Bioethics Discussion Blog: Patient Modesty: Volume 57

REMINDER: I AM POSTING A NEW TOPIC ABOUT ONCE A WEEK OR PERHAPS TWICE A WEEK. HOWEVER, IF YOU DON'T FIND A NEW TOPIC POSTED, THERE ARE AS OF MARCH 2013 OVER 900 TOPIC THREADS TO WHICH YOU CAN READ AND WRITE COMMENTS. I WILL BE AWARE OF EACH COMMENTARY AND MAY COME BACK WITH A REPLY.

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Monday, August 26, 2013

Patient Modesty: Volume 57












Humility and Humiliation: Continuing on with the patient modesty discussion, there is the suggestion that a bit more humility in the medical system might mitigate against patient humiliation.  But to express and demonstrate humility by healthcare providers requires limiting expressions of all-knowing paternalism such as "I've seen it all" and to listen to and act in support on matters of patient gender selection.  But is that possible with professional mindset and practical with regard to current gender maldistribution of healthcare workers? So let's continue on with the discussion. ..Maurice.


NOTICE: AS OF TODAY SEPTEMBER 30, 2013  "PATIENT MODESTY: VOLUME 57" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 58.


Graphic: From yourlifetricks via Google Images

157 Comments:

At Monday, August 26, 2013 8:53:00 AM, Blogger Maurice Bernstein, M.D. said...

amr posted the following to Volume 56 after it was already closed. The following is what was written. ..Maurice.


Dr. Bernstein,

This is in response to your Sunday Aug 25 entry.

What role if any does your ethics committee have in influencing the behavior of your institution? I sounds from your entry that you are advisory at best.

I challenge you sir to obtain and post the hospital admissions form that each patient is required to sign by your institution as a condition of being admitted. This form may not be altered by the patient, and the form is signed on the day of admission.

I think you will find that if the patient objects to the form in any way, the patient will not be admitted.

I think you will find that the form makes mention that it is a teaching hospital and many people will be involved with the patients care that may not be their doctor. It might even mention in the small print that the primary doctor / surgeon that the patient has been working with may not do the actual surgery. This also might be repeated on the surgical consent form. The form will also state that pictures or video may be taken of the patient during surgery.

I think you will find that the USC document only mentions personnel and makes no mention of gender in the care of the patient.

Thus, medical institutions slide through the gender issue by slick legal language.

I think you will find that UC schools, Stanford, and USC all have similar language, just to name some big names in CA. At UCLA the issue of taking pictures became enough of an issue such that the standard acceptance form was changed a few years ago from pictures to “medical” pictures.

I also don’t think you will post your institutions admissions form as challenged. It would be too politically incorrect for you to do so and remain on staff.

Respectfully,

amr


 
At Monday, August 26, 2013 9:00:00 AM, Blogger Maurice Bernstein, M.D. said...

amr was referring to the following posting by me. ..Maurice.


At Sunday, August 25, 2013 9:45:00 AM, Blogger Maurice Bernstein, M.D. said...
Ed, I hope no hospital ethics committee says that "the patient doesn't have a choice". As a member of a hospital ethics committee, I know that we are all attentive to what choice the patient has made. Now whether that patient choice will be accepted and followed by the institution is another matter. If any hospital has a policy to reject certain gender choices by the patient, that policy should be stated and explained to the patient before the patient is admitted for care. It cannot be just assumed that the patient recognizes beforehand that such a policy might exist. ..Maurice.


 
At Monday, August 26, 2013 9:00:00 AM, Anonymous Anonymous said...

Once I worked for a company that laid out a vision of how they wanted their external and internal (co workers) treated.

I was very simple. You either played by the rules or you were fired.

The only way that this mindset can be changed is from the top.

New education in how to think about patients and how to treat them would be the first change.

Then there's a "get used to it" time where people can make mistakes but will be looking at each other with raised eyebrows when someone does.

Third stage, you make a mistake and you are fired.

Let's see how fast the medical community can change their behavior to protect their jobs.

I will also say that this company was privately owned and sold for several hundreds of millions of dollars. They must have been doing something right.

Racial slurs had no tolerance--immediate firing, just as impropriety should have after training. Racial slurs and humiliating patients hurts people.
belinda

 
At Monday, August 26, 2013 9:37:00 AM, Blogger Maurice Bernstein, M.D. said...

amr, if you have researched the wording regarding the healthcare providers in relation to our current discussion of some of the California teaching hospitals admission forms, please post them here for review by my visitors. ..Maurice.

 
At Monday, August 26, 2013 10:30:00 AM, Blogger Doug Capra said...

Hospital ethics committees can say anything they want. They can make up any rules they want. Of course, they need to make a rational argument for their decisions.
Then there is the law and the courts. If a particular ethics committee at a private teaching hospital says that patients have no right of gender choice for intimate care -- they better make sure they enforce their rule equally for both genders at all times. If they don't, I would suggest that they are not following the law regarding gender equity, and if they intimidate patients to accept their rules, I would suggest that might be considered sexual harassment.
But, as some have suggested, if private teaching hospitals want to create a policy that forbids gender choice, they need to post that in public because, as I see it, that's part of informed consent. A patient entering such a hospital needs to know that up front and in big print.
It would also be very interesting to see how many non medical professionals are on that ethics committee. How many regular, ordinary, everyday patients with no connection to the medical profession helped to make that decision? I would suggest that there would be very few if any.

 
At Monday, August 26, 2013 11:30:00 AM, Blogger Maurice Bernstein, M.D. said...

As a member of a hospital clinical ethics committee for many, many years, I can tell you that clinical ethics committees should not be making administrative ethics decisions and policies generally, however, if they are asked to respond, they should be making suggestions or recommendations which meet current ethical consensus and law. The final decision is not made by the committee but by the administration. ..Maurice.

 
At Monday, August 26, 2013 1:04:00 PM, Blogger amr said...

Dr. B,

I have spoken to these issues b4 on this blog and have posted in the past links. I could scan a current UCLA patient disclosure statement, but these are items well defined on the web as well. As I said, I did not expect you to do so for USC. In times past you have not wanted such direct evidence posted on your blog.

And yes ethic committees do hide behind the fact that they don't make policy, just talk about it.

Sorry to be so harsh.

-amr

 
At Monday, August 26, 2013 2:04:00 PM, Blogger Maurice Bernstein, M.D. said...

amr, I don't mind having an identified hospital public document text mentioned or reproduced or linked on my blog. What I don't want written here is "bad" personal hospital experiences with identification of a named hospital. That hospital, for my blog to be ethical and legal, should be given the opportunity to be aware of the patient's comment and to be given the opportunity to defend themselves on this blog, if they desire, when the patient's remarks are posted. Generalized observations and complaints by the patients about hospital behavior is certainly welcome if pertinent to the topic and the hospital remains unnamed or otherwise unidentified. This is my policy irrespective of thread topic.

With regard to the role of hospital ethics committees, we should be teachers of ethics and law but we should never be the ones to establish the final decisions either hospital administrative nor patient clinical. .Maurice.

 
At Monday, August 26, 2013 5:35:00 PM, Anonymous Anonymous said...

one thing that needs to be remembered, a state institution is subject to the favor of the state government for funding and other benefits. Take issues such as institutions failing to honor the wishes and wellbeing of patients otherwise known as tax payers. you might be surprised at how quickly you get some attention. The ethics comittee can make recomendations but you would be surprised what a call from a local state legislator can do, and in many states they are local folks....don

 
At Tuesday, August 27, 2013 3:53:00 PM, Anonymous StayingFit said...

It seems that the Urology-times website has been having some technical difficulties, so I was just now able to read the article to which Ed refers. I have to say that I misunderstood the philosophy of this practice. Since the title of the article is “All-female urology practice's mission is to give women choice in care”, I assumed that the mission of this practice is to have an “all female” staff at this clinic. However, the article makes it plain that male staff would be welcome, and that the founder believes that women would accept a male provider.

So, it seems that the “choice” being given to women isn't so much the option to be cared for by females. Rather, it is the choice not to attend a practice that also cares for men. How does this address the privacy or comfort of patients? No other patients, men or women, would be in the examination room together, so what is the advantage here? That the same doctor seeing you may also see patients of the opposite gender doesn't seem relevant.

I also find it ironic that the ethics board that Ed mentioned decided that patients do not have a right to choose the gender of their provider. However, it would appear that doctors DO have a right to choose the gender of their patients! How can refusing to see patients, based solely on their gender, be considered ethical?

I would have thought just the opposite. That is, that patients have a right to choose the gender of their providers, but that providers are duty-bound to treat any patient, irrespective of the conditions of that patient's birth.

I should mention that this is more than an academic discussion for me. I was recently seeking an appointment with a urologist. I used my insurance company's website, and found the one nearest to me. I called what I thought was Dr. Antonio X's practice. However, the receptionist informed me that Dr. Antonia X's practice only took care of female patients! I admit that I didn't realize that the doctor was a woman when I made that call, and I might not have called if I had. At the same time, I've never had a doctor refuse to see me, based solely on a characteristic over which I have no control. This seems like sexism to me, and I found the experience rather insulting.

 
At Tuesday, August 27, 2013 5:31:00 PM, Blogger Maurice Bernstein, M.D. said...

StayingFit, you picked up on a potentially unethical and really unprofessional point that warrants discussion by society. For a medical/surgical practice to purposely avoid treating "certain" patients for reasons not absolutely defined by the nature of their specialty (such as ob-gyn physicians not treating males) appears to be "a wrong" needing to be corrected. Remember, in the news, a few years ago of a physician who with office signage refused to attend to patients who were NOT Republicans. How about more recent news of physicians who excuse themselves and refuse to treat those obese patients beyond a certain weight? These physicians restrictions as well as urologists treating only females is open to essential discussion in these days within the United States, for example, of more patients entering the insured medical care system. And also with regard to the ethical principle of justice.

StayingFit, thanks for your clarification of the article. ..Maurice.

 
At Tuesday, August 27, 2013 5:47:00 PM, Blogger Maurice Bernstein, M.D. said...

An editor of a magazine not within the United States wrote me the following e-mail yesterday. Since it is pertinent to a discussion of the generic issue of physical modesty and behvior, though not directly related to patient care, I thought I would include it here.


I’m writing an etiquette piece on male gawking of women, specifically when it comes to shirts with a design commonly placed over the chest or those velour sweatpants with “Juicy” on the backside, etc. My main question is how should men approach this that’s respectful and mindful of women? Is there a way? I feel that these clothes are worn for attention, yet not for gawking. Is there a respectful way to appreciate an eye catching shirt design or other piece of clothing when the part that grabs your attention happens to be placed over an area that’s not appropriate to really look, let alone stare? In your opinion, do you think some women enjoy this attention to two specific regions? For those women that don’t like people looking at those areas, what are they to do? Not wear t-shirts that they like anymore? Be forced to dress more conservative?


I would greatly appreciate your input on this if you have time Dr. Bernstein.


I responded with the following. Was there something else I should have written? ..Maurice.


If I understand your question correctly, I would suggest that the women who wear those clothes with attractive images or comments in certain bodily areas are consciously inviting male gawking and if that is their pleasure that should be those womens' own personal decision. Those who want to dress in a less provoking manner should do so. If this suggestion was followed, the burden of the ethical behavior would not be placed on the man.




 
At Tuesday, August 27, 2013 7:03:00 PM, Anonymous Anonymous said...

Well said Staying fit, would it not also indicate the difference of us and them, it is perfectly acceptable for a provider to discriminate based on gender but the patient should not have ther right to choose. I think it but another example where the medical profession holds themselve in a higher light then their patients. The history of provider being something more than regular people and not to be questioned does not go away overnight. I still recall as a child my mother having me put my Sunday best on for the doctors visit. Isn't this just another verstion of that? That said, i wonder what the response would be if a patient refused to accept opposite gender care, would they attempt to force and risk being sued, don

 
At Tuesday, August 27, 2013 7:09:00 PM, Anonymous Medical Patient Modesty said...

Dr. Bernstein,

Let me respond to your below question from Saturday:

Misty , by watching the program are not we performing the very gwaking and providing support to the filming which was discussed here as unethical? ..Maurice.

No, I do not feel we are gawkers by watching this TV show because we cannot see the man’s genitals. TLC used blurring technique to block out his genitals so anyone watching the show could not see his genitals. The reason I mentioned this TV show was because this cases proves how common it is for an urologist to not provide informed consent to male patients about who might be present for their intimate examinations. Most urologists fail to ask male patients about how they feel about having females present for their examinations. I do not agree with TLC crew going in the examining room with the man and seeing his genitals. I was not against TLC sharing this man’s case, but I felt they went too far. There was nothing wrong with TLC filming this man when he was clothed. I cannot help, but wonder if this man really knew that he would have TLC crew present for his examination by the doctor.

I remember how Michelle Duggar from 19 Kids and Counting a few years ago asked the crew from TLC to leave the examining room at her female OB/GYN when she needed to have an examination by the doctor. Fortunately, the TLC crew respected her wishes and left.

Misty

 
At Wednesday, August 28, 2013 6:19:00 AM, Anonymous Anonymous said...

Misty, there is no proof that this man did not give informed consent. While you don't agree with the presence of the filming team, you do not know if this man gave his consent

Sometimes in politics, one religious base tries to influence the rest of the population even though the rest of the population doesn't agree, doesn't hold the same religious beliefs (ex birth control). Abstinence might work for a few, but the bottom line is, take away birth control, and you bring unwanted children into the world. I can't think of a bigger sin.

Using this as an example, why should one segment of the population dictate what's good for the whole. It takes away people's rights.

What is acceptable for one is not acceptable for others. It's fine not to accept opposite gender care, but is it fair to put this presumption on the rest of the population that doesn't care?

Everyone has a different mindset. This man went through his story, even unclothed and didn't seem to lose his dignity in his mind. The only way we would know for sure is to contact him and ask his feelings on the subject.

On the other hand, if this man was pressured (not so much by the medical team, but his need to have this surgery corrected) and this filming was part of the bargain, he might have felt elated at the time but could develop PTSD over time, feeling that he was used and exploited. This is another issue that the medical community must be aware and do what's best for the patient.

The medical community should focus on what is healthy for all. Because this issue is a very personal and sensitive one, and one that can create harmful results if not handled properly, every effort should be made to give informed consent and the mental attitude of that patient when they are admitted.
belinda

 
At Wednesday, August 28, 2013 8:07:00 AM, Anonymous Medical Patient Modesty said...

I had seen the article that Ed mentioned before. I was very disturbed by the last two Q & A items. I think it is terrible that any medical facility would make a such policy that patients do not have a choice in the gender of their provider for intimate examinations. It is clear that this particular hospital does not care about patients’ preferences.

I think it is horrible that it was suggested that doctors’ ultimate goal should be to make patients blind to gender to intimate examinations. This proves that the medical profession is so gender neutral. If medical facilities were truly patient centered, they would work to accommodate patients’ wishes for same gender intimate care. The fact this is a goal for some medical facilities especially teaching hospitals is a concern because some medical students have been allowed to do non-consensual pelvic, rectal, and genital exams on patients who were under anesthesia. I believe that some teaching hospitals did this practice because they knew that many patients would object to medical students doing those intimate examinations.

You all can see a discussion about the issue of a medical student doing a non-consensual pelvic exam on female patients and some comments from Dr. Bernstein, Dr. Sherman, others, and me at http://patientprivacyreview.blogspot.com/2013/04/0-false-18-pt-18-pt-0-0-false-false_1.html. Intimate examinations are also done on male patients without their consent sometimes.

