see in medicine regarding this issue of patient modesty.

 
At Tuesday, December 27, 2011 7:56:00 PM, Blogger Maurice Bernstein, M.D. said...

Jim, would you have felt more comfortable and not violated with the action if your father was also present in the room or would you have felt even more upset (if more upset was possible?} ..Maurice.

 
At Tuesday, December 27, 2011 8:59:00 PM, Blogger abc said...

Thank you both for your responses.

This situation may not just be about the "Elephant" of my personal discomfort and embarrassment, that was "in the the middle of the room." The question may in fact be: "How common is it for people in power, such as medical doctors, to take advantage of their vulnerable patients in a sexual way?" I was brought in for sore throat and similar symptoms, my regular doctor would never have done a genital exam for that...it made no sense to me.....but i felt powerless, vulnerable and exposed.

The difficulty with covert abuses is that the perpetrator will claim "It was medically necessary." It would help me If I could somehow find out that that doctor was guilty for similar abuses and they were verified by a number of victims...then I would feel like I was ready to accept and deal with it---because I would then be sure...its the uncertainty of it all that is so difficult.

This situation happened when I was at a summer sleepaway camp and believe it or not- I called the doctor a few years ago (I had to first track down which doctor the camp used in the late 70's, but I remembered where the office was -and it is still there- it even looks the same on google street view) He is a prominent and respected doctor and he spoke with me on the phone. He said he had no way of knowing if he was the doctor or if it was a summer intern. He often had summer interns due to the vacation area increase in patients. And he no longer has records from almost 30 years ago. I asked about genital exams for throat infections...he said it is possible that in those day he would have done them even in this case...but he said now he only examines genitals if the child gives permission- he acknowledge how times have changed.

I have been told by an expert in the area of abuse that these responses sound like "classic" perpetrator responses.

I can tell you if it would have been better if my father was in the room, my parents no longer came in with me to the doctor at that age...I would probably been embarrassed. But here is what actually happened: The summer camp sent a staff member (21 year old male) with me, he was sitting in the corner of the room reading....when the doctor undressed me...my greatest fear was that the staff member would look up and see my nakedness...and my further embarrassment. I couldn't look at the doctor...and I don't remember how long he touched me for...it may have been very brief. One thing is sure, this experience had a great impact on my life and my sexual development.
Jim

 
At Tuesday, December 27, 2011 9:03:00 PM, Blogger abc said...

One more important point i forgot to emphasize:

HE didn't ask me to get undressed....i was laying down and he opened my belt, opened my pants, pulled down the zipper, lowered my pants and then my underwear...he didn't ask...he just did it...it was THIS, the lack of control, that made me feel so powerless and violated.
thanks,
Jim

 
At Thursday, December 29, 2011 8:30:00 AM, Anonymous Anonymous said...

Recently, one of my students made me aware of an incident that took place last spring in Fort Myers, Florida that I believe is illustrative of the societal attitudes that often make it so difficult for males to receive respectful treatment from the medical profession.
According to WFTX-TV reporter Matt Grant, what took place involved three middle school girls attacking an 11 year old boy and stripping him naked as he cried and yelled for help. The girls not only laughed at and mocked the boy but they also videotaped him and posted the video on YouTube.
Fort Myers police filled out a report but weren’t much help. One office said, “He didn’t know if there was a crime committed but said it looked like a prank.”
Fort Myers Police said the girl could have faced misdemeanor battery charges, but that the boy's mother has refused to press charges. She believes that the girls' parents should punish them instead.
Undoubtedly, if three middle school boys stripped and videoed an 11 year old girl, the boys would have been prosecuted to the full extent of the law, probably tried as adults and punished as violent sex offenders and distributors of child pornography. The fact that what happened in Fort Myers could be considered a “prank” by a male police officer and that the boy’s own mother refused to press charges tells us that there is still a refusal among many in society to accept that females too can be sexual predators and that a grossly unfair double standard exists regarding the protection of the bodily integrity and safety of males.
Considering the attitudes displayed in an incident like this, is it any surprise that male modesty is so often blatantly disregarded in medical settings?
MG

 
At Thursday, December 29, 2011 9:30:00 AM, Blogger Maurice Bernstein, M.D. said...

MG, if this news story is really representative of a societal norm it means that to get more equality for the desires of the male patient and the way, perhaps, the medical system looks upon men, establishing gender equality in all aspects of the system is really going to be a challenge. Somebody better get started now on facilitating that change. And that "somebody" should also include the male patients who should move beyond grumbling to others but contribute by making their demands known to the medical system. None of that has happened in my own medical practice experience.. no man ever talked to me about modesty issues.. but also no woman either (can you believe that?) True, true! What does that suggest? (and Dr. Sherman what is your experience with patients and expressions of modesty?} ..Maurice.

 
At Thursday, December 29, 2011 10:12:00 AM, Blogger Jim said...

MG, you make great points...and while we may want equal treatment and perspectives regarding gender issues...the fact are that social mores and norms are different for boys and girls... and men and women.
To illustrate this I am reminded of the locker rooms in high schools when I was a kid. The boys showers were communal and the understanding was "Boys must not be modest and don't mind walking around and showering naked" (this is of course not the case...many were very self-conscious) BUT imagine my surprise when we the boys had to use the girls locker room when the boys locker room was closed for repairs.....I couldn't understand it at the time...but the girls locker room IN THE SAME SCHOOL, had individual showers with curtains. Society has sent clear and inconsistence messages regarding modesty and gender.
Jim

 
At Thursday, December 29, 2011 11:21:00 AM, Blogger Jim said...

Dr. Bernstein,
When you say
"'somebody' should also include
the male patients who should
move beyond grumbling to others
but contribute by making their
demands known to the medical
system."
WE, society, starting from a very young age, have been taught to respect, listen, trust...AND follow the orders of "the medical community." Why else would WE let someone tell us to strip naked, poke us with sharp objects, and make us eat foul tasting medicines? All this starts when we are children...the winds are changing but its gonna be a slow process....And be careful what you wish for...you may have unintended consequences, perhaps there will be an increase in non-compliance from patients.
Just my two cents,
Jim

 
At Thursday, December 29, 2011 12:34:00 PM, Blogger Doug Capra said...

"...no man ever talked to me about modesty issues.. but also no woman either (can you believe that?) True, true! What does that suggest?"

Let me tell you what I think it suggests, Maurice. In a December 2011 issue of the HuffPost Health Living, Richard C. Senelick, M.D.Neurologist, Author, Blogger and International Speaker published an article titled "Little Privacy in Health Care -- Shame on Us."
He relates the story of his wife who had surgery. After surgery, the nightmare begins. She described her treatment as demeaning and humiliating. Apparently, there were many examples, but Senelick writes about what he calls the most memorable episode, when a male nurse shows up to give her a bed bath. He keeps calling her "dearie," and when he see's she's uncomfortable with him giving the bed bath comments that it "isn't his first rodeo" and that "he wouldn't see anything he hadn't seen before."
I actually thought these were more cliches than anything else. I didn't think there were many actual caregivers obtuse enough to actually use these insulting expressions.
So...this doctor writes: "Not wanting to upset the apple cart, I convinced my wife that it would be easier to just 'get it over with.' It was indeed humiliating and demeaning. I never should have let it happen. I am a physician. I knew better, and yet I felt the power of the system and did not want any retribution for not cooperating."
Here's a doctor, a member of a group that's at the top of the medical food chain, who's afraid of the system and fears retribution. Let me repeat what he said:
"I felt the power of the system..." One more time:
"I felt the power of the system..."
Someone in his position doesn't often feel the "power of the system," especially regarding modesty issue, until it hits home. This experience hit home.
Let me repeat what he also said: "...I did not want any retribution for not cooperating." One more time:
"...I did not want any retribution for not cooperating."

Maurice -- I contend that you and other doctors have not heard patients complaining about modesty issues, but just sucking it up and getting it over with, for the same reasons this doctor states. If a doctor feels the "power of the system," just imagine how it must be for the patient.
You can find the article at: http://www.huffingtonpost.com/richard-c-senelick-md/health-care-privacy_b_1140930.html

 
At Thursday, December 29, 2011 3:05:00 PM, Blogger Maurice Bernstein, M.D. said...

Jim, with regard to non-compliance, that action is not the primary responsibility of anyone except the patient him or herself. Of course, the physician and the medical system itself has the responsibility to facilitate the patient's compliance (such as writing prescriptions, if possible, for affordable pharmaceuticals and to schedule dosing taking into consideration the drug effects but also the social-life issues the patient faces.)

With regard to NOT "unintended consequences" but frankly "UNEXPECTED" consequences" this has already been noted on this thread where patients state they intend to avoid possible life-saving procedures because of failure of the medical system to attend to the personal physical modesty issues. ..Maurice.

 
At Thursday, December 29, 2011 3:45:00 PM, Blogger Maurice Bernstein, M.D. said...

Doug, though I realize that a patient may be on the defensive because the patient is dependent on the medical system to "cure" their symptoms and illness, nevertheless patients will generally not be abandoned by their physicians for "speaking up". A physician, who is part of the system, "speaking up" to others within the system about dissatisfaction with regard to personal treatment has certain professional, political and administrative and even financial impediments to consider. After all, to stir up a pool when you are part of the pool can be a challenge that a physician has to consider. Especially, if the physician is a poor swimmer. ..Maurice.

 
At Thursday, December 29, 2011 5:30:00 PM, Anonymous Anonymous said...

I find it interesting that in business there is a concept that signing a contract under duress nullifies the contract. I recently saw a program where Tom Petty took on the entire recording industry and won because they required him to sign a publishing contract in order to offer him a recording contract....yet, in the most arguably one of the most important and stressful interactions a person may have, that which could end their very life, the patient is soley responsible for this. While it may not be common for a provider to dismiss a patient, the idea of relying on someone you may have offended to keep your best interest at heart is a little unsettling. Now one may argue a provider is above that as a professional, they are the same person who has casued the issue. And if we are expected to see providers as above others in one respect and their ability to remove themselves, why would we not expect the to go above and understand our duress. Providers tend to choose to view themselves as being either just regular people or professionals with special training and abilities as it fits their needs...once again, to those whom much is given, much is expected is easily applied to trust. The same professionals who have developed a reputation for resenting being questioned now blame the patient for not standing up for themselves....alan

 
At Thursday, December 29, 2011 5:58:00 PM, Blogger Maurice Bernstein, M.D. said...