Misty

 
At Thursday, August 29, 2013 7:05:00 PM, Anonymous Medical Patient Modesty said...

Some hospitals in America have laid off employees or eliminated vacant positions. Sometimes, hospitals will give current employees more work to cover for vacant positions. Look at an example of a hospital that will have to lay off some employees that was on the news the other night. This really concerns me because I feel that laying off nurses or doctors could restrict patients’ wishes for same gender doctor or nurse for certain procedures. For example, if the cardiology floor lays off two male nurses, it might be harder for a male patient to have a male nurse for intimate procedures. Also, nurses may have to take on increased hours if some nurses are laid off. I think that nurses who work too many hours are less likely to be sensitive to patient modesty.

I do not think that hospitals laying off non-clinical employees such as receptionists, janitors, maintenance workers, etc. would have an impact on accommodating patients’ preferences for same gender intimate medical care.

What do you all think?

Misty

 
At Friday, August 30, 2013 6:14:00 AM, Anonymous Anonymous said...

Misty,

It really doesn't matter. Lay off's happen all the time.

What does, is making this issue paramount to good mental and physical health and then it's up to the healthcare system for fix the balance.

Any industry that grows and change has growing pains. The healthcare industry is long overdue.

This issue we blog about is really about social change within the healthcare system that is fair and equitable for all, that supports our most fundamental right of bodily privacy.
belinda

 
At Friday, August 30, 2013 9:20:00 AM, Anonymous Anonymous said...

An obvious point that we all need to keep in mind, regardless of what an ethics comittee says, regardles of policy, ultimately we own the decision. They can not force you to accept care from anyone, they can not force you to expose yourself to anyone you don't want. They have the right to not treat you if it isn't life threatening, but think about it, you are in their facility and say you will not expose yourself to opposite gender and don't bend, they have two choices, make reasonable accomodations or discharge you....they discharge you they run the risk of you refusing to pay....we are not helpless, we still own much of this part of treatment. We can't tell them, I think i would be better with 100mg not 50, but on this side, we still have choice if we just excercise it. It is obvious but the discussion somehow didn't include that....don

 
At Friday, August 30, 2013 11:12:00 AM, Anonymous Anonymous said...

Hi Misty. I read the article you mentioned. He blames the lay offs on lack of Medicaid expansion and Medicaid cuts. No where does he mention a declining patient base. Maybe people got tired of being told you can't select the gender of your provider and if you don't want students involved with your care you shouldn't of come here. They have always had the attitude that they are the only game in town. They never learned business 101. TAKE CARE OF YOUR CUSTOMERS OR SOMEONE ELSE WILL. Could it be people are going someplace else or just foregoing health care ? I did notice the scare tactics. First, because of his good management they avoided 500 additional layoffs. Second, hospitals across our state and region have initiated layoffs of hundreds of employees. If you want me as a patient , they need to make me feel safe and respected. Listen to my concerns and find a way to make it happen, not dismiss them and hide behind the consent form. AL

 
At Friday, August 30, 2013 5:59:00 PM, Anonymous Medical Patient Modesty said...

Don,

You made excellent points. Patients have the right to refuse opposite sex intimate medical care. If a facility refuses to honor your wishes, you should find another facility even if it means you have to drive farther. It is certainly worth driving to another facility that is more sensitive to patient modesty. I personally believe that patients should write letters of complaints to the CEO or administrator of a medical facility any time they have a policy that does not allow patients to choose the gender of their doctor or nurse. We need to let medical facilities that are not sensitive to patient modesty that we will not be using them. If a medical facility saw a significant decrease in patients because of patient modesty concerns, they would very likely change their policy. One lady in New York named Kay shared that she would not accept any medical students in her care and she was dismissed as a patient. You can see her case at http://patientmodesty.org/rights.aspx. She found another family practice that was willing to accommodate her wishes.

Unfortunately, many patients feel so vulnerable when they are told about those policies. Many patients who had their modesty violated in medical settings had never gone to the doctor for intimate examinations before. For example, some men who never played sports may not see a doctor for an intimate examination until they are in their 50’s or 60’s. Some patients are so shocked about how easy it is for their modesty to be violated. Also, think about a young pregnant woman who may be unaware that some hospitals allow medical students to participate in childbirth. Some patients may have limited choices about where they can go to. For example, some veterans can only go to VA Hospitals. Also, some medical facilities won’t accept patients with certain types of insurance.

One of our biggest goals at Medical Patient Modesty is to educate people that they can refuse opposite sex intimate care at any time. I have a special concern for teenagers and young people. They are very vulnerable because most of them are unaware about how some exams can be invasive. For example, many teenage girls with abdominal pain may not know that it is common for doctors to insist on doing pelvic exams on them. Any woman with abdominal pain can refuse a pelvic exam and request an abdominal ultrasound instead.

Misty

 
At Friday, August 30, 2013 7:20:00 PM, Anonymous Anonymous said...

Hi Misty. I read the article you mentioned. He blames the lay offs on lack of Medicaid expansion and Medicaid cuts. No where does he mention a declining patient base. Maybe people got tired of being told you can't select the gender of your provider and if you don't want students involved with your care you shouldn't of come here. They have always had the attitude that they are the only game in town. They never learned business 101. TAKE CARE OF YOUR CUSTOMERS OR SOMEONE ELSE WILL. Could it be people are going someplace else or just foregoing health care. I did notice his scare tactics. First, because of his good management they avoided 500 additional layoffs. Second, hospitals across our state and region have initiated layoffs of hundreds of employees. If you want me as a patient, they need to make me feel safe and respected. Listen to my concerns and find a way to comply, not hide behind a consent form. Take care. AL

 
At Friday, August 30, 2013 10:56:00 PM, Anonymous Medical Patient Modesty said...

Al,

I think you have two hospitals messed up. The hospital that is laying off people is not the same hospital that set the policy that patients did not have a choice in the gender of their doctors in the article that Ed mentioned. I just mentioned the hospital that I saw on the news the other night because it made me think that layoffs at a medical facility could restrict patients’ choices. For example, think about how a male patient’s choice for a male nurse could be restricted if the cardiology floor laid off the only male nurse on the night shift.

Misty

 
At Saturday, August 31, 2013 4:07:00 AM, Anonymous Anonymous said...

Misty. I know their different hospitals. I was just trying to make a point. Because their different , doesn't mean they treat people any different. According to him all the hospitals in the area are being affected. After reading the post here it doesn't appear they treat people any different anywhere in the world. AL>

 
At Saturday, August 31, 2013 7:42:00 AM, Anonymous Anonymous said...

Patients have the legal right to refuse anyone who is not directly related to their care. If patients would speak up if a hospital wanted to dismiss them, to remind them that if anything goes wrong, they are liable.

If patients know the law, spit ethics right back to the hospital, they might think twice before dismissing a patient.

I have also found if a patient is willing to discuss their issues, everything that can be, will be done to protect that patient.
belinda

 
At Sunday, September 01, 2013 1:00:00 PM, Anonymous StayingFit said...

As I mentioned previously, I recently found myself in need of a urologist. As I had no idea whom to see, I used the internet to do my research. I finally settled on a large practice, which employs roughly 2 dozen urologists and PA's. I discussed my needs with the receptionist, who helped me to choose which doctor to see. This turned out to be a mistake for a couple of reasons, but I'll need to explain that in another post.

I am taking notes on my experiences, and I will be glad to share any that seem of interest to this blog.
I will also give the background information in a more chronological manner in the future, but one issue seems extremely relevant to patient privacy, so I would like to jump right to that.

One of the items that I discussed with my new urologist was my desire to have a vasectomy. After a very brief consultation, we started the process. I was given a number of documents to review at home, including the “Facility Consent” form.

I applaud this practice for providing this consent form in advance, rather than handing it to me on the day of the operation. I was less impressed with a couple of the items on this form, however.

Item #5 on the form reads:

“In accordance with ordinary practices of XXXXX Urology, I consent to the Admittance of the use of closed-circuit television, the taking of photographs (including videos). I also consent to the use of such photographs and other materials for scientific purposes.”

This, I have to admit, stunned me! What possible reason could there be for having closed-circuit cameras in an operating room, or for taking videos or photographs of the operations?

I might be more understanding, were this a general consent form for an ambulatory surgery center that performs all manner of procedures. But, this procedure would be performed in a large practice dedicated solely to urology. Hence, all procedures performed here would, by definition, be of an intimate nature.

Am I correct that this seems unreasonable? Or, is such a waiver standard practice? Even if it is, I would have a hard time consenting to this.


Item #1 on the form reads:

“I hereby consent to the performance upon StayingFit for vasectomy...by doctor/doctors Joseph X, and/or such qualified assistants as may be selected by my doctor(s)”

I question the need for an assistant during a vasectomy, as I have seen videos of the procedure being performed by the doctor, alone.

Am I correct in my suspicion that the role of such an assistant is likely that of a chaperone? Or, is it possible that the doctor truly does require some help with this?

 
At Sunday, September 01, 2013 2:50:00 PM, Anonymous Anonymous said...

Personally, I would never consent to photos/videos. My vasectomy was conducted by a male physician and male assistant while in the USAF. However, the assistant did nothing but prep and occasionally hand the physician surgical implements. IMO, an assistant is extraneous.

Ed

 
At Sunday, September 01, 2013 3:53:00 PM, Anonymous Anonymous said...

StayingFit

There is no need for an assistant as
there are only a few instruments required for this
procedure. The tray is sterile thus no need for
anyone to hand off or assist. I can think of many
procedures whereby no assistant is necessary.
In fact, there is no need for an
assistant at bedside for a lumbar puncture and
that procedure has a more complex sterile tray
as well as skill requirement than a vasectomy.


PT

 
At Sunday, September 01, 2013 5:35:00 PM, Anonymous Anonymous said...

FYI

The American Urological Association Code of Ethics, regarding informed consent, states:

"I will consider informed consent integral to providing appropriate medical or surgical care. I recognize that my patient must be provided with all of the information necessary to consent and to make his own choice of treatment, regardless of my own advice or judgment. The information provided must include known risks and benefits, costs, reasonable expectations and possible complications, available alternative treatments and their cost, AS WELL AS THE IDENTIFICATION OF OTHER MEDICAL PERSONNEL WHO WILL BE PARTICIPATING DIRECTLY IN THE CARE DELIVERY. Wherever feasible, I will respect my patient's rights and be limited by the scope of my patient's consent."

The reason why many Urologists fail this basic requirement is they know the majority of their male patients will object to opposite gender staff participating in their care.

Ed

 
At Sunday, September 01, 2013 7:50:00 PM, Anonymous Anonymous said...

I had a vasectomy at my PCP's office and it was just him and me. No assistant, a friend of mine had female nurse he personally knew "assit" on his, he said all she did was hold his penis tot he side. Same Dr. different paitent asked for no assistant as he knew the same nurse, the Dr. did it by himself. It should be obvious the to Dr. but they take the path of least resistance. speak up or suffer the consequences, doesn't matter whether they should or should not offer, they won't so you have to take care of yourself...don

 
At Monday, September 02, 2013 8:56:00 AM, Anonymous Anonymous said...

My friend was diagnosed with malignant melanoma. Every year after she was required to go to a medical photographer, strip down to paper underpants and have her photograph taken.

I saw these photographs. They were 8 X 10s and they were of her entire body, including her head, front and back.

I had asked her many times what the purpose was because you couldn't see anything from those pictures.

While I would support photographing her entire body in pieces, close ups that would show changes in moles, I never understood that.

Perhaps someone out there can explain it to me.
belinda

 
At Monday, September 02, 2013 4:26:00 PM, Anonymous Anonymous said...

While traveling this weekend I tuned into a conversation taking place on the radio. They were telling Gyno stories. One lady said her Gyno father delivered her baby. Another lady said her mother works at a Gyno office. Mother and daughter are both patients of said Gyno. The mother set her daughter up with the Gyno's son. After several dates she would tease her boyfriend that she went farther with his father than she did with him. She said she went to third base with his father. She kept saying it was hilarious. She said he is her ex now. Another lady said a new Gyno came to town. She called him very handsome and hot. She switched to this Gyno along with most of the women in her office. So, my question is to the ladies of this blog. Is this really the way women think and act or is this all radio B.S. Thanks AL

 
At Monday, September 02, 2013 6:55:00 PM, Anonymous Anonymous said...

Al, some women behave this way, others don't. It's just like people. Some people have some sensibilities about lots of things and some don't.

Can we really characterize all of one gender or the other to think and feel the same way?

I would say you would get one type rather than another to respond to a radio such as this and that's why it seems like the whole world must think this way and I can understand why this would be confusing to the opposite gender.
belinda

 
At Tuesday, September 03, 2013 5:34:00 AM, Anonymous Anonymous said...

Al:
As far as I'm concerned, that's radio BS. I have lived many years and I have never heard any women talk like that. Most of the women I know and am close to don't even talk much about that sort of thing, but then again most of us haven't bought into that whole yearly gyno thing: absolutely unnecessary! And also most of the women I know would go to a woman gyno if there was ever a need to see one. I think in this day and age, with everything being so sexually charged, a lot of people think that kind of talk is "entertaining". Just look at tv, movies, etc. You almost can't find a show that doesn't have constant sexual banter, joking, innuendos, etc. It actually gets boring after a while. Nothing is private anymore. Jean

 
At Tuesday, September 03, 2013 2:23:00 PM, Anonymous Medical Patient Modesty said...

Al,

A majority of women would not talk that way. Most women dread having gynecological examinations even by female doctors. There are a few exceptions. I have interacted with some women who loved their male gynecologists. I have been very concerned about how one of my friends who used to work for a male gynecologist as a medical assistant talks about how she loves him and how wonderful he is. She has convinced many of her friends to go to that practice. I found it very bizarre that she wanted him to deliver her second baby after working for him. She was his chaperone for many women he did intimate examinations on. It really bothers me a lot that this friend thinks that modesty is so important, but that it does not matter in medical settings.

Many women (especially in smaller towns) before 1990 had no choice because there were hardly any female gynecologists. The truth is many women were actually uncomfortable with going to male doctors for intimate examinations, but they gave in for their “health”. My mom’s family doctor encouraged her to have a pap smear when she was 19 and she refused. But then later, she gave in to having a male doctor for intimate examinations. There were hardly any female gynecologists when I was born in 1979. Many women who have high modesty standards fell to the cultural blind spot that it is okay for doctors to do anything. I shared my concerns about male gynecologists with my mom when I was a kid. She ignored me for years. But when I grew up, she listened to me. She has not been to a male gynecologist in 13-14 years.

Since I started Medical Patient Modesty, I have learned about so many cases where male doctors abused women during intimate examinations. Some of the women who have contacted me shared how they regretted letting a male doctor do intimate examinations on them. I do not know if you’ve had a chance to look at the article, “Why Women Should Avoid Male Doctors For Intimate Female Health Issues?”

Look at this disturbing article about how some women were abused by male doctors in Kenya, Is your wife safe with her doctor?

Also, look at some disturbing articles about how some male medical professionals have been accused of filming female patients that have been in the news this week.

Hidden camera doctor faces jail after admitting hospital gown sex assault

Woman finds mobile filming her in diagnostic centre's changing room

Family doctor who used £60 spycam watch to film intimate examinations of hundreds of women is banned from profession

Didn’t you share that your wife only had female gynecologists when she had both children in the 1960’s? How did she find the female OB/GYNs? It is my understanding that female OB/GYNs were extremely hard to find in the 1970s and before that.

Misty

 
At Tuesday, September 03, 2013 4:20:00 PM, Anonymous StayingFit said...

Everyone, thanks for your responses. I wanted to let you know that I spoke with a nurse from my urologist's office, and she was very surprised that the consent form mentioned the presence of cameras, and the taking of photographs and video recordings. She stated that there are certain procedures that require a photograph, for medical purposes, but she was completely unable to explain the part about closed-circuit cameras and videos.

I told her that I would cross item out, and indicate that I did not give such consent. She agreed and told me this would not invalidate the form.

As for the assistant, on this they seem unwilling to bend. The nurse indicated that this person is needed, in order to setup the instruments and to monitor my vital signs during the procedure. It seems to me that the instruments could be laid out prior to the procedure, with no need for her to remain. Also, as I will only have local anesthetic, I can't imagine why someone would need to monitor my vitals. She could not dispute this, but she insisted that an assistant would be present.

PT, Don, and Ed, thanks much for sharing your knowledge on this! As it turns out, I will probably need to change doctors, because the one that I saw the other day does not do the “no scalpel” type that I would prefer. Unfortunately, I did not learn this until the nurse called about my concerns with the consent form. When I call to arrange to be seen by a doctor who does perform that method, I will also ask for one who is willing to do this without an assistant.

 
At Tuesday, September 03, 2013 5:31:00 PM, Anonymous Medical Patient Modesty said...

StayingFit,

I strongly recommend that you check out other urology clinics. You might have to drive farther, but it is worth it. I strongly recommend that patients drive as far as they have to find a practice willing to accommodate their wishes for modesty.

It is possible for an urologist to do the vasectomy by himself. If you cannot find an urologist willing to do the vasectomy by himself, you should do research on urologists who have male nurses and assistants.

I encourage you to write a letter of disappointment to this urology clinic you've been considering having the vasectomy at. They need to know that you have chosen to not use them because they are not sensitive to male patient modesty.

Misty

 
At Tuesday, September 03, 2013 6:13:00 PM, Anonymous Anonymous said...

StayingFit


You would never need to have your
vitals monitored for a local anesthetic.Why? During
a wisdom tooth extraction did they monitor your
vitals then, no. That dental procedure requires
more anesthetic than a vasectomy and many
women undergo childbirth with no medications
at all. Ask that wanna be nurse what her thoughts
would be if a young male was in the room handing
her female mammographer film cassettes or her
female gynecologist a lubed speculum during her
next pap smear.

PT

 
At Tuesday, September 03, 2013 6:55:00 PM, Anonymous Anonymous said...

StayingFit, you're talking to the wrong folks about the assistant. Recommend you speak with the physician directly and firmly state your intention of taking your business elsewhere if he insists on the assistant. I'm betting he'll roll over on this one since you're undoubtedly not the first to make such a request.

Ed

 
At Tuesday, September 03, 2013 7:54:00 PM, Anonymous Anonymous said...

Misty.

You have a good memory. It was actually in the early 70's that she went to her female Ob-Gyn. She found her the old fashion way. You looked in the phone book and through word of month. I believe there were several females to choose from but you had to look hard and drive to get to them. We drove 35-40 miles one way to get to them. My wife wanted a one doctor or a all female practice to avoid the male that may be on call. We passed up 6 or 7 hospitals to get to the one she practiced at. I can't say enough good things about her. She treated you like one of her children. ( She was in her 70's ). My wife asked her if I could come into the exam room on her first visit, and I continued going in until the day she delivered. During her Ob visits the doctor would show me the changes she was going through. I know there are doctors just like her out there. If you don't find one the first time, try again. To many people just except what's offered and don't question anything. You need to voice your concerns and be prepared to go someplace else. If more people would do that maybe things might slowly change. Take care AL

 
At Tuesday, September 03, 2013 8:30:00 PM, Anonymous Medical Patient Modesty said...

StayingFit,

Both Ed and PT made excellent points. I agree with Ed that you should talk to the doctor directly. You should make an appt. to meet with him alone. If he cannot honor your wishes, then do research on other urology clinics to determine which ones are willing to accommodate your wishes. I strongly recommend you consider having a personal chaperone such as your wife present for the vasectomy to ensure that no females walk in the middle of the procedure. You could have the personal chaperone sit against the door of the examining room to ensure that no one can come in.

Misty

 
At Wednesday, September 04, 2013 6:08:00 PM, Anonymous Medical Patient Modesty said...

AL,

It was so easy for me to remember your wife’s story because I thought it was amazing that she found a female OB/GYN who delivered her babies in the 1970’s. Female OB/GYNs were very rare then. I’m not sure if there were any female OB/GYNs in North Carolina in 1970’s. There might have been a few female doctors in Charlotte area. I did read about a female OB/GYN from Nashville, TN who has been practicing before 1980.

Did you all find a female OB/GYN in a large city? What state were you all in? I know California and Texas both have a lot of all female OB/GYN practices. In fact, one of the largest all female practices in the US is in Houston: Houston Women’s Care Associates

Many rural areas in the US have no or almost no female gynecologists. My 20 year old cousin was the first one in my family to be delivered by a female OB/GYN. In 1993 when she was born, there were only a few female OB/GYNs in a bigger city that was 30 minutes away. My aunt before she got married in 1991 was required to have a pap smear / pelvic exam before she could get a prescription for birth control pills. Fortunately, she found a female family practice doctor in her small town to do the exam. We all know the truth that pelvic exam / pap smear is unnecessary to get a prescription for birth control pills. My aunt stayed with the female OB/GYN who delivered both her daughter and middle son, but the female gynecologist joined a practice that also included male OB/GYNs a few years later. You had to take whoever was on call. My aunt ended up having one of the male doctors for an appointment to have pap smear years later. If I had been her, I would have cancelled the appointment.

I am also very disappointed in how many urology clinics do not have male nurses or assistants available to assist with male patients. I’m grateful for the all male urology clinic in San Antonio and I hope that more similar urology clinics will be started in the US. I wonder if urology clinics in rural areas are less likely than urology clinics in bigger cities to have male nurses or assistants.

Misty

 
At Thursday, September 05, 2013 9:05:00 AM, Anonymous Anonymous said...

I had a disturbing personal conversation with a CNA at my local hospital this week, quotes of which I thought I would share here. I was asking her about where she went to school. She revealed that she had gone from working at a local non-medical business to working in ICU after her six-week course at the community college. She had in fact just finished her recertification. She then proceeded to tell me that she really wants to get her CNA II training next because she "really wants to shove a catheter into a man" while making arm gestures as to how she would do it. She then said, "not women though (making a grimace) just men". She then smiled and said, "I'm mean ain't I". I was so struck by these comments that I felt physically ill. Many of the comments/stories from this blog flooded my mind as to how male patients are treated by female medical staff. By the way, this was no twenty something, this was a middle-aged woman. One of my comments to her in response was that I was shocked that they would allow someone with such a low level of education to perform such an invasive procedure that has potential to injure patients. Blank stare. This experience and others after working in the medical field for the last eight years has taught me that no amount of "professional" training/certification guarantees good moral character and trustworthiness. Knowing what I know, if I were male, I would never, ever let a female insert a urinary catheter in me. LKT

 
At Thursday, September 05, 2013 4:00:00 PM, Anonymous StayingFit said...

T,

Thanks for confirming that there would be no need to monitor my vital signs during a vasectomy. I thought that was a pretty weak excuse. Also, the situations that you cite make a good point, and might help her to see this from my perspective.


Ed,

You are right that working directly with the doctor would be the most effective way to handle this. It is likely that I am going to need to change doctors, anyway, so I expect to have an appointment with the new one, even if he is part of the same practice. When I do, I will be sure to bring this up.

Misty,

Thanks for your advice, and I do intend to pursue other options. I have to wait until I get the results of the ultrasound that this urologist ordered (the vasectomy was not the primary reason that I had to see him). But, assuming that all goes well with that diagnosis, I will then be able to see what my options are with the vasectomy.

And, yes, if this forces me to another practice, and not just another of the doctors within this practice, I will definitely let them know why.

 
At Thursday, September 05, 2013 4:48:00 PM, Anonymous Anonymous said...

Hello.

All this talk about urology got me thinking. Does any urology departments in my area employee male techs. So I called 5 or 6 of the largest centers. What a experience that turned out to be. I can see why so many men get frustrated and just give up. I couldn't get a straight answer from any of them. One said the female nurses will take your vitals then leave you alone with the male doctor. Ok, fair enough. Another said they have 1 male nurse and 1 male NP. Sounding better. After some discussion it turns out urology has 2 departments. One clinical and one for procedures. And no, there are no male nurses in the procedure department. I tried 1 or 2 others and just gave up. I now know what people mean about being ambushed. Hopefully if enough of us call and ask question, something good will become of it. Otherwise were screwed. Take care. AL

 
At Thursday, September 05, 2013 5:59:00 PM, Anonymous Anonymous said...

LKT,
You just gave another example of the culture in medical operations. The CNA you talked to will be rated a good employee if she does her assigned procedures. Remember, it's not about the patients.
BJTNT

 
At Friday, September 06, 2013 6:33:00 PM, Anonymous Anonymous said...

I'm shocked that they are letting anyone with less than an RN certification do a catheterization on anyone. Of note, refusing them verbally does no good: They can be put in while the patient is under anesthesia. The place to withhold consent/refuse is on the blanket consent form - which you CAN alter before admission. They'll tell you that you can't, or shouldn't, but when you get up and even threaten to go somewhere else, they back down.

If it's a verbal refusal, they may do it anyway, or it may be done by another individual (e.g., of the opposite sex). That comes down to "he said, she said", and it's nearly impossible to prove, so getting an attorney to take the lawsuit is next to impossible.

It's a sad situation whereby a patient has to set up for proving his wishes were not adhered to in court to get those wishes taken seriously, but that's the way things are.

--- Injured by a catheter placed in violation of consent.

 
At Saturday, September 07, 2013 12:04:00 PM, Anonymous Medical Patient Modesty said...

The female CNA that LKT interacted with the other day reminds me so much of the “Juicy Nurse” . It is very clear that this female CNA has no respect for male patients. I wish she would be fired from her job. I believe that male patients are mistreated by female medical staff far more than we can imagine. Most men won’t speak up or file complaints when they are mistreated and that’s why we rarely hear about abuse / mistreatment of male patients by female medical staff in the news. It is also scary to think about how this female CNA may injure some male patients due to her lack of experience and compassion & respect for men. It would not surprise me if she does many unnecessary urinary catheters. The truth is so many urinary catheters are actually unnecessary. This is exactly why I wrote an article about how informed patient consent is missing from urinary catheters. I provided tips in this article about how patients can prevent an urinary catheter from being inserted against their wishes. I personally do not think that they should allow CNAs to insert urinary catheters. I found this discussion: Please enlighten me, is the cna allowed to insert urinary catheter in any state? very interesting. Some states apparently do not allow CNAs to do urinary catheters.

As I mentioned in previous posting, I am very concerned that layoffs at hospitals could restrict patients’ choices for preferences for same gender intimate care. I think budget cuts at hospitals will also force them to hire more less experienced CNAs like the CNA that LKT mentioned. I suspect that the CNA may have went into the medical field with the purpose of humiliating and mistreating male patients based on the comments she made.

LKT is correct that no amount of professional training guarantees good moral character and trustworthiness. So many doctors, nurses, and CNAs have mistreated and abused patients. I am tired of hearing them saying, “Do not worry. I have seen everything and I’m a professional”.

I was very honored to help a man who was concerned about modesty during colonoscopy to take steps to ensure that his wishes for modesty and all male team were honored recently. He spoke to the head nurse (female) and the doctor and they were willing to accommodate his wishes for colonoscopy shorts, no sedation, and an all male team. In fact, he said that the female head nurse said that they wanted to do whatever to make him comfortable. It is very clear she is a compassionate nurse.

It is very disturbing about how many urology clinics do not make efforts to hire male nurses and assistants. I wish that many urology clinics would be bombarded with calls asking if they have male nurses and assistants for male patients everyday so they would see that it is a serious issue. I believe that many men just avoid going to the doctor rather than speaking up about their modesty concerns. Some men do not have any intimate male exams or procedures until they are in their 50’s or 60’s if they never had sports physical exams or vasectomies I am very concerned about modest young men who may have urological problems that require a visit to the doctor for the first time. Many of them may not be aware that female nurses or assistants may be present. I think that the reason there are many all female OB/GYN practices in the US is due to a lot of women speaking up that they did not want male medical professionals to be part of their medical care. There are still many small towns and some big cities such as Roanoke, VA in the US that have no or not enough female OB/GYNS.

Misty

 
At Saturday, September 07, 2013 12:12:00 PM, Anonymous Medical Patient Modesty said...

I was not able to post all of the comments in the previous posting so I am posting more comments I wanted to post below.

The discussion about male patient modesty concerns on this blog has been very helpful to me as the founder of Medical Patient Modesty. Our organization is still in beginning stages. I hope that someday when we get the needed funding that we can contact many urology clinics all across the US addressing how important it is for them to hire more male nurses and assistants to accommodate male patients. There are certainly some procedures that can be done on male patients by male urologists without assistance.

It is personally hard for me to understand why female nurses and assistants would want to participate in intimate male procedures. If I were a female nurse or doctor, I would refuse to do any intimate male procedures. Gender neutrality in medicine has really hurt many women and men. One hospital in Salt Lake City, UT is so gender neutral that they even assign male nurses to the OB/GYN department. One lady who had a hysterectomy requested an all female team for her hysterectomy and her wishes were ignored completely. When she complained to the hospital and the female doctor, she was told that all medical professionals were “professionals” and that gender did not matter. I’m sure that at this hospital that there are many female nurses in the Urology department for male patients. This hospital should move all of the male nurses from the OB/GYN department to work with male patients in Urology department. I am so tired of medical facilities being gender neutral. There have been so many consequences. Look at how a male patient care technician has been charged with sexually assaulting a female patient according to a news source.

Misty

 
At Saturday, September 07, 2013 4:34:00 PM, Anonymous Anonymous said...

Catheters used to be placed in male patients by orderlies. Does anyone know what kind of training they had?
belinda

 
At Saturday, September 07, 2013 6:09:00 PM, Anonymous Anonymous said...

I have a challenge for all the ladies here. Call several urology clinics near you. Tell them your calling for your modest husband. Tell them he's having problems down there and will probably be needing a urologist soon. Ask if they have male nurses since he would never agree to female staff present. That's the main reason he hasn't gone in already. I think you may be surprised by what they say. Please share the comments with us. Thanks. AL

 
At Saturday, September 07, 2013 6:58:00 PM, Anonymous Medical Patient Modesty said...

AL: Your challenge is a good idea.

I have been doing a little research. I found this very interesting discussion: Nursing Care Restrictions In The Past. At some hospitals in the past, female nurses were not even allowed to do intimate male procedures.

Misty

 
At Sunday, September 08, 2013 7:26:00 PM, Anonymous Anonymous said...

AL


Who said anyone here is modest, referring to
" ladies calling urology clinics for their husbands. I
want the same respect that any female gets when
they get their mammo or a visit to L/D, simple as
that. I believe that by telling the wives to call a
urology clinic sets their husbands up for failure.