I hope that physicians don't resent being questioned by the patient.. if so, they are in the wrong profession.
Questioning by the patient is an essential part of informed consent. It isn't just consent. It is informed consent. "Informed" means more than a dissertation by the physician. Legally, it also means that the patients understand what they are being informed. Since the doctor can't always guess the patient's uncertainties or misunderstandings about what the doctor has presented as information, it is up to the patient to complete the information process by questioning the physician. When no patient speaks up in the limited time available, the physician has to go on the assumption that his or her disclosure was understood. Perhaps, back in the days of medical paternalism where the patient was expected to accept the directions of the physician, a physician may have been offended on being challenged. However, we are now living in the period of patient autonomy and paternalism has been almost swept away (some feel by too much)..so now physicians must wait for the words of their patients..and hopefully their patients will "speak up". ..Maurice.

 
At Thursday, December 29, 2011 8:42:00 PM, Blogger Doug Capra said...

" nevertheless patients will generally not be abandoned by their physicians for "speaking up". A physician, who is part of the system, "speaking up" to others within the system about dissatisfaction with regard to personal treatment has certain professional, political and administrative and even financial impediments to consider."

I agree with your, Maurice. I provided that article to demonstrate just how powerful the "feeling" of potential abandonment can be for patients. I'm not suggesting the "feeling" is always based upon reality. Sometimes it can be based upon the reality of a past experience. But it is an emotion and it is valid as an emotion and needs to be addressed. Indeed, it is addressed. I was reading the basic consent form for the hospital I go to and on it it says essentially that a patient has the right to refuse treatment he or she is not comfortable with yet still receive necessary treatment without fear of reprisal. Now, why would a document even say something like that unless it's recognized either that patients do indeed feel that way, and/or that patients do occasionally suffer for speaking up.
My experiences have taught me that speaking up is worth the effort and that most doctors will listen and most nurses will advocate for you -- if you speak up with confidence and make your needs known. With those that don't, it's worth going to battle, and if you do, they'll most likely give in. But I just wanted to show how powerful the medical "culture" can be within a hospital -- so powerful that even a doctor feels its weight and is initially hesitant to confront it. Though, I'll bet he won't hesitate to go up against it he observes it again. The question is, though, will it open his eyes to all patients, not just family members. I hope so. I've talked about how professions are socialized to only "see" what the profession considers relevant. Too often, patient modesty and patient embarrassment isn't considered relevant in medical culture, so caregivers have learned not to "see" it.
The example I gave, demonstrates what it takes for a medical professional to actually "see" this modesty issue. It takes a case involving his own loved one. Now he's seen the light.

 
At Friday, December 30, 2011 5:37:00 AM, Anonymous Anonymous said...

I agree with Doug wholeheartedly on this one. Dr. Bernstein, as a doctor, you state that you have never had a patient, male or female, state a modesty concern. That can be due to the reasons Doug stated (patients generally feel reluctant to speak up for reasons given). I also think that in the case of your female patients, the fact that they sought care from a male doctor may mean that they do not object to opposite gender care, as many people don't. So, you may just be in a situation where modesty was never an issue for your particular patient population. I know that I never felt I could speak up about my concern and always just "sucked it up", as infrequently as I went to a doctor. And they obviously never considered that issue (or didn't want to address it) when they noticed how nervous I was. But now that I have found this blog I am likely to voice my concerns in the future should the event present itself. We can also assume that a lot of people are avoiding medical care because of this issue and so you, as a doctor, would never have exposure to these individuals. Jean

 
At Friday, December 30, 2011 9:12:00 AM, Blogger Maurice Bernstein, M.D. said...

I can tell you why I didn't ask patients about modesty issues in advance of the examination.. why I didn't start a conversation.. and why I think other physicians behave likewise. It is because we doctors are carrying with us the modesty guidelines which we learned in medical school and we understand the legal and professional requirements of professional behavior. We also are operating under a now, to me, clearly wrong assumption: patients may have modesty issues but as long as we stick to our set guidelines and requirements at no point, NEVER, will a patient allow modesty to trump the necessity and value of a proper physical examination or procedure to resolve symptoms or disease. If that is really our view of the issue, which I believe it is, then why bring up an "already settled topic". With this as the way the doctor is thinking, it will require the patient to take initiative, bring up the modesty issue and speak their mind. ..Maurice

 
At Friday, December 30, 2011 10:13:00 AM, Anonymous Anonymous said...

Maurice


Some physicians see oath-taking as little more
than a pro-forma ritual with little value beyond that of
upholding tradition.

I'm referring to the oath of hippocrates and one
of the oaths,I will respect the privacy of my patients.

Anyone wanting to read about this worthless
ritual go to www.pbs.org/wgbh/nova/body/Hippocrates-
oath-today-html


PT

 
At Friday, December 30, 2011 11:25:00 AM, Anonymous Anonymous said...

In the end, I wonder what Dr. Senelick realistically felt he had to lose by speaking up. Was it the emotional chiding, or teasing, or even scolding by a fellow caregiver that stopped him? By not wanting to 'upset the spple cart" was he really just feeling the embarrassment of the subject? Was he perhaps afraid that speaking Male-to-Male this subject could actually become a real and dabatable ethical issue? Perhaps he was just denying the years of silently being a part of this same 'get it over with on move on ' treatment.

But would he really be afraid to lose his job or respectable standing in the medical community?

Perhaps it doesn't matter...he has settled his fears and made a very public move. Maybe the line that I find most telling is reassuring his wife that it will never happen again. Guilt is a pretty strong motivator, but a lot of us find that devalueing and humiliating our loved ones a a bigger one.

Suzy

 
At Friday, December 30, 2011 11:33:00 AM, Blogger Maurice Bernstein, M.D. said...

PT, I was not writing my last comment with regard to the Hippocratic Oath either the original or modern versions. (By the way, your link, sadly, goes nowhere.. here is the link to
Wikipedia)

By the way, the "privacy" noted in the Oaths deals with the patient's personal history. Of course, sexual behavior is forbidden but there is no concerns expressed about physical modesty of the patient. ..Maurice.

 
At Friday, December 30, 2011 12:06:00 PM, Blogger Doug Capra said...

"We also are operating under a now, to me, clearly wrong assumption: patients may have modesty issues but as long as we stick to our set guidelines and requirements at no point, NEVER, will a patient allow modesty to trump the necessity and value of a proper physical examination or procedure to resolve symptoms or disease. If that is really our view of the issue, which I believe it is, then why bring up an "already settled topic"."

Maurice: Very interesting observation and, it seems to me, quite valid. What needs to enter into this equation, I believe, is the whole issue of context. Granted, there a minority of patients who would rather die than be exposed to a provider of either gender. But these are so few. There may be some who would rather die that be exposed to the opposite gender. They would probably accept the exposure if only a particular gender were involved. Others may be fine with opposite gender care, but would resent opposite gender observers.
We seem to be stuck on one issue, though. Although I agree that in an ideal world the patient should speak up about his/her needs. But I'm trying to convince you that in most cases this won't happen due to the real or perceived "power" of the medical culture and the patient's embarrassment. So I'm contending that it is the medical profession's responsibility to "allow" the patient the feeling that it's okay to present these issues by providing the clear opportunity, opening up the subject, for the patient to express him/herself about this.

 
At Friday, December 30, 2011 12:28:00 PM, Blogger Maurice Bernstein, M.D. said...

Doug, it will never happen until physicians and other healthcare providers get educated by reading our blogs and others. Because without this education, as I wrote, physicians are going to think "why bring up an already settled topic".

By the way, the issue of patient modesty as a potential risk in medical care, based on a previous thread of mine regarding balancing precaution vs the apparent risk in medical care, has just been published on WWW.KEVINMD.COM blog. It may be worthwhile for some visitors here to go there and "speak up" on that topic. ..Maurce.

 
At Friday, December 30, 2011 12:42:00 PM, Blogger Joel Sherman MD said...

Maurice, you asked for my experience. It is similar to yours that no patient, male or female, has ever expressed modesty concerns to me.
As a cardiologist, I don't do intimate exams so there is less reason for modesty concerns, but certainly women may be exposed above the waist. I am aware that some women are not entirely comfortable with that, but as you say, I have to assume for adults that they expected some exposure at some point and came knowing that. There are no women cardiologists in my community so they have little choice except to avoid exams or go out of town.

 
At Friday, December 30, 2011 2:25:00 PM, Blogger Maurice Bernstein, M.D. said...

Joel, based on what I've read here, I would say that the gender of the tech doing the echocardiogram or less likely the EKG would be of patient concern. Also, how the patient is attired or undressed to undergo coronary angiography or coronary stent placement would also be of concern.

I just can't imagine any patient suffering chest pain from an suspected acute coronary artery syndrome worrying about how they are dressed or undressed or uncovered during diagnostic or therapeutic cardio-vascular procedures. On the other hand.. based on some of the comments here, maybe I should imagine! ..Maurice.

 
At Friday, December 30, 2011 4:23:00 PM, Anonymous Anonymous said...

Dr. Sherman's post on KevinMD's blog was mentioned on Trisha Torreys patient advocate blog. Dr, Berstein posted on the same. There is an interesting book called the Tipping Point that talks about how the internet has opened a whole new phenonmina on how information spreads, it speaks of seeds that grow. Think of these articles on this issue, how many vs the previous 10 years? The seed has been planted.