That it eliminates the discrimination factor as
well as removing the possibility that female health
care workers are in no way culpable for any un-
professional behavior. Thus labeling male patients
modest which by the way it seems OK to do so
when it's a male patient but not female. What's
up with that AL.

Furthermore, you said previously that " I guess
we are all screwed." Who is the payer and the
payee in this transaction. I get sick, sick and tired
when it is mentioned that " I guess we have to go
elsewhere" mentality. I am not going anywhere else.

I am the patient, it is they who will have to adapt
to my needs. The insurance company decided that
xyz urology clinic would best serve my needs. They
did NOT ask me when the decision process of who
is on my plan! They have to provide the same care
in the same packaging when it is provided to me
that some female patient would get. Otherwise the
insurance company is just as discriminatory as the
urologist.

It about time this discriminatory practice ends
let alone talked about in forums like this. There
should not even be a discussion forum on this
subject, it's pathetic.

Ever notice these law schools are pumping out
more grads than there are jobs for them. They have
lots of student loans to pay off and they are hungry.

PT

 
At Monday, September 09, 2013 11:51:00 AM, Anonymous Medical Patient Modesty said...

I wanted to let everyone know that Dr. Sherman responded to my concerns about the unethical female CNA that LKT interacted with on the article I wrote about urinary catheters. He agrees that the comments that the CNA made were very disturbing.

Misty

 
At Monday, September 09, 2013 8:22:00 PM, Anonymous Anonymous said...

There are cna's who insert urinary catheters and
if anyone feels that is disturbing most emergency
rooms have their ER techs doing that. Who are ER
techs, people with less training than a cna.

Remember, state nursing boards govern licensing
of cna's,yet there is no governing agency over an ER
tech. Cna's have a license, ER techs do not. In fact,
state nursing boards revoke more cna's than rn's or
lpn's.

Patient abuse tends to be the number one reason
for cna license revocation. Their scope tends to vary
from one hospital to the next.


PT


 
At Thursday, September 12, 2013 8:56:00 AM, Anonymous Medical Patient Modesty said...

I am not sure how many of you saw this, but a lady sued a hospital over a transvaginal ultrasound that went bad. You can check out the article. This can also be a patient modesty issue because she should have been offered the option to have an abdominal ultrasound instead. Many patients are unaware that abdominal ultrasounds can be as good as detecting some issues such as ovarian cysts as transvaginal ultrasounds.

Misty

 
At Thursday, September 12, 2013 10:54:00 AM, Blogger Maurice Bernstein, M.D. said...

Despite all the controversy written to this Patient Modesty thread about patient visual or physical contact by the healthcare provider, the new thread I just published here on my blog Eye to Eye Communication and Laying On of Hands: Anachronistic Medicine?" presents an 18 minute video by a physician who explains why eye to eye communication and the "laying on of hands" is not becoming out of date and should be continued to be taught to our medical students. ..Maurice.

 
At Saturday, September 14, 2013 7:25:00 PM, Anonymous Medical Patient Modesty said...

There are some articles on Medical Patient Modesty about male patient modesty and urological procedures. I feel we need to update and add more information. I really appreciate some of the men bringing some important issues to our discussion in this forum.

I would like to do research about why a number of men are resistant to having vasectomies. I believe that patient modesty is probably one of the reasons some men refuse to have vasectomy. One of my cousins who had 3 children felt her family was completed so she asked her husband to have a vasectomy and he refused. She ended up having a tubal ligation herself. Tubal ligations have some risks. You usually have to be put under anesthesia for tubal ligation while only local anesthesia is necessary for vasectomy. Tubal ligation can easily be done on a woman right after she has a C-Section. I have done some research on Essure . This procedure can be done in a gynecologist’s office. But I’m concerned that it may be riskier than vasectomy. I am concerned that essure inserts may cause some complications. Look at some stories of women who experienced serious problems from Essure. I also feel Essure is more invasive than Vasectomy. I personally do not know of any women who had Essure. I do not think it is wise for a woman to use birth control pills until she reaches menopause because long term use of birth control pills increases a woman’s chance of getting breast cancer. Also, birth control pills often cause women to gain weight. I think birth control pills should only be used temporarily until a couple feels their family is completed.

It is very disturbing that many urology clinics use female nurses for vasectomies. I know that many vasectomies actually can be done by the urologist without assistance. Have any of you ever heard of any men who refused to have a vasectomy because he did not want a female nurse or assistant to be part of his procedure? Vasectomy is a good and safe permanent birth control method based on research I’ve done so far.

Check out the story of Brett who was concerned about his modesty during vasectomy. Fortunately, his urologist employed male nurses for male patients.

Misty

 
At Sunday, September 15, 2013 7:46:00 PM, Anonymous Anonymous said...

It should be noted that most Urologists do not hire
nurses in their practice, rather medical assistants. At
this time there is no governing body overseeing medical
assistants and the scope of their practice. Very disturbing.

PT

 
At Sunday, September 15, 2013 11:00:00 PM, Anonymous Anonymous said...

Beauticians have more stricter rules and professional
licensing than medical assistants.

www.medicalassistantsite.com

One physician uses student medical assistant student and his reason " every 3 months I get these ma students and I never have to pay them."

One physicians uses his medical assistants to actually perform skin exams.

This site found using Yahoo, called
Medical assistant is a stupid career

www.indeed.com/forum/medical-assistant/medical-
assistant-is...

Go to page 38

PT



 
At Wednesday, September 18, 2013 10:25:00 AM, Anonymous Medical Patient Modesty said...

I wanted to let you all know that they put an article about Medical Patient Modest and the walkathon that I am organizing in a newspaper last week at http://themountaineer.villagesoup.com/p/waynesville-woman-creates-nonprofit-to-help-promote-medical-patient-modesty/1054893. I hope that many people who read this article will take time to learn about Medical Patient Modesty. Many people are unaware about unnecessary procedures and how their wishes for modesty can be easily violated in medical settings. I enjoy helping to empower patients. I really appreciate all of the great insights you all have shared on this blog. I’ve been busy trying to raise funds lately, but I hope to do more articles in the near future.

Does anyone here have suggestions about how we could do a survey for at least 1,000 men asking if female nurses or modesty concerns hinder them from having a vasectomy? I am very interested in doing research about why a number of men refuse to have a vasectomy once their wives and they agree that they are done with having children and if modesty is a top reason.

Misty

 
At Wednesday, September 18, 2013 6:52:00 PM, Anonymous Anonymous said...

Misty, you might want to focus on what makes men uncomfortable and not focus on one procedure. There are many where modesty is compromised.

Doing a broader scope survey would focus only on modesty issues instead of vasectomy.

For instance, some men might not want to have it done because they think it will devalue them as a male. Some may not want to have it done because they are not married, or, unhappily married and may want to marry again.

If the survey is broader and focuses on psychological comfort you will get a more valid response.

Good luck and congrats on all your hard work
belinda

 
At Sunday, September 22, 2013 6:06:00 AM, Anonymous Anonymous said...

"The comment suggests there are patients who may find ultimate comfort in hospital care. The Anonymous visitor writes:
"They want to stay because its the closest they have ever been to God-like care and consideration in their lives."

It's also possible that many are perverts who want to visit a brothel-like setting paid for by their insurance company or the government.

 
At Sunday, September 22, 2013 6:30:00 AM, Anonymous Anonymous said...

"the medical community (including me prior to starting this thread)is unaware that there is a problem."

Where do they find these medical people that are so stupid that they honestly don't understand morality? Have they never used a male/female restroom or locker room? Did they grow up in nudist colonies where nudity is ignored? Have they never been involved in American society? Almost all of us have been taught since infants that seeing or being seen naked by the opposite gender outside of relationships is wrong.

How can any medical personnel possibly claim they have no knowledge that most people don't want to be seen naked or fondled, especially by non-crucial staff members? Were they all raised on another genderless planet?

 
At Sunday, September 22, 2013 6:21:00 PM, Anonymous Medical Patient Modesty said...

Anonymous on September 22, 2013 at 6:30 AM:

You have asked some very excellent questions. I have done some research and found out some medical professionals were actually very uncomfortable with doing intimate exams or procedures on the opposite sex when they started nursing or medical school. In fact, I know of a male Christian nursing student who was very upset about how he was going to have to do breast exams in nursing school because that went against his convictions. He also was very hesitant about giving a female patient a bath. Sadly, he got so desensitized that he finally gave up his convictions and gave in. Nursing and medical schools work to desensitize you to accept that private parts are not sacred and just like elbow. I encourage you to read this great article: Nudity and Christian Worldwide. The article focuses primarily on nudity and sex scenes on TV shows. But it has many points that we can apply to medical settings. Many people who continue to watch sex scenes and nudity on TV become desensitized.

I believe that many nurses and doctors go through desensitization process that make them insensitive to patient modesty. There are some great doctors and nurses who will accommodate patients’ wishes. But gender neutrality is very common in medicine today. If you look at history, male doctors were not allowed to examine private parts of women centuries ago. You should check out historical progression of pelvic examination . Also, male orderlies and doctors took care of male intimate health issues years ago. Morals in America have really gone downhill. Are you aware that some places are considering having gender neutral restrooms in the US?

My elderly grandfather has dementia and fell a lot recently because he has low sodium. I have helped some, but I never want to see him naked because I do not feel it would be appropriate for me to see him. He still deserves dignity and respect even if he has dementia. My grandma has changed his diapers and given him a bath. I refuse to help with those tasks or be present. I was taught when I was a kid that I could not see him naked. I do not feel that I should see any man who is not my husband naked.

Misty

 
At Sunday, September 22, 2013 6:24:00 PM, Anonymous Medical Patient Modesty said...

Anonymous on September 22, 2013 at 6:30 AM:

You have asked some very excellent questions. I have done some research and found out some medical professionals were actually very uncomfortable with doing intimate exams or procedures on the opposite sex when they started nursing or medical school. In fact, I know of a male Christian nursing student who was very upset about how he was going to have to do breast exams in nursing school because that went against his convictions. He also was very hesitant about giving a female patient a bath. Sadly, he got so desensitized that he finally gave up his convictions and gave in. Nursing and medical schools work to desensitize you to accept that private parts are not sacred and just like elbow. I encourage you to read this great article: Nudity and Christian Worldwide. The article focuses primarily on nudity and sex scenes on TV shows. But it has many points that we can apply to medical settings. Many people who continue to watch sex scenes and nudity on TV become desensitized.

I believe that many nurses and doctors go through desensitization process that make them insensitive to patient modesty. There are some great doctors and nurses who will accommodate patients’ wishes. But gender neutrality is very common in medicine today. If you look at history, male doctors were not allowed to examine private parts of women centuries ago. You should check out historical progression of pelvic examination . Also, male orderlies and doctors took care of male intimate health issues years ago. Morals in America have really gone downhill. Are you aware that some places are considering having gender neutral restrooms?

My elderly grandfather has dementia and has been falling a lot recently because he has low sodium. I have helped some, but I never want to see him naked because I do not feel it would be appropriate for me to see him. He still deserves dignity and respect even if he has dementia. My grandma has changed his diapers and given him a bath. I refuse to help with those tasks. I was taught when I was a kid that I could not see him naked. I do not feel that I should see any man who is not my husband naked.

Misty

 
At Sunday, September 22, 2013 7:25:00 PM, Anonymous Medical Patient Modesty said...

Belinda,

Thank you for the compliment!

I agree with you completely that it is important to address modesty concerns for many other intimate procedures on male patients. The big difference between vasectomy and many other male procedures is that vasectomy is an elective surgery that men choose for permanent birth control. Also, there are many healthy men who may have never gone to the urologist because they did not have any urological problems before who want to have a vasectomy. I have a special interest in addressing modesty concerns for vasectomy because a number of men who are happily married refuse to have vasectomy after they have mutually agreed with their wives that they are done having children. I was disturbed when one of my cousins shared that she wanted her husband to have a vasectomy, but he refused. She ended up having her tubes tied instead. My cousin experienced some bad side effects of birth control pills and she definitely did not want to continue them. Tubal ligation is much riskier than vasectomy. They seem to be happily married so I do not think that played a role. They both mutually agreed that they only wanted 3 children. I know some men are afraid that there will be a lot of pain with vasectomy. You are right that some men believe the myth that vasectomy will devalue them as a male.

Many women would be upset if their husbands had vasectomies with female nurses present. One lady shared with me about how it bothered her that her husband had a female nurse present for his vasectomy.

I would love to do a survey with happily married men who know without doubt that they do not wish to father any more children about reasons why they avoid vasectomy. I wonder how many men would avoid a vasectomy because they are concerned that females may be involved in their vasectomy.

Brett shared about how he was concerned about possible embarrassment of vasectomy. He did not want any female nurses. Fortunately, his urologist employed male nurses. Brett definitely had concerns about his modesty as you can see.

Misty

 
At Monday, September 23, 2013 12:21:00 PM, Blogger Doug Capra said...

Misty and belinda

Let me see if I understand where you're coming from on this. Correct me if I'm wrong.
You seem to be saying that there is something innately wrong, objectively immoral, about cross-gender intimate care in medicine, regardless of whether the patient minds and/or permits it. Is that correct?
Thus, if the patient permits cross-gender intimate care, there must be something wrong with the patient's moral compass, correct? Thus, the patient shouldn't be given that choice, correct?
As I see it, you mix what I consider to be two separate aspects to cross-gender care and gender-neutrality. The first -- a medical professional's ability and to administer cross-gender intimate care. The second -- the patients choice of whether to receive cross-gender intimate care.
As I see it, medical professionals must be trained to administer cross-gender intimate care. And they must be willing to do it, especially in emergencies or when no one else is available.
The other aspect of cross-gender care and gender neutrality is from the patient perspective. This is where I agree with you. The patient must have that choice.
Now, what happens from a provider point of view, I think, is that they begin to believe that because they are gender neutral the rest of society should be gender neutral. Some become convinced of this, and that affects their attitude toward patient choice. Some of these providers may not care what gender treats them during intimate situations. Others may care, but don't see the double standard or choose not to see the double standard.
But, if you're saying that medical professionals shouldn't be allowed to treat the opposite gender during intimate care -- then I disagree with you. If you're saying that, you're also negating the patient's ability to choose, for whatever reasons, the gender they desire.

 
At Monday, September 23, 2013 12:33:00 PM, Blogger Doug Capra said...

Misty
I want to comment on the recent article you provided for us. I will quote the first two paragraphs and comment:

"The most precious and sacred form of personal information that we possess is our body. It is our own flesh and blood, which holds and sustains our being. Our body is our instrument for living. It is so personal and intimate that we frequently hide it, as though its public display would be a natural source of shame. Michel de Montaigne, the French Renaissance author, puts it well: "Man is the sole animal whose nudity offends his own companions and the only one who, in his natural actions, withdraws and hides himself from his own kind" (1).

Thus, it not surprising that visiting a physician and allowing for an intricate inspection and examination of our dearest possession, our body, is a source of trepidation and anxiety for us. Perhaps the deepest level of vulnerability in an exam is the genital and pelvic examination. A glimpse into history demonstrates that until very recently, pelvic examinations in women were handled by females, likely to ensure comfort and privacy all the while preventing improper interactions from male counterparts."

MY COMMENTS

Notice the gender neutral language:
"that we possess is our body." It's "we" and "us," which is inclusive of both genders.
"Our body is...we frequently hide it..." Again, it's all about us and we.
Note the last sentence of the first paragraph that begins with :Man is the..." and ends with "...his own kind." Here we actually use a male gender noun and pronoun.
In the second paragraph we get "...our dearest possession, our body, is a source of trepidation and anxiety for us." Again, gender neutral language.
Then -- WHAM -- the last paragraph of the second paragraph jumps from all this gender neutral language to a female specific exam.
I mention this because this is typical of studies like this. It's rare for the WHAM to ever go to any kind of male illness or exam.
This is the "pretend" gender equity that we're dealing with in medicine. The premise is always for gender equity, equal treatment, gender neutrality. But when the rubber meets the road, it's all about female modesty.
Interesting, isn't it?




 
At Monday, September 23, 2013 1:52:00 PM, Blogger Maurice Bernstein, M.D. said...

I am with you Doug on both of your posted comments.

If patients express any concern regarding their body either covered or uncovered, my experience is that it is about the underlying defect within their body which led them to be seen and evaluated by the physician. And it is precisely the goal and attention of the physician to discover that defect and fix it.

One point that I might vary from Doug's conclusion is from the physician's point of view, physicians are not taught in their training in any way to be "gender neutral" or treatment or relationship to the patient should be in any way "gender neutral". One of the first items on the physical exam in the "general description" of the patient is to establish the patient's gender. From there, the doctor-patient relationship is guided by the gender, the differential diagnosis is guided by the gender and how the patient is examined is guided by the gender. And certainly, as shown by the discussions here, the patients themselves don't look at, define nor relate to the physician or any of the the other healthcare providers as "gender neutral". So, who looks at who as "gender neutral"--- nobody! "Gender neutral" description of a human in essence changes a human subject into simply an object. And, in my view, neither patients nor physicians are objects, physically, legally or morally. ..Maurice.

 
At Monday, September 23, 2013 6:17:00 PM, Anonymous Anonymous said...

Not sure i follow you Dr. Bernstein I have seen comments such as, I am not a male or female nurse I am a nurse over and over. Providers constantly tell us we should not see them as male of female but as professionals. The idea of gender nuetral among providers has and is put out there constantly other than the anatomy of the paitent. Sorry I think your stretching here. No we do not see the provider as gender nuetral, no the patient is not seen as genderless by the provider, but when it comes to modesty all of a sudden that definition changes and we are not to see the provider by gender, so the view of a patient genderless is selective by providers when it fits their needs...don

 
At Monday, September 23, 2013 6:28:00 PM, Anonymous Anonymous said...

"So, who looks at who as "gender neutral"--- nobody! "Gender neutral" description of a human in essence changes a human subject into simply an object. And, in my view, neither patients nor physicians are objects, physically, legally or morally. ..Maurice."

The most succinct and eloquent summation of the issue yet! I wish all providers would conduct their interactions with patients from a similar empathetic, ethical, and professional stance!

Ed

 
At Monday, September 23, 2013 7:00:00 PM, Anonymous Anonymous said...

My concern is not with MDs when it comes to patient modesty, but with the rest of the staff. MDs have the education, training, and hopefully the experience that entitle [my belief] them to perform cross-gender care. None of the staff has that qualification.
Why is the discussion about MDs? Do they hire the staff or even make the decision on who is hired? I agree that MDs are the only hope to change medical operations because the administrators are not concerned with patient modesty. Oh, the administrators will say they are concerned and certainly have a policy, but that's just lip service. BJTNT

 
At Monday, September 23, 2013 7:11:00 PM, Anonymous Anonymous said...

We patients are the problem. Medical operations {MO} personnel not only restore our health, but on occasion save our lives. How ungrateful can we be? Not only are we ungrateful, but we patients have the unmitigated gall to criticize the good guys.
So what if there is unnecessary genital exposure, the good guys are restoring our health, if not saving our lives. Isn't the exposure worth it?
So what if there are unnecessary eyeballs in surgery when we are unconscious and naked, the good guys are restoring our health, if not saving our lives. We unconscious patients are unaware of the exposure and should only be concerned with the great deed done for us. And yet we are critical of MO personnel.
P.S. - How many times do we hear a patient say that her MD was happy that she lost "n" pounds. Who cares if the MD is happy about this? Then again, "it's all about them" and not the patients. What a culture that MO has imposed on us patients - politicians take heed how it's done.
BJTNT

 
At Monday, September 23, 2013 7:15:00 PM, Anonymous Anonymous said...

My concern is not with MDs when it comes to patient modesty, but with the rest of the staff. MDs have the education, training, and hopefully the experience that entitle [my belief] them to perform cross-gender care. None of the staff has that qualification.
Why is the discussion about MDs? Do they hire the staff or even make the decision on who is hired? I agree that MDs are the only hope to change medical operations because the administrators are not concerned with patient modesty. Oh, the administrators will say they are concerned and certainly have a policy, but that's just lip service. BJTNT

 
At Tuesday, September 24, 2013 10:12:00 AM, Anonymous Anonymous said...

Ok I understand a little better with the clarification Ed put on it
helped me focus. I think most of us on this thread agree, we are not gender nuetral, our gender is a huge part of who we are and who our providers are. That however does not stop the medical community from pushing that mantra for their own benefit. The question then remains the same, what can/are you, meaning YOU individually doing to change it...don

 
At Tuesday, September 24, 2013 4:15:00 PM, Anonymous Anonymous said...

Doug, I believe that Misty's positions are based from a moral and religious standpoint.

Mine are quite different. About half my life I never gave the gender of a heathcare provider any thought at all, even for intimate procedures. That all changed when I was sexually abused in a hospital. The cruel and degrading treatment was so severe that in another setting would be considered torture.

Since that time, I personally never want to feel degraded in a healthcare setting again. By keeping it gender specific, I am able to tolerate almost anything.

It is my opinion that mental health must come before physical health because without a healthy mind, you have nothing.

So, I have made the decision based on my experience that for intimate care or procedures, I do not want any men present.

The interesting thing is that both male and female staff were responsible for what happened that day. However, I find having males present now for intimate procedures intolerable and I choose an all female team.

I hope this clears things up.
Belinda

 
At Tuesday, September 24, 2013 6:14:00 PM, Anonymous Anonymous said...

Don. I'm a volunteer member of a online forum about consumer opinions for a local hospital. They usually ask questions about what color the walls should be or the color or style of the providers clothes or the design of their signs. Usually at the end there is a comment box. That is where I ask the question they never will. I tell them unless I get to choose the gender of all the people involved for all intimate care my family and I will never see the inside of their hospital or clinics. We'll go where we feel we are treated respectfully by giving us the choice.
Also, the past few months another hospital is running a TV add about how can we make health care better. So, I went online and gave them my two cents worth. Will it make a difference. Probably not but at least I tried. I would like to continue this, but I will be doing disaster relief in Colorado and will not have access. Keep posting and I'll read it when I return. Take care. AL

 
At Tuesday, September 24, 2013 6:36:00 PM, Anonymous María said...

Mr. Douglas, I really disagree with you this time "MDs must be rained to provide cross gender care". That's something I deeply disagree with. To begin with, intimate care is rarely, if ever needed to save a life. Second (I seethed as I read that) how many ear, nose & throat doctors, for instance, even remember how to do a breast or prostate exam properly, since they're so engrossed in their specialties?

 
At Tuesday, September 24, 2013 7:17:00 PM, Anonymous Medical Patient Modesty said...

Doug: Since the medical community has erred morally, dedication to patient education and advocacy is vital. It is impossible for one person to call the medical system to account for cross-gender examination offerings, even though it is morally significant from the perspective of the Creator. It is not impossible for the medical community to enforce patient choice of modesty. Patients must be able to maintain their freedom of choice in care. However, it is the moral responsibility of the medical community to conform to patient choices with respect to modesty. Medical Patient Modesty is devoted to educating patients in the opportunities they have for choice, and advocating for them with respect to modesty needs in order to re-introduce our culture to the concepts of gender that God intended. This is where the medical community lacks sensitivity and moral fiber. As a whole, the medical community may have abandoned the moral compass of God, but it is dealing with a patient base that has not. To force its lack of moral compass on the general population is no greater error than for one to condemn it for lacking a moral compass. In fact, it may rather be less socially desirable for the medical community to disregard the written choices of its patients than for one to call it to account before God.

I disagree with you that all medical professionals should be trained to administer cross-gender intimate care. Medical schools need to change their curriculum. Not every medical student should be required to learn how to do pelvic, genital, rectal exams, pap smears, and prostate exams. Why should a medical student who knows that he wants to be an orthopedic surgeon be required to learn how to do intimate exams? Also, think about how it makes no sense for a female medical student who desires to become a gynecologist to learn how to do urological procedures on men when she will never work with male patients. I think medical schools should eliminate the requirement that all medical students be required to learn to do intimate examinations. I encourage you to look at my discussion on Dr. Sherman’s blog about this issue . Look at my comments starting on April 3, 2013. Most life threatening issues do not require complete stripping of a patient. It is true that a female heart attack patient may need her blouse / bra removed to save her life, but she should not be stripped completely. I personally believe that medical professionals should try their best to provide some drapes to at least cover her breasts partially if possible.

Misty

 
At Wednesday, September 25, 2013 1:18:00 AM, Anonymous Anonymous said...

Don, having recently moved, I'm in search of a PCP, Urologist, and Dermatologist. I've considered calling different practices and inquiring about ancillary staff gender or simply choosing a practice, making an appointment, and standing my ground. Not sure which approach I'll choose.

Misty, just because the medical community doesn't conform with your narrow minded moral principles, that doesn't mean they've erred.

Many, maybe most, are OK with opposite gender intimate care and I respect that. I just want my preference (it is a preference because at the end of the day I'm not going to sacrifice my health because of it) respected in the same manner and that ought to be good enough for you too! The fact that you're not OK with it doesn't make you morally superior to anyone (patient or provider) who chooses otherwise.

Frankly, while I respect your opinion, extreme that is is, it's your opinion alone.

Ed

 
At Wednesday, September 25, 2013 5:28:00 AM, Blogger Doug Capra said...

Maria, Misty and belinda:
I'm trying to get at why you believe what you believe. This is how I interpret what I read above:
Maria -- You tell me you disagree with me but you don't say why. Why do you believe what you do? Why am I wrong?
belinda -- Your position seems to be a personal position based upon your personal experiences. You are claiming your moral position but don't necessarily claim it for everyone else.
Misty -- Your position seems to be summed in in this statement: "Medical Patient Modesty is devoted to educating patients in the opportunities they have for choice, and advocating for them with respect to modesty needs in order to re-introduce our culture to the concepts of gender that God intended."
You seem to be claiming patient gender choice while at the same time claiming to have the inside information as to God's intention in regard to what choice is the moral one. That's fine. However, you seem to want a system created that doesn't really give the patient a choice of gender because opposite gender care, in your view, is immoral. So, in an ideal world, you wouldn't allow hospitals to even offer opposite gender care. In an ideal world, you'd make sure patients didn't have that choice -- because your mission is to "re-introduce our culture to the concepts of gender that God intended." And you claim that you know what God intended while others don't."
Misty -- am I correct in my summary above?

 
At Wednesday, September 25, 2013 7:29:00 AM, Anonymous Anonymous said...

Doug,
I don't believe I've ever disagreed with any of your positions. Please correct me if I'm wrong.

My position is that the medical community must become patient friendly.

This modesty issue can have devastating consequences for a patient who is not informed, has not had a previous hospitalization and doesn't know enough to ask the right questions. Also ,a previous history of sexual abuse (especially if previously occurring in a hospital).

I believe it's up to the medical community to do their homework as to "do no harm" and institute practices reflective of what that means to protect patient health.

Additionally, standard of care procedures that are not necessarily mentally healthy for the patient should looked at by the mental health community for improvement. An example of this might be prepping for surgery shaving a patient in intimate areas with an entire staff of people in the room.

Deviant/inappropriate behavior must be punished severely to lessen the chances of
incidents and have a policy 3 strikes you're out.

I disagree with Misty that physicians should not be cross trained. In the event someone comes into a hospital every doctor should have a basic knowledge of all the body systems. Wouldn't it be a tragedy if someone came into the hospital (when they didn't have this issue) with an emergency and the doctor on duty had no clue?

Opposite gender care is fine if it isn't forced upon you, if you have no problem with it and if the patient has the last word on how they want to be treated. This is a reasonable approach.

I have often wondered in a real emergency, how much would I care about who as treating me? I don't know and won't until it happens.

Finally, the line is so thin between what is proper and what isn't a great place to start would be for the hospitals to "clean up their act" limiting the number of personnel in the room when someone is completely defrocked of their clothing. If the patient is awake, they won't remember all the people trying to help them, they will remember the one person standing on the sidelines gawking at them.

This is a human rights issue at it's fundamental base. It is an absolute insult to patients and outrageous business practice.

The real issue, is why don't they acknowledge and why won't they clean up their act?
belinda

 
At Wednesday, September 25, 2013 8:01:00 AM, Anonymous Anonymous said...

Doug,

I am not claiming a moral position at all. I am claiming that certain protocols in hospitals are harmful to some and that there be some acknowledgement that these same procedures can and do cause irreparable harm.

This seems to be the strongest reason to make change because obviously, the medical profession cares little about our feelings or moral convictions. If they did, things would not be the way they are.
belinda

 
At Wednesday, September 25, 2013 9:29:00 AM, Blogger Maurice Bernstein, M.D. said...

Next Tuesday morning I am going with my six first year medical students to our city's Children's Hospital for them to observe their first surgical procedures. We all get dressed up in our surgical outfits and one or two at a time go into the various operating rooms. Though they are "wide eyed" during the experience observing something they never observed previously (and rarely a student may get "sick"--that's why I'm supposed to be there) but please don't call them "gawkers". To me, I can imagine, I see some of them (at this point I really don't know which ones) in the years ahead will be saving the life of a child or an adult in an operating room and Tuesday, that is their beginning. Yes, often the students have a chance to communicate directly with the parents before and sometimes after the surgery and in my years of repetition of this experience, the students have never been rejected by the family, though rarely a surgeon might refuse a student entry to the operating room because of reasonable procedural reasons but not just for "looking on".

When I read everything my visitors write here and they write about "gawkers" in a negative sense, I do wonder if they are also writing about my first year student group that will be entering operating rooms next Tuesday for the first time not as a patient but as a first year medical student. ..Maurice.

 
At Wednesday, September 25, 2013 10:59:00 AM, Blogger amr said...

Dr. Bernstein,

Thanks for sharing this with us. Here is the deal for myself. Are you as the teacher of these students telling them that it is important

to get affirmative consent from the patients BEFORE they observe? Bluntly, will these patients being observed be told that 1st year

medical students will be observing and have a chance to decline?

If the answer is yes, then go for it. If your answer is, "I don't ask, I don't know, I don't care", or "general admissions release is

good enough", then this is THE MAJOR issue of this blog and your "explanation" is more like a "justification".

Also, I would love to see that goes on in an OR. May I join your group? (I'm serious.)

amr

 
At Wednesday, September 25, 2013 11:44:00 AM, Blogger Maurice Bernstein, M.D. said...

amr, if indeed you are "serious", perhaps I should rightfully call you a "gawker" if your interest is only to "see" what "goes on" in an operating room.