While those who would face death rather than being exposed the the opposite gender, I would lay money, a large number would admit to avoiding or delaying procedures or testing and modesty concerns played a part in it. It is suggested people get a colonosocopy at 50, now it has to be covered in insurance policies by law, yet how many avoid it due to embarassment. As we discussed if you look at the extremes, the ER, having chest pains, etc. you will get a different reaction from the same people as when you look at the normal more frequent issues, colonoscopies, vasectomies, physicals, pap smears, etc. And, while the number who die vs seeking help due to modesty may be small, what do you think the number whose illnesses were made worse by delays or died because they waited to long and modesty was a contributing factor is? I put up with all sorts of pain and discomfort as well as inconvienece for years because I could not bring myself to face the humiliation I antcipated to deal with hemmroids. Its still uncomfortable to talk about it...I wasn't afraid of the procedure, the pain, or anything else, the fear of the humiliation and opposite gender exposure kept me away...think that is uncommon? Chest pains thinking I was having a heart attack I'm on my way to the ER, but before I became a little more enlightened, I would avoid seeking care for embarassing things (opposite gender exposure) as long as I possibly could.

Dr. Bernstein, I understand recently we been encouraged to question and get second opinions, which is why I used the term "reputation for"

 
At Friday, December 30, 2011 6:55:00 PM, Anonymous Anonymous said...

Maurice


The oath mentioned nothing about physical modesty,
only privacy, which can be construed in a number of
ways.
The link I provided was from a program called
Nova, and my point simply was to illustrate that the
modesty guidelines taught in medical school as well
as the legal and professional requirements of
professional behavior seem to be different from
one practitioner to another or the lack of.

PT

 
At Friday, December 30, 2011 9:46:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, in the realistic and present day world of medical practice, the way medicine is practiced both in terms of emphasis or de-emphasis of oaths, medical school teachings and established legal and professional requirements are going to be different between one physician and another. There are going to be shortcuts and at times excesses depending on the situation and even the mood of the physician. Doctors are going to take chances or they will strictly follow what they believe are standard operating procedures ("standards of practice"). Yes,the Oaths are there, the laws and professional requirements and all the tools for professional behavior as provided by the medical schools are there but in the end, each doctor in their own professional environment will obey them as they see fit at the time. And it is up to their patients and their colleagues to finally grade the doctor. ..Maurice.

 
At Saturday, December 31, 2011 7:55:00 AM, Anonymous Anonymous said...

I’ll believe the medical profession and the courts are serious about holding females accountable when they commit sexual assault on men when Twana Sparks is in prison and the hospitals admins who knew and the OR nurses that saw this and did nothing (except laugh) are fired and have their licenses revoked.

http://www.outpatientsurgery.net/resources/forms/2010/pdf/OutpatientSurgeryMagazine_1001_ent.pdf

Suzy even wrote about this (which I do thank you for) but only received 3 comments. I guess its no big deal since men were the victims.

http://patientmodestysolutions.blogspot.com/2011/01/sparks-are-still-flying_8076.html

 
At Sunday, January 01, 2012 10:01:00 AM, Anonymous Anonymous said...

the issue of male modesty has been debated here and elsewhere. I think it is a subcatagory of the bigger issue. Men do face additional issues in this both from the gender dispairity of healthcare workers and the attitude. I really wish Terry had willing and able to stay, her statement that in healthcare females are considered gender nuetral, males are not tracks with what we see in society. The earlier post about the two girls stripping and mocking a boy in Fla is an example, would if have mattered if the mother didn;t press charges if two boys had done this. I actually partciapted in the blog and wrote the hospital that was involved with the sparks offense, there is no way a male Dr would have walked from this, the one nurse who did blow the whistle ended up fired for other issues, she was suing the last I knew. That said, the issue of male modesty in my opinion will go further and faster if it is part of the larger issue rather than attempting to push it on its own. Lets face it, men are not as good at speaking up, partly becasue we didn't have to and partly because society has turned a deaf ear to the problems of males since we are considered to have it all. Partnering to solve the whole issue will provide opportunity to address the seperate issue of male modesty....alan

 
At Sunday, January 01, 2012 11:34:00 AM, Anonymous Anonymous said...

alan:

I agree with all that you say. Working together is the only solution.
Here is one lingering thought: I often come back to this and wonder if it may be the unique challange we face with male modesty:
Society believes men can not suffer from "unwelcome sexual attention".
The laws are clear. It does not state that gender denotes anything regarding unwelcome attention, leering, touching, abuse, battery, rape, or even uncomfortable circumstances. Yet women are EXPECTED to not put up with it, and men are EXPECTED to not only take it, but revel in it;enjoy it; and certainly not ever be offended by it.
Until society admits that men can be hurt, offended, humiliated, taken advantage of, and abused at the same personal level as women, will there not always be a bit of a disparity in modesty rights?
Should we keep this in mind while advocating...or simply state:

ALL PEOPLE: REGARDLESS OF AGE, GENDER, RACE, ETHNICITY, CREED, OR SEXUAL ORIENTATION,DESERVE THE SAME RIGHTS AND RESPECT TO SAFE AND DIGNIFIED CARE.

Guys, as a woman, am I looking at this wrong?

Suzy

 
At Sunday, January 01, 2012 2:00:00 PM, Blogger Doug Capra said...

"ALL PEOPLE: REGARDLESS OF AGE, GENDER, RACE, ETHNICITY, CREED, OR SEXUAL ORIENTATION,DESERVE THE SAME RIGHTS AND RESPECT TO SAFE AND DIGNIFIED CARE."

suzy -- The essence of what you state above is contained in the law. One problem is, most men aren't willing to fight it. It's considered unmanly, not macho, and most certainly, politically incorrect. I wonder how many men that Dr. Twana Sparks assaulted either pressed criminal or civil charges. Has anyone checked? I'll bet none of them did. In the case with the middle school boy who was stripped by middle school girls and exposed on the web -- they key is that his parents didn't pursue in court. No criminal charges? They certainly could have gone for civil charges, pain, suffering, etc. -- made the other parents "pay." But they didn't. I think we'd be surprised how the courts would stand behind men and boys if they would only use the courts.
Another point. The recent nurse, Terry, who showed up here and disappeared -- I have no way of knowing why she hasn't returned so I'm just making an educated guess. But my experience is that a significant number of medical professionals just don't what to "discuss" this issue. Like Terry, they have their opinion, and that's that. When confronted with valid questions that challenge their point of view, they just don't what to engage. I surmise they just don't find the subject worth debating. That's what may have happened. If not, and Terry is still reading these posts, I'd encourage her to really engage in this discussion civilly with us and be willing respond to civil challenges to her opinions.

 
At Sunday, January 01, 2012 8:35:00 PM, Blogger Maurice Bernstein, M.D. said...

You may be interested in joining the current conversation ("Do Oaths and Rules Make a Good Doctor") with my visitor Moofie on a topic I put up as a take off on my comment here about the Oath and rules and laws and what beyond these regulations really would determine which doctor is a "good" doctor. ..Maurice.

 
At Sunday, January 01, 2012 9:18:00 PM, Anonymous Anonymous said...

I spent the past year dating a former doctor. When I asked him about examining females, he made a typical response, once which I see echoed on medical students blogs everywhere; "Not all patients are hot 21 year olds," he said. Then he said that when he learned pelvics,the women were "Old, like seventy-something." I said, "They're still people, aren't they?" To which he remained silent.

Horrible that this is the typical HONEST response if you talk to guys in medicine today. Which just shows there will always be an element of sexuality present in any kind of a male/female female/male exam.

Also, I also still hear, from doctors and nurses, that they are "OK" with examining patients of either gender. My sister,who is an RN was musing about how she would feel examining men's penises in her new job for planned parenthood. I say what about how the poor guy feels?

Docs and nurses still don't get it; its not about them, it's about the patient.

Anne

 
At Sunday, January 01, 2012 9:34:00 PM, Anonymous Anonymous said...

Drs Maurice and Joel:

Joel, you express that it's hard to imagine "a patient"- you don't say woman, being uncomfortable with ekg/heart procedures and Maurice, you say you can't imagine "any patient" - (you don't say woman which shows you are not thinking of patients as people) with a severe heart problem even thinking about modesty concerns. Well, neither of you have breasts! How would you feel about a female attaching electrodes to your penis or a female doctor dong a procedure there? Why are you forgetting that a women's breasts are sexual organs? Why does society not recognize this? I think it's because it's more comfortable for people in the medical profession not to. Anne

 
At Sunday, January 01, 2012 10:01:00 PM, Blogger Maurice Bernstein, M.D. said...

Anne, my medical students are taught about female modesty concerns when examining the breasts by inspection or palpation and to keep the breasts covered until uncovering is needed for examination. Also, to avoid unnecessary touching of the female patient's breast. For example, to examine beneath the patient's breast we advise the students to have the patient herself elevate her breast rather than the students elevating the breast themselves. Or if it is necessary for the student to elevate the breast themselves, to elevate with the dorsum (top) of the hand rather than cupping the breast. Why do we go into all of this detail in technique with our students? It is simply because we are not forgetting that modesty and sexuality issues are of concern. So, yes..for females we do have an understanding of the sexuality of female breasts otherwise we would examine female breasts just like examining males. ..Maurice.

 
At Monday, January 02, 2012 6:12:00 AM, Blogger Joel Sherman MD said...

Anne, I have no idea what you're referring to. My only post on this thread says, 'patient, both male and female.' And I didn't use the word 'imagine.'

 
At Monday, January 02, 2012 9:49:00 AM, Anonymous Anonymous said...

In 2005, there were 918,000 physicians in the United
States. At that time there were about 2.3 million
registered nurses and 700,000 licensed practical nurses,
thus about 3 nurses for every physician.

There are very few physician associations in the
united states,yet thousands of nursing associations.
As an example, here are a few.

American association of colleges of nursing
American association of critical care nurses
American nurses association

The list goes on for another 387

Then the list starts again for another 256

Association for black nurses,one in every major city
Association for Hispanic nurses.
Association for Asian nurses
Association for native American nurses
Association for Indian nurses

Why are there so many nursing associations and
what are their functions. Interesting thing about these
associations are that not one of them mentions anything
about patients, it's all about nurses,it's all about them.

PT

 
At Monday, January 02, 2012 11:27:00 AM, Blogger Maurice Bernstein, M.D. said...

I thought the following comment which was published today on my "I Hate Doctors: Chapter 3" thread would be pertinent for this patient modesty thread, so I have copied it here. ..Maurice.