I am taking the liberty of reproducing here the exact words of the objective of the visit as written by the medical school and sent out to each student and myself:


OBJECTIVES: By the end of the session, the student should be able to:

• correlate the basic science/gross anatomy with the surgical anatomy of the patient in surgery.
• describe the role of the surgeon in relation to the other members of the surgical team.
• describe the unique characteristics of the operating room environment and culture.


You and we might be interested to focus on the word "culture" since a view of that "culture" is what has been hanging out there virtually since the very first pages of this Patient Modesty thread back in 2005.

With regard to informed consent for the students to be present, remember most of the patients are children and it would be their parents to be responsible for informed consent. I have no knowledge of what the parents are specifically told other than it is commonly known that this hospital is a teaching hospital but when the students are introduced to the parents, as I observed, there have been no rejections. ..Maurice.

 
At Wednesday, September 25, 2013 4:02:00 PM, Blogger amr said...

Dr. Bernstein,

When I first joined this blog, I said that I may ask you questions that would feel uncomfortable. Remember that I have several family members who are doctors. This is important because I hear from them the same equivocation regarding this issue of patient consent and modesty; good people all. I think that health care providers go through a cultural shift and turn a blind eye to the problem.

Your responses makes several attempts to not answer my questions. Also, throughout the years on this blog, you have given responses along the line of “what I don’t know, the better off I am regarding my moral compass as a doctor.” Case in point here is that after all these years of this blog, it appears as if you haven’t at all been curious enough to find out what the parents have or have not been told. Asserting that it is “commonly known that this is a teaching hospital”, is simply a rationalization for not actually finding out and you assuming that tacit consent is given by walking in the door. The fact that you have never heard a “rejection” doesn’t mean that it would not happen if the “patient” (read here parent if you will) were given a choice, or knew that they had a choice.

Going back to my earlier blog entry about your hospital’s consent form. Have you availed yourself of the opportunity to read it and to ask an administrator what happens if a patient objects to signing the document or wishes to change it? I’m guessing that you have not wanted to find out so you haven’t inquired. I think you will find that the patient will be told that unless it is signed without changes, services will not be provided. I again challenge you sir to inquire and report back to us.

I’m sensitive to the fact it might not be good for you position at your medical school should you publish findings negative to the institution.

My point about wanting to tag along is just that a point. The process of consent must be active not passive, regardless of who is observing.

amr


 
At Wednesday, September 25, 2013 4:39:00 PM, Anonymous Anonymous said...

Some 20+ years ago I had female surgery, and clearly remember 6 or 7 "extra" people in the OR standing off to the side before I was put under. (This was before the use of pre op Versed.) What struck me even then was how young they looked, even through their surgical masks I was a good patient in those days, and said nothing, but I ALWAYS REMEMBERED IT and IT ALWAYS BOTHERED ME.
Maurice, please, please tell me you are going to give those patients a choice if it's okay for the students to be there. If I was having surgery at your hospital tomorrow and you just told me that, I might cancel it. Seriously.
LJ

 
At Wednesday, September 25, 2013 7:16:00 PM, Blogger Doug Capra said...

Maurice
I, too, and somewhat uncomfortable with your comment as reprodueced below:
"With regard to informed consent for the students to be present, remember most of the patients are children and it would be their parents to be responsible for informed consent. I have no knowledge of what the parents are specifically told other than it is commonly known that this hospital is a teaching hospital but when the students are introduced to the parents, as I observed, there have been no rejections. ..Maurice."
1. Children have rights, too, and although they are minors and subject to their parents -- exceptions are made during exams of minor adolescents when certain questions are asked. They are asked these questions alone. I would think that the dignity of all children might suggest they be asked personally about observers and students. I would suggest that it may not be uncommon for the parents (who are not the ones on the OR table) to feel just fine with observers, and yet the child does not feel that way and perhaps feels powerless, abandoned and mistreated. Don't they deserve the dignity of being asked their opinion.
2. Frankly, after all the discussion on this blog about informed consent, I, too, am surprised that you are not aware of how consent is acheived to grant your students access to these patients. The "how" is, I believe, an essential aspect of the ethics of this issue.
3. I have a hard time understanding "other than it is commonly known that this hospital is a teaching hospital." The fact that a hospital is a teaching hospital means little when it comes to patient dignity in regards to informed consent, esp. in regards to any non essential personnel observing. This seems to be one those "assumptions" hospitals make, i.e. once patients "know" this is a teaching hospial (or it's embedded within a form they sign), then they should just expect certain things to happen without being asked.
Having said all that, I still believe most patients will grant access to medical students in most cases (maybe not intimate procedures, etc.) -- if they feel safe and treated with dignity and respect. In my view, whether they feel this often depends upon the "hows" of informed consent and whether patients they feel a partner in their own care.

 
At Wednesday, September 25, 2013 7:31:00 PM, Anonymous Anonymous said...

AMR has some very good points, I really respect what you are doing here Dr. Berstein, it has really helped me. However telling us what the students are told does not tell us if the patients are informed or given a choice. Forcing a patient to sign a consent form that takes that choice from them in order to recieve care, perhaps life saving care is extortion. And there is a very imporant point that the medical community ignores, we are there for our care not your education, we are paying the bill, if you want me to partcipate in your education, pay me, give me a discount...I am not here for your benefit, That seems to be loss in the myoptic world of medicine....don

 
At Wednesday, September 25, 2013 7:34:00 PM, Blogger Maurice Bernstein, M.D. said...

amr, as I have written here many times over the years, to meet the goal of changes in the medical system directed to provide comfort for those patients in whom the system, to them, appears and behaves in a uncaring manner with regard to their modesty issues, it is the responsibility of the patient's themselves to speak up to their healthcare providers and the clinics and hospitals to provide those changes. Remember, there are patients like me who are satisfied with the system with regard to modesty issues. And I am sure there are physicians like me, before I started reading comments on this thread, who, though aware of the general guidelines for professionalism and patient modesty they learned in school, have not had direct dissent from their patients about how their modesty issues were handled in their practice. This is true.

Therefore, for there to be a change to meet the needs of all patients who find lack of attention to physical modesty in all of its permutations, it becomes the responsibility of those patients themselves to act.. (and I have written all this before and before) ..to speak up to their healthcare providers and to form advocacy groups to make changes not just in their local medical community but for all communities.

My contribution is not to be searching through hospital admission forms and then doing what? My contribution has been to initiate my blog topic where discussions can occur and by advising my visitors to "speak up" but also develop advocacy groups (like Misty's) to direct their view and recommendations to those hospitals, systems and organizations where these recommendations will be considered and hopefully acted upon. In this way, I think I have already contributed ..Maurice.

 
At Wednesday, September 25, 2013 8:01:00 PM, Blogger Maurice Bernstein, M.D. said...

Doug, yes, minor children who become adolescents deserve to provide assent for a procedure and indeed, in California, adolescents actually are allowed independent informed consent for abortions. But beyond what my experience has been with this children's hospital of a formal program established for these beginning medical students for many years, I know nothing further. Should I find out more and if I find that there is no administratively informed parental consent specific for the program in which, as a monitor for my students, I participate, should I then refuse participation and attempt to have our medical school drop this students experience without some change? It is easy to say "sure you should" but is that the right way to achieve that goal of specific consent? ..Maurice.

 
At Thursday, September 26, 2013 6:43:00 AM, Blogger Doug Capra said...

Maurice wrote: "Should I find out more and if I find that there is no administratively informed parental consent specific for the program in which, as a monitor for my students, I participate, should I then refuse participation and attempt to have our medical school drop this students experience without some change? It is easy to say "sure you should" but is that the right way to achieve that goal of specific consent?"
I'm not judging you or your hospital. I don't know what's going on there or how informed consent is handled. And I'm not saying these children are being treated badly. I just don't know. In my post I did say I was "uncomfortable" with your answer, and I still am.
The question you've posed above, is the kind of question students get on an exam in an ethics course. It's an ethical dilemma. Only you can answer that question.

 
At Thursday, September 26, 2013 6:51:00 AM, Anonymous Anonymous said...

I agree, it is not your duty to provide material, you have done your part and then some by facilitating this forum. We should be the agent of change not you and you have contributed in ways you will never know. I read an article that was written by Jan Henderson, Jan. 4, 2011 titled How Bodily Exposure Went from Unacceptable to Required". She qoutes Amy Friedman MD from an article she wrote in JAMA Nov. 2010. Dr. Friedman relates her experience of going in for a colonoscopy and was very telling as a provider becomes a patient. I apologize if this was posted here before, it has been a long journey and it is possible this was brought up before so I apologize in advance if this is a repeat but it is relevant to todays discussion. There are several long qoutes so I will post them in several seperate posts. I would be interested in peoples responses.
One comment on the current discussion, providers ridicule and condemn patients for avoiding care due to modesty concerns, the reasoning nothing should put your health at risk...YET, providers have no problem with an Admission form that denys you care if you do not agree to let them use your their education. Does this not seem a bit hyporitical to providers? Does the practice of denying care based on something so self serving not seem wrong? And if not, does that not say something about the self centered aspect of medical care that is at the root of what we are discussing? I will post the articles as soon as I get time. Dr. Berstein please feel free to hold and post together or individually as you see fit. I tried to read Dr. Freidman's article but without a subscription I could only view the first page. I will try to post the link but I struggle at this. www.thehealthculture.com 2011/03/history-of-patient-modesty-part-`-bodily-exposure-went-from-unacceptable-to-required, not sure this will get you there or not.

 
At Thursday, September 26, 2013 8:51:00 AM, Blogger amr said...

Dr. Bernstein,

This is a follow-on comment to Doug Capra of Sept 26, @ 643am.

You wrote to me and he quotes: “Should I find out more and if I find that there is no administratively informed parental consent specific for the program in which, as a monitor for my students, I participate, should I then refuse participation and attempt to have our medical school drop this students experience without some change? It is easy to say "sure you should" but is that the right way to achieve that goal of specific consent?"

Doug poses the notion that your question should be on an ethics exam and poses an ethical dilemma. The way you pose your response states the moral relativism that often accompanies these discussions. What is the greater good being served? You suggest only that the students needs are, in the end, more important than the patients needs. I will repeat that this has been the public defense of non-consensual pelvic exams in the OR while the patient was asleep. I see this as the same argument, but in a different setting. And to repeat, I have witnessed female patients speaking up and saying that they will not be seen by a male dermatologist.

Change must occur from both directions in order for there to be change. The women’s vote in the US would not have occurred simply by women marching.

It is the tone that you set as a teacher that is really at issue (with respect). There are many ways to deal with this as part of being an agent of change vs. just sitting on the sidelines and saying, “my work is done.” As a parent, you must know that your teaching of morals is as much about how you act as much as what you say. Your students are listening. But if you don’t say anything, there will be noting to hear.

1) You could have your students actively seek consent from the parents or other adult patients.
2) You could personally ask the parents in front of the students
3) You can discuss this as a problem with the current culture of medicine and suggest that the students have a role if effecting change from within
4) Discuss in class the notion of affirmative consent and tie it into your visit to the OR
5) You can discuss with your students how the demands of their education might desensitize them to the needs of the patient.
Once aware, who knows over time how that could effect for the positive the situation in the future.
However, since you have been consistent that this really isn’t a problem in your mind in medicine today, I do get that you are content in not even planting the seed in your students.

This is the challenge we face.

Truly with respect,

Amr


 
At Thursday, September 26, 2013 9:14:00 AM, Anonymous Anonymous said...

Dr. Freidman's comments that really shed light on to the WHY we have an issue with this are ones that align with my personal opinion when she writes "Too often it feels like we healthcare professionals have surrendered our souls in succumbing to demands for increasing efficiency, minimization of time spent at every node along the pathway and rapid shuttling patients in and out of facilities. We often strip them of critical remnants of personalization specifically to meet regulations. Having learned that treating patients like human beings does not facilitate reimbursement we have capitulated. After all the delivery of TLC consumes time and prevents one's ability to accomplish other competing tasks.
She then asks a question that seems to come from a soul conflicted. "How has the pendulum swung this far? Why do we tolerate an environment in which a reticent but unafraid patient emerges from an uncomplicated encounter feeling dispassionately processed rahter than embraced"
Does that not sum up the conflict between providers and patients? Does it not shed light on how providers can chide patients for putting their health at risk for modesty sake and then extort them into agreeing to be lab rats for teaching students with the threat of not treating them for the same ailments? It does not change the fact that if it is to change for us, we patients must drive that change with our mouths, out feet, and our dollars. It does however strip away the cloak of justification through claims of ignorance and exceptionalism. You know wrong from right, you know you are human subject to the same insecurities and fears of your patients, you know the scrubs you wear are not those of a super hero that puts you on a pedestal beyond reproach or questioning from patients...it just runs counter to the other demands you must meet by the various masters you answer to, be they human or time....I do not blame Dr. Bernstein for not challenging the consent process. We all have conflicts between our personal and professional lives. Does anyone here align 100% with either the policies of their employer or what they must do as a business owner? I don't. The most we can ask is for honesty, acknowledgement that a policy or action is right or wrong, it is all that should be expected. More than that is a gift. We must also remember that right or wrong in these cases is in the eye of the beholder and just because it does not align with ours, it does not automatically make it wrong...don

 
At Thursday, September 26, 2013 10:02:00 AM, Anonymous Anonymous said...

Besides emergency procedures, there is another reason why medical personnel must be trained on both genders. There are a small number of people who are neither male nor female or maybe they are partly both. Gender identity is sometimes ambiguous. Medical personnel must perform procedures on these people.

Gerald

 
At Thursday, September 26, 2013 11:08:00 AM, Anonymous Anonymous said...

I had intended to post these qoutes prior to Dr. Freidman's but got happy fingers and lost it. Jan Henderson writes "Affronts to patient modesty are intensified by this impersonal atmosphere. With the passage of time, patients have come to accept a new lack of privacy. But, the sense of embarrassment remains undiminished. Thus we have a possible answer to why we say patient feel this way and providers claim to be ignorant of the same. The Stockholm syndrome occurs when hostages begin to identify with their captors as a self defense coping mechanism only to suffer PTSD when the threat is gone. Could this be happening at a lower level here?
Dr. Freidman gives a glimpse of how trading sides of the gown shed a different light on the experience. "Though I hadn't shared my sentiments with anyone I felt vulenerable and completely sheepish about having a very human reaction to such a common procedure. But this was my bottom and I was not happy to have to share it with others. Here to be exposed and invaded in truth I was embarrassed and sought compassion". And there you have it, the good Doctor no doubt had subjected patients to similar embarassment during her practice but she stated "But this was MY bottom...." and thus the situation is completely changed....interesting comments...don

 
At Thursday, September 26, 2013 11:23:00 AM, Blogger Maurice Bernstein, M.D. said...

I want to settle this matter of when or when not I as a physician and teacher should become an activist in condemning a medical teaching behavior and which one.

First, as I have previously written, our first and second year students having no direct responsibility for the medical management of the patient never interviews or performs a physical examination on a patient without the patient knowing the name, medical educational status of the student, what the student intends to do and never, beyond that, start the session without the acceptance, the consent of the patient. Period!
I see no ethical or legal issue with that.

Next comes to issue of simply "looking at the patient" for medical educational purpose and value but not "laying on of hands" (that is, actually touching the patient) such as done in a physical examination or performing some procedure. "Looking at the patient" by a medical student for the purpose of medical education (which has the potential of benefit not only for the student but for society in general beyond that of the individual patient) does not represent assault or battery and is not the same invasion of privacy as that of a "peeping Tom" where there is no benefit except for the prurient interest of the Tom. This medical educational "looking at the patient" should not require direct patient consent particularly if the patient is aware that this is a teaching institution

Beyond looking at a patient for educational reasons, any attempt to obtain medical history from the patient, any attempt to touch the patient physically, any attempt to perform a procedure on the patient whether it is to draw blood from a vein or perform a pelvic exam should require the specific informed consent of the patient and that consent must be relative to that specific student.

One may argue that even "looking" is invasive and must require specific consent. I don't think it so if the goal is medical education. However, when amr wrote " I would love to see that goes on in an OR. May I join your group? (I'm serious.)" and I wrote back "amr, if indeed you are "serious", perhaps I should rightfully call you a "gawker" if your interest is only to "see" what "goes on" in an operating room." Ahh! That should require patient consent.

I hope I have clarified my position on specific consent and which behaviors would guide my activism. By the way, as you may know, the
teaching system is changing and pelvic exams done on unconscious patient by a medical student with no specific consent by the patient for that student to perform the exam is no longer considered acceptable by many teaching institutions. ..Maurice.

 
At Thursday, September 26, 2013 12:02:00 PM, Blogger Maurice Bernstein, M.D. said...

By the way, for those who have not reviewed all previous Volumes of this thread will have missed this pertinent description of the life and requirements for one medical student who rebelled about being taught by academic compulsion genital exams. Just click here to go to Volume 42, June 29 2011 and read this lengthy highly descriptive and emotionally loaded dissertation. ..Maurice.

 
At Thursday, September 26, 2013 12:04:00 PM, Blogger Doug Capra said...

"This medical educational "looking at the patient" should not require direct patient consent particularly if the patient is aware that this is a teaching institution"

I firmly disagree with this statement, Maurice, but I do concede that it is a debatable issue. But as you've stated it, it's too broad. At heart, the patient is not a teaching tool, even when they enter a teaching hospital. Being viewed during a procedure or operation without specific consent, IMO, is being used as a teaching tool. What disturbs me most about this issue is that most patients would willingly be a teaching tool in most cases because of the importance to the medical profession. I certainly would. But just assuming that they "should" be is offensive to me. It reinforces the role "patient" as someone who, once they enter the confines of a medical teaching institution, automatically assumes the primary role of a teaching tool. Medical students, who have no license to practice, need to get patient permission for any interaction, IMO.
Your other statement: "By the way, as you may know, the teaching system is changing and pelvic exams done on unconscious patient by a medical student with no specific consent by the patient for that student to perform the exam is no longer considered acceptable by many teaching institutions."
That fact that the system is "changing" and that you've qualified this change in "many" but not all institutions, just shows how the system tends to hold tightly on to practices that, though unethical, suit the institutions's purposes, and not necessarily the patient's.

 
At Thursday, September 26, 2013 12:06:00 PM, Anonymous Anonymous said...

"One may argue that even "looking" is invasive and must require specific consent. I don't think it so if the goal is medical education."

What you or any other provider or student thinks about their role in my healthcare is bull@#&% and absolutely reeks of paternalism. No one will participate, regardless of the purported rationale, in ANY capacity, without my prior informed consent. This attitude that you know what's good for us IS the problem!

Ed

 
At Thursday, September 26, 2013 2:04:00 PM, Anonymous Anonymous said...

Maurice, I completely disagree with what you said regarding sexual battery. From the patient perspective, stripped against their will, "looked at" for medical purposes is sexual battery without informed consent

You are only looking at this from one side.

You, your spouse, or your child consents for student to watch. They are not toe they will be unclothed for this examination. If the patient has not given informed consent to be examined or "looked at", is sexual battery, if it amounts to doing something that is against the patient's will.

If informed consent for bodily exposure is withheld, this would win in a court of law.
belinda

 
At Thursday, September 26, 2013 2:37:00 PM, Blogger amr said...

Dr. Bernstein,

Thank you for your clarity. I would like to thusly deconstruct your arguments and positions. Ethical relativism can be asserted in the two statements you made below and I see these as a part of continuum between what the medical profession deems acceptable vis a vis the society in which it operates.

(Ethical relativism is the theory that holds that morality is relative to the norms of one's culture. Please refer to:
http://www.scu.edu/ethics/practicing/decision/ethicalrelativism.html as a starting reference point)

Dr. Bernstein: “One may argue that even "looking" [1st year med students] is invasive and must require specific consent. I don't think it so if the goal is medical education.”

And …

“By the way, as you may know, the teaching system is changing and pelvic exams done on unconscious patient by a medical student with no specific consent by the patient for that student to perform the exam is no longer considered acceptable by many teaching institutions.”

Taking a step back one could ask the question: These practices are acceptable to whom” Or put another way, by whose moral standard are either of these considered acceptable?

I believe that it is just as wrong for me to tag along as it is for your students (or you) to do so without affirmative consent.

Clearly by the fact that the pelvic exam practice not being completely stamped out, we see a blending of Ethical Relativism between the Ethics of the society as a whole and the Ethics of the medical community.

Each of these issues come down to a patients right to control his/her body and who views or touches it, at any time. You as a doctor, and by extension the profession, for the benevolent benefit of society, are picking and choosing when we as patients have control, and when we don’t. Then arguments are constructed to justify a position. Since you have a dog in the fight, it is ultimately self-serving for you to maintain that observation for the purpose of education is OK, but a non-consensual pelvic exam is not. The laying on of hands is a distinction without a difference since it is a continuum in the name of “education.”

And just to make sure that we don’t have control, the legal types make it clear that we don’t by the legal release we are made to sign on the threat of withholding treatment.

The patient either has authority over their body, or they don’t and the medical profession attempts to maximize its control over such for its own benefit.

But what makes this interesting is that the boundary between what is ok and not ok keeps shifting.

amr

 
At Thursday, September 26, 2013 3:30:00 PM, Blogger Maurice Bernstein, M.D. said...

Doug and amr, standards of medical practice in general and ethical standards of medical practice are fluid and are obviously open to change as medical science advances and as policies and society's view of professional behavior changes. After all, the practice of professional medicine virtually throughout the world is under society's "thumb".

Yes, a patient who is physically stripped by another against their wishes and expression of rejection is a criminal act. Yes, a patient has a right to discuss their modesty issues with the surgeon as part of the informed consent and perhaps some change in practice can be carried out to meet the patient's desires. However, think of this "analogy": A homeowner calls the plumber to fix a leaking toilet in the bathroom but won't allow the plumber into the house because the passage way to the bathroom goes through rooms that "are a mess" and the homeowner would be embarrassed to have a "stranger" view them. The homeowner, therefore requests the plumber to do the fixing but from the outside of the house. And, of course, despite the fact that the plumber was called for the service, if he bursts into the house without the homeowner's permission and views the messy rooms, well...that would be a criminal act of illegal entry..right? Please don't criticize to harshly my analogy. If you have a better one, write it.

But, is that "illegal entry", in all of its definitions, into the private body of the patient really going on in operating rooms?
I'll let you know what I see about that after Tuesday. ..Maurice.

 
At Thursday, September 26, 2013 5:10:00 PM, Blogger amr said...

Dr. Bernstein

Really, a plumber. Yes your analogy doesn't hold water (pun intended). More to the point the analogy would be: Oh, you need your toilet fixed. I will fix your toilet if and only if these 5 other apprentice plumbers can come along and watch me work, or maybe help me a little. Or even, you agree to have Sam the plumber come into your house and you arrange to leave the key for him. You find out later that he showed up with 5 other guys and they entered your house without your permission.

But the issue we are now discussing has more to do with consent than it does with what might be observed. You are rationalizing the removal of a patient’s rights for the sake of someone else’s benefit.

When we found out that my wife’s doctor had allowed a salesman into her surgery after she had explicitly checked off on the form she did not want this, we were livid. His excuse was that he really doesn't control who comes into the OR since it is a teaching hospital. He claims that the guy was only there for a few minutes and was ushered out as soon as the doctor noticed him. The problem with his story is that the log for in/out showed that the guy was there for 45 minutes. When that was brought to his attention his office administrator stated that sometimes the sales people ask a special favor like this so that it appears to their supervisors they were on the job. If this happens at UCLA, I would be shocked to hear that is doesn't happen at USC.

So, Dr. Bernstein, this is the “other side” of the institution you work for. Can you then wonder why, once trust is broken it is hard to rebuild. But more to the point, if you then have a teacher argue that it is OK for his students to observe, without concern for the patients affirmative consent, one then must begin the question the entire ethical base of the institution.

You aren't on the sidelines on this issue of patient rights as you would wish to have us to believe.

This is said again with respect. I have family who share your opinions. I believe you to be a good person.

Amr



 
At Thursday, September 26, 2013 5:17:00 PM, Anonymous Medical Patient Modesty said...

Dr. Bernstein,

The scenario about plumber you used is not a good example. Messy rooms and modesty concerns are completely different. Many people who have modesty concerns would rather to let strangers see their messy rooms without consent anytime than having their private parts exposed to strangers without consent.

Think about this: Let’s say that a homeowner called a male plumber to come to fix the leaking toilet. The plumber arrives and the homeowner says you cannot come in my bathroom right now because my wife is taking a shower. But the plumber ignores the homeowner and refuses to wait for the wife to come out of the bathroom.

Also, think about this scenario. Let’s say that a bunch of high school girls went in the girls’ restroom and locker room to take shower and change their clothes after playing volleyball on Friday afternoon before Labor Day weekend starts. They went in the restroom the same time the male janitors are supposed to clean the restroom. The janitors have other commitments an hour later and will not be able to clean the restroom until the following Tuesday if they do not clean the restroom right away. The janitors may argue that they are professionals and that they are just doing their job cleaning the restroom. Medical professionals should respect patients’ privacy and modesty as much as non-medical professionals.

It is interesting you brought up the stressed medical student. She also contacted Dr. Sherman and me years ago. It made me sad that she was kicked out of medical school. The medical school should have accommodated her. She was going into a specialty that did not require her to do any intimate examinations. She would have made an excellent patient advocate. I appreciate her boldness in speaking up that pap smear and pelvic exam were unnecessary for obtaining a prescription for birth control pills. The truth is there should always be informed consent for pap smears and pelvic exams. Doctors should never try to force patients to have intimate examinations. I encourage you to look at some discussions we had on this article about teaching medical students about patient modesty. Look at Dr. Sherman’s comments that some medical schools may make full allowance for religious and cultural beliefs of medical students to refuse to do intimate procedures. I found your comments in the last paragraph on February 4, 2012 interesting and I actually think it is a good idea for medical schools to tailor curriculum more specifically to the goals of special students. For example, I think that a female medical student who wants to be a gynecologist, but has strong convictions that she should not do any intimate male procedures should be allowed to get through medical school without ever doing intimate procedures on male patients. Once she becomes a gynecologist, she will only work with female patients and babies.

Misty

 
At Thursday, September 26, 2013 5:23:00 PM, Anonymous Anonymous said...

A patient who is not informed that they will be stripped is too dumbfounded and things happen so fast that when they have the chance to respond it's too late.

One could say that it's a safe assumption that people do not want to be publicly stripped. So...if there is lack of informed consent, something happens so unexpectedly that you cannot respond, is that sexual battery?

Yes it is, if one party knows what's going to happen, asks permission to have visitors for educational purposes, does not inform the patient, then the informed consent is thereby illegal, constitutes deceit and a legal basis to claim sexual battery
belinda

 
At Thursday, September 26, 2013 6:06:00 PM, Anonymous Anonymous said...

I could not disagree with you more Dr. Berstein and your example shows the justification techniques your profession employs often. They cite life and death situations in the ER to justify modesty violations on routine check ups and procedures. So let me ask you, if the plumber invited the class from the local trade school to observe would that be fine. After all, if 15-20 trade students got value by tromping through your house to watch and learn? Would that not benefit society by having these trained plumbers in the field providing services? And under your scenerio the home owner should not have to be asked or give permission after all, it benefits society. And did you not say that reporters in the locker rooms was wrong, but these people can make the same argument you use to justify these students, Arguing your profession is above reporters could be made, and support the arrogancy of the medical profession that they know best for us and our wishes and concerns are secondary. And while med students & peeping toms are different, they are alike in they are violating a patients modesty for their benefit not the patient or persons. My nephew watched a surgery, he is an undergrad student not accepted in a medical school. A man in my office consented to allowing a HS student watch his colonoscopy I refused a college student studying to be a NP permission to watch the intimate part of my physical. We are individuals not patients. To say that we have no right to consent for something that embarrasses, makes us uncomfortable, or even traumatizes us because the medical community has decided it is for the benefit of society and the student is truely troubling. You require consent to this violation as condition of treatment in a teaching school my tax dollars support and again even you have chided people for putting their health at risk for modesty. Shame on the medical profession for such arrogancy, you do not get to decide what is right or wrong for me, I do. If so should I not have the same right to do so for you...unless of course you truely believe that you as a medical community do in fact hold some sort of moral and intellectual superiority to the rest of us, and it entitles you to make these decisions, for us,,,and the answer is so simple, all you have to do is ask, it is so so simple and yet the medical community doesn't think we deserve that simple consideration, that simple show of respect...shame on you all,......don

 
At Thursday, September 26, 2013 7:21:00 PM, Anonymous Anonymous said...

Facebook.com/nurses page has a happy nurses week
card that says " we see more penises than a prostitute"

That comment speaks volumes about how
unprofessional those people really are.

PT

 
At Friday, September 27, 2013 12:32:00 PM, Anonymous Anonymous said...

Dr. Berstein I just want to clarify when I say shame on you I was referring to the medical community not you personally. It is not uncommon for people to identify with their profession to a degree that influences their view of right or wrong. There is the well known phenomena of mob mentality where we do something in a group we would not as an individual, is this perhaps not an example of that. Your group says it is right to take away our right of consent..so you agree with it? Didnt want you to think I meant or was attacking you. I am glad you are honest with us..don

 
At Friday, September 27, 2013 2:18:00 PM, Anonymous Anonymous said...

I am in England. if I go to hospital using the national health service I will be in a 'teaching' hospital as every hospital now styles itself so. 10 years ago there were few teaching hospitals.
according to you, dr Bernstein, I have to make myself available for anyone who has marginal medical experience and be practised on, is that correct?
when people go to hospital, they go for their own benefit, not the benefit of students or even the benefit of 'future generations'. you don't have the right to use a patient for your/anyone's benefit.
I am surprised that this still has to be pointed out to you even after all these blogs over the years. why do you profess to have respect for patients and their 'modesty needs' when you clearly do not?

 
At Friday, September 27, 2013 2:31:00 PM, Anonymous Anonymous said...

PT, I am not able to find www.facebook.com/nurses. Is that the correct link? If there is a statement to the effect you state, how would the female nurses like it if a male nurse in L&D (I realize they are non-existent.) were to make a statement like "We see more vulvae than a pimp?" Women would "out for blood" if they were to read something like that. They would want the person who placed that comment to be fired and jailed.
Gerald

 
At Friday, September 27, 2013 4:55:00 PM, Anonymous Anonymous said...

I lean towards the side of Dr. Bernstein. Perhaps his analogy is not the best, but the point is that medical training is vitally important. Medical students need to "see before they do." Perhaps teaching hospitals should require a patient to sign a waiver at admission that medical students of either gender may participate in any and all exams or treatment. Maybe they already do this. The only exceptions would be those who might be admitted through the emergency room. I realize that this goes against some patients' modesty concerns but the next generation of physicians must learn somehow. If we were to require that medical students can only perform exams on Standard Patients (those who are paid), then the cost of training soars and the nature of the patients' problems are limited.