I’m not an MD, but I’m a nursing student. In one of my classes, a lawyer from my university’s medical center spoke with us about legal issues that we may encounter in the future. I remember him speaking about assaults and warned us to never touch a patient if a patient tells us not to touch them. Any unwanted physical contact would be considered assault even if it’s just a harmless, light touch on the hand. I read a story on this blog about a woman who did not want residents touching her or examining her as she was going into labor, but felt that she had no choice or say in the matter. After reading this, I immediately thought that this would be considered an assault. There was no medical need for residents to examine her. It was just practice for the residents. She went on to write that no lawyer would take the case because it was considered standard procedure. No lawyer would take the case, because lawyers are after money and this would be difficult to get a sizeable settlement, but she could have gone to the police and speak to them about her concerns. The police can charge a person for assault and the DA’s office can prosecute. Large hospitals usually have the actual police on site.

On another note, nursing students must complete an L&D clinical. We’re paired with an L&D nurse and we shadow them during their shift. Nursing instructors know that some women are uncomfortable with a male nursing student especially when they are giving birth, but here’s the dilemma, male nursing students must also complete the L&D clinical. To solve this problem, nursing instructors just don’t ask women if they are okay with a male nursing student taking care of them, but the women can refuse and I hope women know they can refuse. They just have to speak up.

Please don’t assume that just because someone is well-educated and has a professional degree, that he or she will have the highest moral values. I worked for a female anesthesia attending at a large university teaching hospital and she experiences sexual harassment constantly from so-called peers. She is mostly in the OR and has described the OR as a male locker room. If surgical attendings don’t treat their peers with respect, why should patients expect anything different from attendings or maybe even residents?

In one of my nursing classes, we have to learn to give breast exams. I’m not sure when nurses will have to perform this exam, but I had to learn it and practiced on a prosthetic breast. We were placed into groups of four and there was a male nursing student in my group. He seemed to enjoy giving a breast exam too much and had a very perverted look on his face. We were all supposed to take turns giving the breast exam, but he wouldn’t let anyone else near the prosthetic breast. I was the only one who spoke up. I told him he looked like a pervert and the rest of the female nursing students need to practice as well. The other female nursing students thought I was too sensitive and quickly dismissed my concerns that this guy was being a pervert. After my outburst, this guy became the most considerate and reserved guy towards the female manekins.

SN

 
At Monday, January 02, 2012 4:04:00 PM, Anonymous Anonymous said...

Suzy I think you are on the money with your statements. Awhile back there was a thread on allnurse where one nurse in paticular made the statement that all men are basically perverts and like pretty young nurses taking care of their intimate needs. When I challenged it that I did not she basically said I was a lier or odd. I think your take on it is one of the major issues that drives this for males. Look at the post from the why I hate doctors post, three examples of invasions, 3 female patients being vicitims and 3 male violators, including a pervert male student.
There appear to be a lot of things contributing to this paticular aspect of the issue. The view that men don't care or even like it is deffinately one, the view that female providers are gender nuetral and male providers are potential molesters, is another. I live in a small town, the only male nurse at our hospital not only quit the hospital, but the profession. I asked him why, he shrugged and said a lot of reasons, mainly I got tired of being treated different like I couldn't be allowed to do what they do, I wasn't one of the girls, after awhile I just gave up. I hate our letigonous society, but perhaps its time to do what women had to to gain ground, sue them and put the fear of a lawsuit in their mind, it seems to work. I hate that, but really, its what seems to get their attention.,,,alan

 
At Monday, January 02, 2012 4:44:00 PM, Blogger Jim said...

Here we go again with the gender double standard relating to sexual abuse!
If Twana Sparks was a male doctor and the patient was female....the doctors license would have been revoked for good! (and that would imho be the appropriate response!!!
http://www.outpatientsurgery.net/resources/forms/2010/pdf/OutpatientSurgeryMagazine_1001_ent.pdf

 
At Monday, January 02, 2012 6:39:00 PM, Blogger Jim said...

Maurice,
I have a serious and practical suggestion for you to give you students based on my personal experience.
Please have the doctors ask the patients to lower their own underwear...there is a violating feeling and loss of control when it "is done" by the doctor. I am male, but I think this would be helpful for both genders. I've had doctors do it both ways....and I feel much more in control and respected when I am asked to do it.
Another two cents,
thanks,
Jim

 
At Tuesday, January 03, 2012 6:11:00 AM, Anonymous Anonymous said...

Jim, While I understand and agree with, that lowering your own clothing gives you control, in some patients, however, they end up feeling like they contributed to their own humiliation.

It is similar to an abducted person being asked to strip themselves instead of others.

Nobody knows how they will feel because we are all different and so are our experiences.

Therefore, it is up to the MD to explain what is going to happen and who will be in the room when it happens. Then, ask the patient if they are in agreement and give them the choice of how things will be done.
belinda

 
At Tuesday, January 03, 2012 8:10:00 AM, Blogger Jim said...

Belinda,
Good point. We are all different and our personal experience colors our perspective. (As i explained above, I was traumatized by a doctor that undressed me when I was 12 years old.) However, asking if the patient is "in agreement" is a formality in most cases, because, as discussed above, the patient is "under duress" and most would never say "No" or disagree with a doctor.
I guess the bottom line is doctors need to treat patients with respect and include the patient by explaining "what" and "why".
I once went to a doctor that, while examining the genital area, kept saying "I'm sorry, I'm sorry...I know this isn't pleasant (he did not know my history)to me that was over the top...I was thinking...you shouldn't be "sorry" unless you doing something wrong or maybe, he was uncomfortable....Hmmmnn

 
At Tuesday, January 03, 2012 11:25:00 AM, Blogger Maurice Bernstein, M.D. said...

Jim, we teach that all patients, who have capacity, should be asked to remove clothing themselves. In case of degrees of incapacity, patients are asked whether the student should help them and the student responds appropriately to the answer. Remember, that though society gives physicians the permission to examine a patient's body, that examination can only be carried out in its various aspects with the approval (consent) of the patient. We teach that and we physicians all know that. If patients observe some other behavior in actual practice, then the observation should be made known. ..Maurice.

 
At Tuesday, January 03, 2012 11:56:00 AM, Blogger Jim said...

I wonder if pediatricians are taught to see their patients as "having capacity," whether parents' are in the room or not?
Jim

 
At Tuesday, January 03, 2012 12:56:00 PM, Blogger Joel Sherman MD said...

We have posted a new article on an important but rarely discussed subject, the modesty of young children. Please take a look and add your comments.

 
At Wednesday, January 04, 2012 6:18:00 AM, Anonymous Anonymous said...

I am curious to know if Mark is still checking in on this blog. If my memory serves me correctly, he was to have a meeting on Jan. 3 with the administrators of the facility where he had his procedure to address his concerns. If this happened, I (and I'm sure others here) would be interested to hear what the outcome of that meeting was. Jean

 
At Wednesday, January 04, 2012 5:25:00 PM, Anonymous Anonymous said...

Jean, you are right, I did meet with them. It went well. It started with an apology and then we discussed my issues. In the end they thanked me for being the poster child for male dignity. (I was the first man to talk to them and they appreciated it.) They are going to change procedures and protocols based on my input. They promise to give me written updates and include me on reviews of the changes. Of course now we wait to see if things really change. 

This should be encouragement to everyone to speak up. 

Mark

 
At Wednesday, January 04, 2012 7:12:00 PM, Anonymous Anonymous said...

Mark, thanks for the update. What did they say about the conduct of the first nurse, the grinning smiling one? What was the explanation of why the second nurse was there? Did you ask if an all male team was available and if it wasn't why don't they hire more male nurses? Can you provide more details about what was said at the meeting? I would really appreciate it. Alex

 
At Thursday, January 05, 2012 5:44:00 AM, Anonymous Anonymous said...

Mark

I had the very similar experience with my ultra sound. I was very encouraged not only by what the did, but the attitude toward me bringing the issue forward. The question now is how to get more men to step forward. Suzy and I are working on a website that we hope to lever to become more interactive with providers. If anyone wants to move from posting to becoming engaged in the process you are invited to join in at the link Dr. Bernstein has posted above....alan

 
At Thursday, January 05, 2012 7:57:00 AM, Blogger Jim said...

Mark,
Thank you for following up and pursuing change at that facility.
Your experience reminds me of when I had to have a lump check on my chest (read mammogram) I AM A MALE....but the only place to send me was a womans clinic that that did mammograms. It wasn't awkward in the exposure sense because I only had to take off my shirt.....BUT the staff was so awkward..they had no idea what to do with me...they didn't want me in the waiting room so they had me wait in an x-ray room that wasn't being used ...then the machine wasn't designed for a mans chest so the technician had some trouble getting a good image...then they needed to do a sonogram to double check the results....more awkward. the technician and the doctor seemed flustered....fortunately the results were negative. BUT I get my annual reminders (unnecessary in my case and a little humorous to me). And yes everyone there was female!
Jim

 
At Thursday, January 05, 2012 10:45:00 AM, Anonymous Anonymous said...

Excellant post alan. If we could get permission from Mark and others to publish these new protocals and updates,(including the Facility's name) it would be much more encouraging than publishing the bad/humiliating stories.
Each website has it's followers and serves a specific audience purpose, but I wonder if it might be a good idea to reference the other website and have people come to our blog and post how they would make it better. How it might serve more needs that we share here. It may help with the real change we are seeking. ?

Suzy

 
At Thursday, January 05, 2012 11:41:00 AM, Anonymous Anonymous said...

Alan, it seems very few men speak up to those who can change things. 

46% of the nurses in the military are male. (A small number considering the ratio of men in the military.) With the reduced overseas presence, many of these male nurses are returning to private life. I wrote to my congressman Frank Wolf to ask that these men be encouraged to use their medical background in the public medical system. As they leave the service they could receive counseling and job placement help. This is a near instant source of trained and experienced male nurses. No response yet from him. It would help if others wrote. 

Mark

 
At Thursday, January 05, 2012 5:06:00 PM, Anonymous Anonymous said...

Mark

Great idea, now this is what we need to gravatate to. My congressmen is big into veterens affairs, the just opened a new VA clinic near me, I am going to fire off a letter suggesting he look into this immediately...alan

 
At Friday, January 06, 2012 9:01:00 AM, Blogger Maurice Bernstein, M.D. said...

A little step forward: From CNN today-

Washington (CNN) -- The Justice Department announced Friday that it is expanding its decades-old definition of rape to include attacks against men.
Now, any kind of nonconsensual penetration, no matter the gender of the attacker or victim, will constitute rape.
The crime of rape will now be defined as "penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim," the Justice Department said.


Wouldn't you say that for the United States..this change in the definition of rape is about time! ..Maurice.

 
At Friday, January 06, 2012 10:39:00 AM, Anonymous Anonymous said...

would it not seem to be common sense, does not the fact that it is 2011 and we are just making that change say something. The double standard in this area is a contributor to what we are discussing here from teenage girls forcibly stripping and taunting a weeping boy walking away without charges to the different penalties handed female vs male teachers who have sex with student. The double standard is obvious, just as obvious as the answer, men need to stand up challenge and if needed file suit. Males do lack one very important ally in this, the media. The media has found a great hot button issue championing womens causes but very rarely mens. So it's up to guys to hold them accountable. My local TV station ran numerous breast cancer spots during November which was prostate awareness month, nothing on prostate cancer. A local male elementary school teacher got notice when he had his students wear mustaches as a fund raiser, when interviewed he made the statement, I just thought it was important for everyone, especially young men to know women are not the only ones with important health issues....we should all take notice and follow the lead...alan

 
At Friday, January 06, 2012 11:10:00 AM, Blogger Doug Capra said...

Maurice: Absolutely, it's about time. But, to me, the striking thing about this is that the change is just happening now. It shows how far behind we are regarding men's rights in areas like this -- and adds evidence to the difficulty men can have regarding modesty attitudes in the medical community. Consider, for example, a man who is assaulted in the manner described above -- going to the ER somewhere. How will he be treated? Will the ER report his assault as just an assault or a rape? What attitude might they have? I'm not suggesting they won't be professional in treating him. But the word "rape" has more power to it than the word "assault," and that could make a difference in how the whole case is viewed.

 
At Friday, January 06, 2012 4:15:00 PM, Anonymous StayingFit said...

I agree that the new definition of rape, though still imperfect, is an improvement. Please bear in mind, though, that this definition is used for reporting purposes, only. It does not directly change the way that local law enforcement investigates or prosecutes allegations of rape. It also does not force the police to file a case as an alleged rape. So, along with convincing the medical staff to treat a man as a victim of rape, the police will have to be convinced to do so, as well. And, of course, there is still the difficulty of getting a man to admit that he had been victimized in this way.

I will also be very interested to see if this changes anything in our prisons. I have seen some estimates that place the number of men raped in prison each year to be close to 140,000, a figure that exceeds the number of women raped each year. I will believe that society's attitude has changed when this is cause for prison reform, instead of jokes by late-night comedians. The definitional change for rape makes me cautiously optimistic, and is, at a minimum, a good first step.

However, I also noticed that the new definition of rape includes the following:

“It also says if a victim cannot give consent for any reason, the crime is a rape even if force is not used. That includes any victim who cannot consent due to alcohol or drug use.”

I have to wonder at the practical implications of this. For instance, if both parties have been drinking, could one of them still be accused of rape? Also, how much alcohol must someone consume before they are deemed unable to consent? Is everyone who ever had a couple of drinks at a bar and awoke to a bad case of the “oh no's” now considered a rape victim? The misapplication of this portion of the definition could harm men more than the other improvements would help them, and could reinforce the very same stereotypes that the recognition of men as rape victims might have helped to dispel.

 
At Friday, January 06, 2012 4:45:00 PM, Blogger Joel Sherman MD said...

StayingFit, you're right that interpreting any sex under the influence of alcohol as rape could hurt men, but your other comments also apply, i.e. this is for reporting purposes only.
This scenario happens all the time on college campuses and is responsible for the very high rape statistics that feminists talk of. But criminal convictions for rape on campuses are low because drunken recollections of assaults are very difficult to prove. Few of these cases are ever prosecuted.

 
At Saturday, January 07, 2012 4:17:00 AM, Blogger Hexanchus said...

Agree that the federal guidelines are for reporting purposes only.

Sexual assault crimes are defined by state law. Many have a crime called "unlawful sexual penetration". The caveat is that most of these laws have defined exceptions that clearly protect medical personnel in the course of an exam or treatment. My state, for example, lists the following exemptions:

(1) The penetration is part of a medically recognized treatment or diagnostic procedure; or

(2) The penetration is accomplished by a peace officer or a corrections officer acting in official capacity, or by medical personnel at the request of such an officer, in order to search for weapons, contraband or evidence of crime.

 
At Saturday, January 07, 2012 8:02:00 AM, Anonymous Anonymous said...


“It also says if a victim cannot give consent for any reason, the crime is a rape even if force is not used. That includes any victim who cannot consent due to alcohol or drug use.”


StayingFit wonders who would be charged with rape if a man and woman are both blotto when they have sex. Well, that is the purpose of defining rape as "penetration" alone, exempting "envelopment" as a crime. Under this definition, only the man has penetrated, so only the man gets charged. Radical feminists have been fighting for these changes...nuff said. For instance, a 40-yr.-old woman does not "rape" a 10-yr.-old boy since she didn't penetrate him.
--rsl

 
At Saturday, January 07, 2012 11:04:00 AM, Blogger Suzy Furno-Maricle said...

rsl:
'The crime of rape will be defined as "penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim" '

I think it has always been theoretically clear that a female can rape a male, but now with the words in place society will not be able to easily reject it. Without being too graphic and with the continual respect to Dr. Berstein's blog: "no matter how slight" gives us the clue that it is written to cover many biological intrusions. And although (what I read) may be vague, the term "oral penetration" does not imply automatatic guilt of inflictor (sp) or inflicted. One could read that as "She forced me to participate in oral penetration" just as easily as "He forced me to participate in oral penetration".

Suzy

 
At Saturday, January 07, 2012 11:43:00 AM, Blogger Doug Capra said...

Here's an interesting discussion of the new rape law. It's more complicated that it seems. Although a move in the right direction, it still may not be enough.
http://toysoldier.wordpress.com/2011/10/20/fbi-expands-rape-definition-kind-of/

 
At Saturday, January 07, 2012 11:55:00 AM, Blogger Doug Capra said...

Here's an interesting quote from an article worth reading:

"Sexual assault of children by women is underreported because patriarchal, cultures don’t like admitting that women can be sexually motivated or use sex to wield power in aggressive and monstrous ways. That would mean admitting that some women are more “like men,” not the champions of a higher morality, not weaker, not all naturally more “nurturing.” That’s a lot of subversive information if you want to highlight how vulnerable and dependent women are. In addition, in the same environments, boys grow up knowing that to be weak or powerless in particularly when the aggressor is female is a big no-no."

I hope you can all see how this is intimately connected to male modesty. You'll find the article on this very interesting site:
http://goodmenproject.com/gender-sexuality/rape-culture-men-women-power/

 
At Saturday, January 07, 2012 12:47:00 PM, Anonymous Anonymous said...

Everything I write on here is a direct reflection of the problems that exist in healthcare regarding modesty and damage from violations of such.

Rape is any definition no matter who it happens to is a terrible thing.
However, it's not the only thing that causes severe issues with mental health.

Enclosed here is a pertinent article that deals with cruel and degrading treatment, loss of control and other such issues. I hope you will find the study both informative and interesting.

http://www.eurekalert.org/pub_releases/2007-03/jaaj-pap030107.php

belinda

 
At Saturday, January 07, 2012 1:27:00 PM, Blogger Suzy Furno-Maricle said...

Doug:
When I wrote the article “Are Women Ready to Sexually "Come Out" Of The Medical Cultural Closet?” I was bombarded with hate e-mail. Half was from men who wanted to still believe that there are “women you take home to mother, and women you just take home”. Hmmm…Take all of those women and throw us in a room and you will find that each one of us is both. Ironic but true, and that tells us a lot about how society wants to see women no matter how they are faced with the facts.
By the way, the other half was from women who consider me a traitor to our gender.
Part of the rest of the male modesty issue depends on how men see gender-neutral and how women see gender-neutral.
Perhaps as an experiment, we could do a “He Said..She Said” and see where the disparity in perception lies.

Suzy

 
At Saturday, January 07, 2012 3:02:00 PM, Blogger Maurice Bernstein, M.D. said...

I would, based on my personal experience, call myself "gender neutral" for caregiver gender in my role of a patient under the care of physicians and nurses. Yes, I have had physical examination by opposite gender physician and "intimate" nursing care by opposite gender nurses and yet I had no thoughts of abuse or sexuality but only considerations of my own medical condition. This was because all parties were performing professionally and getting their jobs done. That is why, as a physician, particularly having not received any feedback by patients to the contrary, I felt that they were gender neutral as I was and I never considered that despite the job that I and other providers performed professionally still brought up thoughts by the patients of caregiver gender mismatch, unprofessional invasion of privacy or sexual abuse. Never. This thread has truly been a learning experience for me and since reading the responses, I now have thoughts as I examine a patient on the exam table as to what uncomfortable feelings is this patient having beyond their symptoms but about me as the examiner. No.. I haven't gotten to the point of presenting all the modesty concerns described here as introductory quizzing of the patient prior to any examination. Why not? Because I am still not sure whether what is described on this thread represents a statistical outlier phenomenon and my quizzing the patient would only introduce an unnecessary concern to the majority of patients who themselves have enough in terms of medical issues to be concerned.

You may want to argue this point..but this is my opinion and the way I work. Show me statistics that confirm that virtually every patient will require provider gender selection to allow a comfortable but thorough examination and then my communication with that patient on the office or examination table will change. ..Maurice.

 
At Saturday, January 07, 2012 5:51:00 PM, Blogger Doug Capra said...

"Show me statistics that confirm that virtually every patient will require provider gender selection to allow a comfortable but thorough examination and then my communication with that patient on the office or examination table will change. ..Maurice."

In all these volumes, I'm not sure anyone has suggested that "virtually every patient" will "require" this. I believe we're dealing with a minority of patients, but what could be a significant minority. Does this minority deserve patient-centered care to match their values? Most medical ethical guidelines suggested they do?
The problem is, and you give me the answer to this question: How do you know which ones require provider gender selection, which ones might want it, which ones don't need it -- unless you ask? How do you know? Is there some other method I'm unaware of? I suppose you can make an educated guess based upon patient behavior -- but that would still be a guess. This is epistemology. How do doctors "know" what they "know" about patient modesty? Indeed, what do they claim to "know?" Or, do some regard the whole topic as something not worth knowing? Does patient modesty not exist to some of them as a relevant concept? You ask to see the statistics. They're not out there. We don't have them. Why? Is it because there's not interest in "knowing" the statistics? If there is no interest, what does that say about the relevance of the issue in within the profession?
Of course, you can assume that, if patients require provider gender selection they'll ask for it. And when patients are empowered to make that gender selection, a significant number of them do. But as we've discussed, there a significant difference between the choice relationship a patient has with his or her personal physician, and what one encounters when one is sent to specialists and then to the hospital. I thought we've made a strong case that, under the circumstances, considering the contexts of alien environments and strange caregivers, and the power of a hospital's institutional culture, mosts patients won't "upset the apple cart," as the doctor said, whose article I quoted a few posts back.
No -- we can, at least you and I -- that all patients don't require this. No one to my knowledge is stating that. I'm certainly not.
But as I've said in the past, I don't think it's a question of a fixed stance for every patient under all circumstances. How many if not most patients feel about this issues is fluid and changes depending upon how respected and safe they feel, and that can change from context to context. My contention is that, someone who says they don't care about gender one way or other -- might quickly change that stance if they feel they're being disrespected and humiliated. And vice a versa -- someone who thinks they care about gender, may conclude it doesn't matter if they encounter empathetic, thoughtful, respectful care.
I don't think this issue is as simple as some people make it out to be. It's as complicated as human nature.

 
At Saturday, January 07, 2012 8:39:00 PM, Anonymous Anonymous said...

A funny thing happened over the last 20 some odd years
ago. Nurses stopped wearing skirts and started wearing
pants, scrub pants. I suppose that by wearing pants they
appear more male like, more gender neutral appearing
and they can say they put their pants on just like the
males do.


PT

 
At Saturday, January 07, 2012 8:58:00 PM, Blogger Maurice Bernstein, M.D. said...

I am wondering whether we should put too wide interpretation into what is simply a medical professional's business suit. On the other hand, in fact, I am concerned about the over-use by doctors and nurses and techs and others of scrub suits. I have seen hospital workers walking down out of the hospital to a local eatery with those suits on. I have always wondered what are they trying to prove? Ah! ..but that's another topic..or is it? Maybe PT is on to something. ..Maurice.

 
At Sunday, January 08, 2012 7:01:00 AM, Anonymous Anonymous said...

Maurice,

We are all a sum of our parts. You are saying that you are gender neutral when it comes to who cares for you. Part of who you are was raised in this culture.

It is human nature based on society's norms and what we are taught for more people than not, to want same gender care for intimate exams or for a restroom attendant in a hotel.

You have been trained to be neutral and therefore, it is my strong opinion, that because you are a sum of your parts that you have this attitude (that I think is very healthy and wished we all could share).

It is also (and I have said this before) that you have no history of cruel and degrading treatment, sexual abuse or other issue with the healthcare system and that most of us have.

Think of the most humiliating thing that could happen to you, and then let it happen in a very public way. For some, it is to be publicly stripped naked (the things that nightmares make and commonly so) or...something else.

Whatever pushes your buttons you would to any length possible to avoid it from happening again.

You might remember in a former post, that I was just like you. The gender of the provider wasn't questioned, thought about and there was no embarrassment about anything medical until....

It would be interesting to know what you think about this.
belinda

 
At Sunday, January 08, 2012 7:04:00 AM, Anonymous Anonymous said...

Hospital gowns are a way of dehumanizing the patient and hospital scrubs are used to evoke feeling of power and control.

It is preposterous that medical workers wear these things on the street (including the booties) and ten walk into the OR after lunch.

That's why when I go to the hospital I will never wear (and never have) a hospital gown and if I must, scrubs will do, thank you.
belinda

 
At Sunday, January 08, 2012 1:06:00 PM, Blogger Doug Capra said...

"Show me statistics that confirm that virtually every patient will require provider gender selection to allow a comfortable but thorough examination and then my communication with that patient on the office or examination table will change. ..Maurice."

Maurice: In all these volumes, I don't think anyone has suggested that "virtually every patient" will "require" this. I believe we're dealing with a minority of patients, but what could be a significant minority. Does this minority deserve patient-centered care to match their values? Most medical ethical guidelines suggested they do?
The problem is, and you give me the answer to this question: How do you know which ones require provider gender selection, which ones may want it, which ones don't need it -- unless you ask? How do you know? Is there some other method I'm unaware of? I suppose you can make an educated guess based upon patient behavior -- but that would still be a guess. This is epistemology. How do doctors "know" what they "know" about patient modesty? Indeed, what do they claim to "know?" Or, do some regard the whole topic as something not worth knowing? Does patient modesty not exist to some of them as a relevant concept? You ask to see the statistics. They're not out there. We don't have them. Why? Is it because there's not interest in "knowing" the statistics? If there is no interest, what does that say about the relevance of the issue in within the profession?
Of course, you can assume that, if patients require provider gender selection they'll ask for it. And when patients are empowered to make that gender selection, a significant number of them do. But as we've discussed, there a significant difference between the choice relationship a patient has with his or her personal physician, and what one encounters when one is sent to specialists and then to the hospital. I thought we've made a strong case that, under the circumstances, considering the contexts of alien environments and strange caregivers, and the power of a hospital's institutional culture, mosts patients won't "upset the apple cart," as the doctor said, whose article I quoted a few posts back.
No -- we can, at least you and I -- that all patients don't require this. No one to my knowledge is stating that. I'm certainly not.
But as I've said in the past, I don't think it's a question of a fixed stance for every patient under all circumstances. How many if not most patients feel about this issues is fluid and changes depending upon how respected and safe they feel, and that can change from context to context. My contention is that, someone who says they don't care about gender one way or other -- might quickly change that stance if they feel they're being disrespected and humiliated. And vice a versa -- someone who thinks they care about gender, may conclude it doesn't matter if they encounter empathetic, thoughtful, respectful care.
I don't think this issue is as simple as some people make it out to be. It's as complicated as human nature.

 
At Sunday, January 08, 2012 2:43:00 PM, Blogger Maurice Bernstein, M.D. said...

Doug, of course I don't know " which ones require provider gender selection, which ones may want it, which ones don't need it -- unless you ask?" But, if those who "want it" and represent a gross minority of the patient population and don't themselves bring it up, I worry about personally and verbally initiating a doctor-patient relationship with the asking of the question "how do you feel about which gender caregiver will take care of you?" It is kind of "rocking the boat" needlessly at that point because if the patient strongly didn't want me as a male physician they certainly would not have made the appointment. That decision is not influenced by a power differential but by their autonomous decision to make an appointment to see me, a male.

And I don't have to tell them there are a bunch of females and an occasional male in the office environment--they can observe that on their own. Of course, what they might not know for sure is the gender of a provider who will do a nursing, assisting or testing procedure. Now, it is at that point, knowing by my description that the presence or management will not necessarily be by just me, for the patient to tell me about their gender desires if they had not said anything about that previously. Do I have to initiate specifically the issue of gender selection at this point. I think not. I have already provided the patient with a description of the participants in their care. Now is the time, if desired as part of their informed consent or dissent, for the patient to speak up about their concerns regarding what I described. If trust and confidence has already been developed in the earlier phases of the doctor-patient relationship and the patient shows to continue the relationship, I see no reason, based on inequality of power, not to expect the patient then to speak up to me their concerns. What I can do about them is another matter.

"Rocking the boat" is what I fear if the vast majority of my patients have an interest in diagnosis and treatment and no desire to engage into an issue of gender selection. If I bring up the issue personally at the onset, I am concerned it will be distracting to them with regard to the purpose of their visit ("doc, why are you bringing up this matter? I am worried about the blood in my stool")

Doug, I agree with the idea brought up earlier on this thread that, as long as we know now that there may be some population of patients with gender concerns, incorporating the gender concern question in the written admission paperwork would be a satisfactory alternate to the doctor directly and personally bringing up the topic. ..Maurice.

 
At Sunday, January 08, 2012 3:23:00 PM, Blogger Doug Capra said...

Maurice: I don't disagree with you. You make some good points. But you're basically discussing the doctor-patient relationship -- perhaps a patient and his or her trusted primary care physician. That relationship, however, may not include you bringing in an opposite gender chaperone, student or nurse for an intimate exam. Would you bring up the subject in those cases?
You write: "I have already provided the patient with a description of the participants in their care."
Here's where I think there's a disconnect. I don't know what you personally do, but my research and experience indicates that -- No -- doctors often don't go into detail relative to "participants" and who, gender-wise, will do specific kinds of "care," especially intimate care. It seems me that it's just assumed that because this is the way it is, the patient will either have no problem with it or that the patient will express his/her desires, or that it doesn't really matter how the patient feels.
You write: ""And I don't have to tell them there are a bunch of females and an occasional male in the office environment--they can observe that on their own."
True -- but we're not just talking about the "office" environment. We're talking about opposite gender chaperones, students, cna's, nurses. You say they can "observe" that on their own. No -- not unless they've experienced the ICU, or had a testicular ultrasound, or had an invasive prostate procedure, or otherwise experienced a hospital stay that involved the kind of care we're talking about. You'd be surprised how many patients go into the hospital with no idea as to what will happen to them and who will do what. And for some, that's just fine. For others it isn't. No -- they don't "know" what to expect -- and they are rarely told ahead of time who will do what, gender-wise.
This is where we seem to have a disconnect. As a patient, I would surmise many patients would feel comfortable enough to express themselves to their PCP. Some maybe wouldn't. But all that changes as the patients moves through the system and eventually finds him/herself in an alien environment where he/she knows nobody and doesn't really know what's happening. If patients say nothing, too often caregivers interpret that as "No problem." That isn't always the case.

 
At Monday, January 09, 2012 7:18:00 AM, Anonymous Anonymous said...

Maurice: because of your position, I don't think your personal experience with opposite gender intimate exams will be the same as most of ours. No matter how unprofessional they would typically be, they would be foolish to act this way in front of you. So you get the most profession experience. 

On the other hand because of your position I believe the intimate "details" will be noticed. If they are discussed in the break room depends but more likely for you then me. 

Just because "you don't have anything they haven't seen before" doesn't mean they are mentally neutered. 

Mark

 
At Monday, January 09, 2012 7:34:00 AM, Anonymous Anonymous said...

Maurice, the issues that fuel this blog are not about nudity. They are about unexpected situations, loss of control, and feelings of humiliation.

It seems that the healthcare system through it's training have some kind of brainwashing mechanism that destroys their sense of humanity and patient dignity, that it is a lost concept without boundaries.

The reason that I say this is from my research into the medical industry and the way it works, what sometimes happens to patients, and the egregious lack of dignity that would humiliate anyone.

Forced nudity is the first protocol in torture. It makes one submissive, humiliated, lose control and all that destroys the very soul of that person. For all intense purposes, a patient who doesn't know it's coming, or doesn't know that the room will be filled with people (and only consented to a procedure) can be traumatized. There is a difference between humiliation and trauma but so often they are linked together.

Let's pretend that we, on this blog are a minority. Doesn't the mental health and overall well being of that patient count? Isn't their outcome just as important as a good medical outcome. If one answers no to this question, then the entire medical foundation "to do no harm" no longer exists.

The medical community must recognize the dynamic of what's happening in order to make changes necessary to protect all. Every day someone else is either abused or feeling abused and that just creates more of us.

Because of this, it's just a matter of time that change will come probably through legislation rather than the medical system. For this, I have lost much respect for a flawed system, knowing the damage they cause and the unwillingness to protect their patients.

This is a problem that needs fixing.

Take away the unexpected and you take away trauma. The medical industry (yourself included) pretends that this gender issue doesn't exist. The only place it doesn't exist, is in the mindset of the medical community and the arrogance of that community not to recognize that human beings have feelings and deserve validation; just as the medical community enjoys for itself. In fact, more so because we're paying for your services.

So, I ask you these two question. What is happening in medical training that makes this community have a disconnect with humanity? Secondly, how do you propose to fix this.
belinda

 
At Monday, January 09, 2012 8:17:00 AM, Blogger Maurice Bernstein, M.D. said...

Mark, I want to tell you and the others something about my (and I bet a whole lot of other doctors) perspective as we perform any part of the physical exam (including the "intimate" parts). We would never say out loud or even say to ourselves the statement "you don't have anything I haven't seen before". My mindset and my teaching of medical students is not carrying out the physical exam in that direction. A doctor can't go into the exam with that perspective since the object of the exam is to exclude the presence of abnormal and pathologic findings. That means at every step in the process we have to be looking not with the intent to find normality but to exclude abnormality. A "seen all this before" is starting out inspecting and examining with half-closed eyes ("seems and thus looks normal to me" attitude). Yes, what we have seen before both normal and abnormal is in the back of our minds as a standard for comparison but we must go into the exam paying attention to find the abnormal and not assuming that "this isn't anything I haven't seen before". ..Maurice.

 
At Monday, January 09, 2012 8:52:00 AM, Blogger Maurice Bernstein, M.D. said...

Belilnda, you write " the issues that fuel this blog are not about nudity. They are about unexpected situations, loss of control, and feelings of humiliation." I understand. And that is what is what we instructors teach the students in I am sure all medical schools: There is no need for full nudity, attention should be paid to proper draping and undraping (and as I have already written carried out by the patients themselves if they are able) and that each component of the exam is preceded by an explanation of what will happen next. All of that is taught and this is what I see the students doing and this is what I personally practice.

In the environment in which I have control this is what is going on. There is no unexpected situations, loss of control or declared feelings of humiliation by our patients. I have no control over what happens elsewhere and since reading these Volumes, I have been educated that there is a group of patients of unknown numbers who find the medical system they experience leads to unexpected and perhaps unwelcome situations, a feeling of lack of control and humiliation. I have never said to my visitors to ignore doing something about these observations and feelings. I have said repeatedly for them to speak up, get together in an advocacy group and educate the rest of the medical system who haven't read my blog or Dr. Sherman's or other blogs where these concerns have been discussed.
I have written, the last with Doug, two articles to the AMA News on this very issue and I have recently been informing my students about the views expressed here. I continue to practice and teach attention, for all patients, to potential concerns for bodily modesty and the need to inform patients what they may experience nest. That's all I can do, myself. It is up to you Belinda and the others to go further. ..Maurice.

 
At Monday, January 09, 2012 9:44:00 AM, Anonymous Anonymous said...

Thank you Maurice.

 
At Monday, January 09, 2012 11:08:00 AM, Anonymous Anonymous said...

Can you post links to your AMA News articles?

Mark

 
At Monday, January 09, 2012 12:00:00 PM, Blogger Doug Capra said...

Maurice: I'm sure you know that I like to debate. You know I appreciate all the work you have done and are doing regarding this issue.
Mark brings up an interesting point when he writes: "because of your position, I don't think your personal experience with opposite gender intimate exams will be the same as most of ours."
There is some truth to that. Unless medical professionals go out of their way to make sure no one knows who they are, they may be treated differently, out of "professional courtesy." Recall the article a posted about the doctor whose wife was embarrassed and humiliated when she got a bed bath from a male nurse -- and how his eyes were opened as to this modesty issue. Note the article below, in KevinMD, by a doctor who talks about the unfairness of how a significant number of medical professionals are treated when they need medical services, as compared with the general public.
http://www.kevinmd.com/blog/2012/01/healthcare-system-unfair-unbalanced.html
This is not uncommon. When it doesn't happen the way described by this doctor, professionals get a real insight into how the system works -- the good, the bad and the ugly.

 
At Monday, January 09, 2012 12:28:00 PM, Blogger Maurice Bernstein, M.D. said...

I have had opposite gender "intimate" pubic area pre-surgery shaving by two female nurses who appeared to be performing their duties properly and in a professional manner. I was always glad the 2 times I was treated in the hospital as an adult and physician that I wasn't treated "differently" (any VIP treatment) then any other hospital patient. And that is the way I see it. Now, I do know that other physicians may request VIP treatment if they don't see that offered spontaneously but I disagree with that request and wouldn't accept it if offered. VIP treatment towards a physician can be a dangerous practice in many ways and certainly doesn't keep the hospitalized physician educated as to what it is like to be an ordinary patient in a hospital bed. ..Maurice

 
At Monday, January 09, 2012 12:45:00 PM, Blogger Maurice Bernstein, M.D. said...

Mark, at your service! Here are the links to the 2008 article I wrote to AMA News alone and the 2011 article which I wrote with Doug. ..Maurice.

 
At Monday, January 09, 2012 1:11:00 PM, Anonymous Anonymous said...

As odd as this may sound I am in near complete agreement with what Dr. Bernstein wrote regarding having that conversation with patients. It was my suggestion that the appropriate place to open that conversation was on the intake form for several reasons. (1). the patient is more likely to be open and honest and feel less intimidated (2)exactly to Dr Bernstein's point, you may actually cause a patient to feel embarrassed by drawing attention to it where they may have been OK before. Some people are able to create whatever they need in their mind to accept it. Whether convincing themselves its nothing, only to have that shattered by drawing attention to it or having them question it. If it is noted on the intake for the door has been opened, if it isn't providers should assume it is OK and go forward. I would hope if this was actually used it would be noted throughout the procedure(s) for all caregivers not just the MD....I do question how many providers feel the patient is fully informed of what to expect erroneously. I had to have a procedure and asked to be emailed a sheet of what to expect. I got a mechanical sheet of what was going to be cut, snipped, and sutured. When I emailed back and replied I was looking for detail on who would be doing what, what I needed to be done in prep etc. The reply, we don't have that in written form, it varies....I think providers assume to much becasue they do it everyday patients know more than we do. Ever have an IT guy try to tell you how to program your PC, they skip 1/2 the stuff assuming you know, after all its elementary....to them....alan

 
At Monday, January 09, 2012 1:15:00 PM, Anonymous Anonymous said...

One other comment, Dr. Bernstein indicated it was up to us now. I am going to make one last offer for people to give us thoughts on developing a website. We are going ahead with or without suggestions and or help, but if you are really interested in trying to do something constructive we would love to hear from you. The link is posted above, if you choose not to understood, but 4 years of blogging the issue seems to be about sufficient to start something if it is going to happen. Doug, Mark, Dr. Sherman we would paticularly like to have you join us but understand everyone has time constraints. Dr. Bernstein, obviously you are welcome but I understood your preference to remain more of a moderator than a partcipant in this...alan

 
At Monday, January 09, 2012 1:26:00 PM, Anonymous Anonymous said...

Well here is part of the problem, and why it is difficult to gauge whether we are a minority in how we feel or a minority that will speak-up for the majority...
Patients are not taught or encouraged to speak up.
Since childhood how many of us are told that caregivers are the major exception to the privacy concerns about our body. We are told to ignore embarrassment (or humiliation) for the sake of health. We are told to get over it, go home, and move on. We are told as children (and later adults) to stop being silly, endure what you must, and let it go. So is it any wonder that, when patients act as they are conditioned to, that caregivers say that no one ever complains about these things? Of course they don't. The medical culture has tried to condition them into the gender nuetral mindset and expect them to act accordingly.
How many time have we heard that 'Health trumps humiliation"? That is not exactly an invitation to express concerns. That's a preconceived notion that we are abnormal or unusual if we can't or don't feel that way. If people are treated as small, they become small. And worse...they become silent.
Maybe we need to consider that if they do speak up, they are not a minority in beliefs: just a minority brave enough to talk about it.

Suzy

 
At Monday, January 09, 2012 7:52:00 PM, Anonymous Anonymous said...

Suzy I agree with what you say and further question truely if providers are truely unaware or just trying convince us and themselves its ok. Consider some of the things that come up here. Terry the nurse said females are gender nuetral males are not. As has been brought up numerous times, find a male mammographer. There are numerous examples where modesty is recognized, even on ocassion legally as in males discriminated against in L&D. So, how then do we explain recognizing and applying modesty only on ocassion? How can a woman be modest of a mammogram but not for other exams of the breast or pelvic area? And I agree, for many years we have been told to just accept it and get over it. We weren't even given the thought there was an option. It does not surprise me people don't speak up, on the other hand, has anyone ever asked? Ever? before, during, after? It is don't ask don't tell....don't ask if they care and don't tell they can ask..agree with Dr Bernstein, but until providers start giving paitents the chance to express on intake...I won't believe they really want to know....alan

 
At Monday, January 09, 2012 9:22:00 PM, Blogger Maurice Bernstein, M.D. said...

Golly! We are in the 140 comment range already on this Volume and only since December 20.. despite the holiday period. But before I create Volume 47 I want to place here a commentary which arrived today for my medical student abuse thread and which seemed to me to fit with what is implied in many of the writings on this modesty thread. ..Maurice.


To whom this may concern,

I am the child of a urolgical surgeon. I love the human body and appreciate its capacity to adapt to numerous situations. I have both the aptitude, the finances, and the drive to go to medical school. However, given the horrendous abuse I suffered as a child, including physical , sexual, and emotional, I can say that I would never be able to go through that again. I have no doubt that a lot of it stemmed from my father's training as a resident surgeon. These abusive practices not only affect members of the medical community (doctors, nurses, etc) but their children as well. WHY WHY WHY is this necessary? Do you not realize how many lives you ruin? Not only one BUT SEVERAL? What is being accomplished with this inhumane process? NOTHING! Every individual should have the right to achieve their potential, the hazing and abuse that goes on makes that impossible. No human being can learn and excel under these conditions. The system needs to be fixed somehow and as a result, drives away the decent human beings who sincerely have a desire to help. IF THE MEDICAL PROFESSION WAS NOT THE ABUSIVE, CRUEL, DISGUSTING SYSTEM THAT IT IS: I WOULD HAVE GLADELY BEEN A DOCTOR.
THE MEDICAL SYSTEM IS STAGE FOUR, GLEASON 7 PROSTATE CANCER. IT is uncontrollable cellular growth with few chances of repair in sight. I don't think in my lifetime, the system that transformed my father into a horrendous sadistic MONSTER will ever change. It is my one hope, before I die (I am in my 20s now) that some miracle might happen. What a damn shame.

To the post on Saturday, April 19, 2008 1:49:00PM - I know from experience the abuse that you speak of. I know that no words I write can even begin to do justice towards the feelings of horrid pain and rage that you probably feel inside. The dehumanization process that strips you of every possible bit of soul, self esteem or will to live.I applaud your decision to be a human first and a doctor second. Please be assured my thoughts and prayers are with you. If you have any doubts about your decision, please go back and read my post. Without knowing it, the choice to refuse to be molded into that model of cruelty and evil, you have made the world a better place already. Thank You.
Sincerely,
DR

 
At Tuesday, January 10, 2012 6:07:00 AM, Anonymous Anonymous said...

Suzy (and Mark), well said! I agree 100% as to your reasoning about why patients don't speak up about modesty concerns. I was in that category at one time. And I also think that although we may be the minority, it is probably safe to assume that there is a significant number of others out there who don't feel comfortable with compromising their modesty but just have never felt they had a "right" to question. Jean

 
At Tuesday, January 10, 2012 4:00:00 PM, Anonymous Anonymous said...

Interesting article on Trisha Torrey's patient advocate blog about a doctor who dismissed a patient because she had googled her symptoms. While this is A specific Dr., I think right or wrong many people still feel, and to some degree rightly so that providers have placed themselves on pedestal and resent being questioned. I recall a few years back my mother was in a small hospital's ICU, we were asked to make that decision no one wants to make. The attending said her Xray indicated what he took to be advanced stage lung cancer. About all he could do was make her comfortable, we asked should we send her to a hospital in Indianapolis to have them look, obviously annoyed he said its your call I can't tell you want to do and walked out. A male nurse was attending her at the time and looked at us and said "I can't tell you what to do, but if she was my mom I would get her down there right now". We called for a transfer, upon arrival they took her in and drained a huge amount of fluid off her back that had gathered outside the lung and was restricting its ability to function. Seems it cast a shadow on her lung that had been read as being in her lung. We had her for several more years. Now granted, again it was THAT MD., but if we experience this type of attitude on the life of a loved one..why would we not be hesitant to speak up for something we know providers downplay and place no importance on like our modesty and gender choice of providers. Need more reasons, scan allnurses and read some of those threads. So yes, it is the patients duty to speak up, but until providers let patients know its ok, your not blameless by any stretch of the imagination....you are percieved to have the power, you control the actions and situation, you have set the dynamics over decades of you tell we follow, you have responsiblity in this issue as well....alan

 
At Tuesday, January 10, 2012 4:31:00 PM, Anonymous StayingFit said...

Dr. Bernstein, you state that “I would, based on my personal experience, call myself "gender neutral" for caregiver gender in my role of a patient under the care of physicians and nurses.” I am fortunate that I can say the same, at least for the most part. However, this does not mean that I, and others like me, do not want to be asked if we have any concerns with opposite-gender care. To me, this connotes respect, both for my choices and my comfort.

For instance, back in September, I went to a prostate cancer awareness clinic, which, to my surprise, included digital rectal exams for participants. When I was escorted to the examination room, the nurse informed me that my examiner would be a woman, and she wanted to be sure that this was OK. I told her that it was, but that I was grateful that she asked. And I truly was (I'm certain that another man was, too, since he asked for a different doctor).

Prior to being informed of my examiner's gender, I had wondered if my doctor would be a man or a woman. I was not concerned enough that I would insist on one or the other, but it was something that I had considered. So, when the nurse asked my preference, she certainly was not introducing a thought that had not already occurred to me, and I suspect that this is true for most patients. It is something that we have thought about. Therefore, far from “rocking the boat”, I think that most patients, even those who are gender-neutral (but not gender-unaware), would appreciate the respect that you show them by simply asking.

 
At Tuesday, January 10, 2012 5:12:00 PM, Anonymous Anonymous said...

Alan

What do you believe you can accomplish with
another website,more than perhaps this blog and Dr.
Shermans? I am not doubting your desire to advocate
on this subject, but I believe this problem needs to be
taken to the institutions.

In other words they are not going to come to
us,we have to go to them. In essence this is a civil rights
issue whose time has not come. It is comparable to the
the black rights activists of the 60's whereby many know
of the problem, they just don't want a solution.

Additionally, you are working against long instilled
ideals, " nursing is the most trusted profession" and so
forth. You need many examples contrary to these ideals
and you need to have some medium to present to all the
institutions. How are you going to do that? What medium
are you going to use?

The very groups whose attention you want have
no desire to visit these blogs let alone appreciate this
subject matter. I'm not attempting to dash your hopes
but I believe there are other more fruitful and efficient
ways to achieve this. At some point I'll make these steps
known.

PT

 
At Tuesday, January 10, 2012 6:54:00 PM, Anonymous Anonymous said...

I am not looking to change the culture as much as provide a tool to educate those who are looking, and to interact with facilities. I do not have the allusion that this will reach the masses and spark a revolution. On the other hand if it helps 10 people or 10,000 it is a seed for change. If 10 people ask for help and they refer 10, if we contact 10 facilities and cause some type of change, those 10 facilities will touch 1,000s of people. I don't expect to change the world, just a little part of it with the hope it will spread.....alan

 
At Wednesday, January 11, 2012 7:28:00 AM, Anonymous Anonymous said...

PT--For once I totally agree with you!

The reasoning may be connected to whether the person had concerns BEFORE something happened or...if they had concerns AFTER something happens.

While modesty is something that is instilled, I, personally, never had these concerned and never asked question about who, when where, etc. While unaffected healthy individuals may or may not have these concerns, their level of that has to be considered minimal because unless they experienced the horrific, ridiculous things that sometimes do happen, they do not have the framework of experience to know exactly what to ask for or...the awareness that they have to ask for anything depending on their individual medical experiences of the past.
belinda

 
At Wednesday, January 11, 2012 1:17:00 PM, Anonymous Anonymous said...

PT:
There is more than one way to service change. If you have a plan, does it need to be exclusive? Are we to say " Oh...he has it covered, so well...never mind. Let's just wait and see what he comes up with."

We've been waiting along time. Some of us feel it's time to move forward. If you have a scheme to "bust-out' the system from within, then great. I would believe it when I see it. In the meantime, (just as civil rights by the way) people need to know what they want, how to get it, and what to do if they don't. Do we remember the word 'empowerment'?
That never meant let's wait for the culture to change itself. It meant, instead, let's be strong enough to force the change.
You can't have too much support...or too much groundwork for change.
If you have a plan...let's hear it and get to it!
In the meantime...I'm not waiting Superman....I have my own champions of fate.


Suzy

 
At Wednesday, January 11, 2012 5:25:00 PM, Anonymous Anonymous said...

I had an interesting conversation today that is slightly related to the issue but perhaps sheds a little light on the gender issue paticularly for men. I am switching my companies insurance to a HSA plan. I was discussing coverage with the new provider and agents, discussing enrollment. Here was an interesting fact, the insurance company requires a married man's wife to sign a consent form for him to have a vasectomy, they said some hospitals also require this for fear of liablity suits from the wife. So I asked, so does a wife need their husbands signature and consent for an abortion? The looked surprised and said well no...So PT I understand your NUKE EM ALL attitude, sue them to hell and they will pay attention, and if you take that action God Bless you, have at it. However, for those of us who chose to take a less confrontational approach, doesn't make us wrong, just different. Rosa Parks was a single woman who started a movement with a simple act of resistance, Malcohm X took another path, my style is more like Rosa than Malcohm....alan

 
At Wednesday, January 11, 2012 5:56:00 PM, Blogger Maurice Bernstein, M.D. said...

NOTICE: AS OF TODAY JANUARY 11, 2012 "PATIENT MODESTY: VOLUME 46" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 47

 

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