I believe that if someone has extreme modesty concerns, they should not go to a teaching hospital for care. The situation in Great Brittain (or at least England) apparently may be different in that all hospitals may be considered "teaching hospitals." Here in the USA, only a few are. I realize that I will probably be the recipient of numerous complaints on this subject. I also realize that my modesty concerns are less than some others. My modesty concerns are primarily with the technicians, office staff, and perhaps the RNs.
Gerald

 
At Friday, September 27, 2013 6:03:00 PM, Anonymous Anonymous said...

Gerald

It is at www.Facebook.com/nursespage

Once at the site scroll down,you will see it. Even
more disturbing is there are over 40,000 likes to
that post alone.


PT

 
At Friday, September 27, 2013 6:24:00 PM, Blogger Maurice Bernstein, M.D. said...

Let me summarize what I approve and what I disapprove and if present in the system must be changed.

First and second year medical students with no direct clinical responsibility for the patient: NO HISTORY TAKING OR PHYSICAL EXAMINATION (INSPECTION, PALPATION, PERCUSSION AND AUSCULTATION) WITHOUT SPECIFIC CONSENT BY THE PATIENT AFTER THE STUDENT IS FULLY IDENTIFIED AND THE ACTIVITY TO OCCUR IS DISCUSSED WITH THE PATIENT.

HOWEVER, SIMPLY OBSERVING A PROCEDURE OR OPERATION PERFORMED BY OTHERS GIVEN SPECIFIC PERMISSION BY THE PATIENT IN A KNOWN TEACHING HOSPITAL BUT WITHOUT REQUESTING SPECIFIC PERMISSION FOR THE MEDICAL STUDENT TO OBSERVE IS PROPER.

Beyond that, in the third and fourth clinical years, EACH STUDENT SHOULD BE GIVEN SPECIFIC PERMISSION BY THE PATIENT FOR A HISTORY AND PHYSICAL EXAM AND FOR THE PERFORMANCE OR PARTICIPATION IN ANY PROCEDURE FROM DRAWING BLOOD TO PELVIC EXAM TO SPECIFICALLY DEFINED PARTICIPATION IN A SURGICAL PROCEDURES. HOWEVER, SIMPLE OBSERVATION BUT WITHOUT PARTICIPATION BY A THIRD AND FOURTH YEARS STUDENT IN A KNOWN TEACHING HOSPITAL MAY OCCUR WITHOUT SPECIFIC PATIENT PERMISSION.
I would disapprove a system that does not follow this formula for informed consent. At my school, I am assured that my criteria are met with regard to first and second year medical students. I would need need to investigate with regard to that policy is met for the third and fourth year students.

I FIND THERE IS NO RATIONAL BASIS FOR SPECIFIC FIRST YEAR STUDENT APPROVAL BY THE PARENTS TO ENTER AN OPERATING ROOM AT THE CHILDREN'S HOSPITAL AND SIMPLY OBSERVE AND NOT OTHERWISE PARTICIPATE AS LONG AS THE PARENTS ARE AWARE THAT THE CHILDREN'S HOSPITAL IS A TEACHING HOSPITAL.
In conclusion-

SPECIFIC PERMISSION FOR A SPECIFIC STUDENT FOR EVERYTHING DONE EXCEPT SIMPLY OBSERVING FOR EDUCATIONAL PURPOSES.

..Maurice.



 
At Friday, September 27, 2013 6:59:00 PM, Anonymous Medical Patient Modesty said...

I believe that medical students should always ask patients and children’s parents for permission before observing and participating in procedures regardless of their experiences. Medical students and professors should respect patients’ wishes if they say no. I suspect the reason why they do not ask for permission is because they are afraid that patients will decline to let them observe or participate in their surgeries.

It irritates me about how many hospitals say that a family member cannot be present for a patient’s surgery because of germs, but then the hospital allows as many people including medical students and sales reps be present for surgeries. How hypocritical that is! The truth is the family member is most likely cleaner than the surgeon, nurses, medical students, etc. The more people you have in the operating room, there will be more germs. I am tired of hearing hospitals saying they want to limit the number of people in operating room because of germs.

Again, this is exactly why Medical Patient Modesty encourages patients who are concerned about their modesty during surgery to have a personal advocate not employed by the hospital to be present to block unwanted people in the operating room. For example, let’s say that a woman is having a hysterectomy and she wants to be 100% sure that no men except for her husband see her. It would be prudent for this lady to have her husband or a female friend to sit in the operating room blocking the entry of the door.

Also, I strongly recommend that patients having surgeries that do not require the removal of underwear such as hand to have a personal advocate present to make sure that his/her underwear is not removed.

What Dr. Bernstein has shared about medical students observing and participating in surgeries confirmed that there is no guarantee that a patient’s wishes would be honored once he/she is under anesthesia.

It is obvious that the medical students observing surgeries is for their own benefit. In fact, the risk of contaminating the operating room is higher with medical students.

PT: I could not find the facebook page you referred to. Unfortunately, there are many female nurses who get sexual gratification from working on male patients so it does not surprise me that some female nurses would make those comments. One man told me that he was very disturbed by how his ex-girlfriend who was a Trauma nurse and her nurse friends made fun of the genitals of male patients who were in comas.

Misty

 
At Friday, September 27, 2013 7:03:00 PM, Anonymous Anonymous said...

Here is where I think the arguement falls apart from a real life personal experience. My brother was diagnosed with two type of cancers. His PCP & oncologist referred him to a cancer surgeon at IU med. because in his opinion he was the best in the region and one of the best in the country. IU med is a teaching facility, so is this truely free choice, is this really informed consent or is it coerced consent. When you take a man with a family and tell them, your best chance is at this facility, but in order to access that treatment you must agree to let us use you for teaching. Is that truely compassionate care, have you really put the patients welfare first when you condition treating them on consent to something that has absolutely no benefit to him and may even be truamatic? Does this follow the doctrine of do no harm if the patient is emotionally traumatized by this. To exert this type of pressure on someone who is fighting for their very life so a medical student can watch and benefit is in my opinion immoral. In business there is a law that if you exert undue emotional stress or pressure on a person to sign a contract, that contract can be deemed void. And yet, the medical community considers it acceptable to tell a person fighting for their life that unless they conesent to letting medical sudents watch they will not be treated,,,, as consent. It may make sense to people in your community, but I doubt you will find little support from society if they truely understand the process and mentality....don

 
At Friday, September 27, 2013 7:41:00 PM, Blogger Maurice Bernstein, M.D. said...

Discussing possibly observing nudity in the medical education process, first I must say that live patients on the hospital wards or in the clinics are not observed nude by the students or by their instructors. For first and second year students, based on my experience with the process, in the operating rooms, the students don't observe the patient nude but regularly observe an operative site with the remainder of the body covered. So there is nothing that an awake or anesthetized patient should be concerned about modesty in terms of observations by students.

Do the students see patients nude? Yes, "former patients". Who are these "former patients"? The deceased. Yes, the students do see these individuals in a totally nude state in the first year anatomy lab and in our school we take our student groups to the Coroners Office and the bodies of none of the deceased are in any way covered. They are all on the multiple tables totally nude. In none of these situations is there any attempt to contact live family members for their specific permission to allow a medical student to observe an entire autopsy and see both the outside body and the inside body of their relative. Of course, all these persona are deceased and personal modesty is no longer an issue.

So this is what I know. I still say simply observing and not participating in a procedure on a living patient does not require patient permission if the purpose is student medical education. This is not just my permission, it is a societal permission and I reject any implication that a medical student has become a "Peeping Tom" on the rationale that the patient wasn't specifically informed and consented for that specific student's presence.

I agree that there are degrees of physical modesty in everyone but there are certain limits to the final expression of how these concerns should be expressed and handled in the medical system. ..Maurice.

 
At Friday, September 27, 2013 7:51:00 PM, Anonymous Anonymous said...

This issue isn't just about students, it's about medical personnel overstepping their bounds, being in places where they don't belong and a sense of entitlement of being anywhere they want.

Awake patients are entitled to privacy when being prepared for surgery. I have seen this again and again where patients are offered no dignity or respect.

There is a problem in healthcare and let's face it, the medical community lives in 'la la' land.
belinda

 
At Friday, September 27, 2013 7:59:00 PM, Anonymous Anonymous said...

I guess we will have to agree to disagree on a few things here. I do not agree society has agreed to let the medical community impose their agenda on patients whom are assume to given up their right to determine if they partcipate or not. One would then also make the same conclusion about reporters in the locker rooms yet the vast majority of fans say they shouldn't be in there while players shower. I will agree with you however that peeping toms and med students are the same. The motivation is completely different other than the fact that they are both there for their own benefit not the patient.victim...nothing alike...don

 
At Friday, September 27, 2013 8:04:00 PM, Anonymous Anonymous said...

Misty


Use yahoo as your search engine and type in

Facebook.com/nursespage

You will see it at the top of search engine results


PT

 
At Friday, September 27, 2013 9:33:00 PM, Blogger amr said...

Dr. Bernstein,

You state: “HOWEVER, SIMPLY OBSERVING A PROCEDURE OR OPERATION PERFORMED BY OTHERS GIVEN SPECIFIC PERMISSION BY THE PATIENT IN A KNOWN TEACHING HOSPITAL BUT WITHOUT REQUESTING SPECIFIC PERMISSION FOR THE MEDICAL STUDENT TO OBSERVE IS PROPER.”

Restating your position by shouting it doesn’t give your argument any more weight.

Others on this blog in recent posts have said about choice (or no choice) I will not repeat. However I would like to riff on the situation a bit.

You say that it is ok for your students to observe the OR because it is a child they are observing and that you are “sure” that the parents know that this could/will happen because the hospital is a known teaching hospital.

What if you asked the parent and they refuse? Would you still hold to your argument that observation does no harm?

If a parent comes up to you states specifically that they do not want your students observing, what would you do? (Hint: you may not answer this by saying it has never happened so it isn’t an issue.)

What if it were an adult patient. Is it still ok that no specific consent is obtained?

What if a group of nurses were observing non-consensual pelvic exams, is that ok with you?

What if your students happened to be in the hospital without you, and a doctor recognized them and offered to have them come into an OR and observe a non-consensual pelvic exam, is that ok with you?

Put another way, is there any situation in this teaching setting where you would defer to the wishes of the patient should they not want to be observed?

Ultimately, the challenge here might well be to suggest to your students that they read these latest entries on this blog and have a class discussion about this. What say you?

Amr

 
At Saturday, September 28, 2013 8:29:00 AM, Anonymous Medical Patient Modesty said...

Don is correct about coerced consent. I am so sorry about what has happened to Don’s brother who has cancer. He deserves compassionate care. Forcing him to have medical students without his consent is not compassionate at all. Every patient should be asked for consent about whether they want medical students. One of my friends who had a female gynecologist for her C-Section repeatedly asked that no medical students be present and her wishes were ignored. She is still emotionally traumatized by this experience. Sadly, she decided to not have any more children because of this traumatic experience.

I believe the main reason why medical students and medical school professors do not ask for consent is because they fear that some patients will decline to have them observe or participate in their procedures. But they always should ask for consent in order to be sensitive to patients. There certainly will be some patients who will consent to their participation and observation for educational purposes. But medical students should never be forced on patients who do not want them.

I agree with Belinda that it is not just medical students that we have to worry about. I have gotten so many cases where patients’ wishes for all same gender team were ignored. Too many medical professionals have ignored patients’ wishes that certain medical professionals not be present. Patient’s wishes should be number 1 priority.

AMR asked some very excellent questions and I’d love to hear Dr. Bernstein’s responses on those questions.

I found the Nurses Facebook page that PT referred to. The picture with caption about nurses seeing more penises than prostitutes was posted on October 8, 2012. I commented at the bottom of the picture. The comments of most people were very disturbing. I also posted tips for nurses to respect patients’ modesty at the top of the facebook page for Nurses. I’m sure that many of the nurses who see my comments probably won’t be happy.

Misty

 
At Saturday, September 28, 2013 9:25:00 AM, Anonymous Medical Patient Modesty said...

Look at the sad case of Susan who stated to her female OB/GYN that she did not want any medical students or residents present for her surgery to remove ovarian cyst. The female OB/GYN ignored her wishes. She "coerced" Susan to sign a consent agreeing to the male ob/gyn resident. It is horrible about how the female OB/GYN deceived her. This is exactly why every patient should have a personal advocate not employed by the medical facility present for all procedures especially if you will be under anesthesia.

Misty

 
At Saturday, September 28, 2013 11:56:00 AM, Anonymous Medical Patient Modesty said...

I wanted to share with you all about a disturbing case I got from a man about his wife who is a RN:

My wife is an RN at a hospital so she and I both understand the necessity for compromising a patients modesty. She had also expressed her concerns and shock that patients were being unnecessarily totally exposed during surgery. Today my wife had outpatient surgery to repair a tendon in her left ring finger. When she returned from surgery to the recovery room her gown had been removed and she was totally nude during her surgery. Her gown was laid over her during transport from the OR to recovery. Why was it medically necessary for a patient to be nude to have surgery on a finger????

The lady is a nurse who understands patient modesty concerns. It is so ridiculous that she was fully nude for a simple surgery on her finger. She could have easily worn her street clothes for this type of surgery. There was also no reason for her to be put under general anesthesia. They could have just used local anesthesia. This case proves why you cannot blindly trust operating room staff to protect your dignity. Again, this is exactly why Medical Patient Modesty strongly recommends that every patient have a personal advocate present for surgeries.

Misty

 
At Saturday, September 28, 2013 2:33:00 PM, Blogger Maurice Bernstein, M.D. said...

amr, I don't know what further to say to your questions to me yesterday. It is clear that my view is that the observation of an operation or other procedure by medical students (or nursing students, since you asked) in a teaching hospital is an activity which is part of training and simply observation should not represent an assault on the patient.

Now, if a patient is "stripped nude" and against any standard of practice for the procedure, one may reasonably infer that someone's self-interest was involved and it wasn't that of the patient and such self-interest is unacceptable and there must be consequences. Otherwise, all patients entering an operating room as a patient has to enter with an understanding that coverings (whether a glove for a finger operation or a breast for breast surgery) are going to be removed along with other body coverings as part of the surgical standards of practice.

Again, instead of moaning and groaning about isolated "made newsworthy" unethical or illegal acts by doctors and nurses, the main point of discussions should be about the necessity to see that these acts are punished and prevented but also to stimulate and encourage the creation a medical system that is friendly, humanistic, ethical and appropriate for every patient of either gender and of all degree of concern about physical modesty and the furthering, but safely, necessary medical education.

Again, no moaning and groaning but discussion about how to facilitate such a change. ..Maurice.

 
At Saturday, September 28, 2013 2:48:00 PM, Anonymous Anonymous said...

A good place to start would be to look at what is considered "standard of practice" and then look to the mental health community to see where improvements can be made so that patients are not traumatized based on what is considered "standard of practice".

Pre op should be conduced in a private area for the patient where prepping needs to be done and then, when intimate procedures are completed (perhaps behind a curtain with minimal personnel, and same gender if needed would alleviate some of these concerns.

The problem is that the medical community must acknowledge that some of their "standard of care behaviors" are traumatic to enough patients that something needs to be done to change what is considered "standard of care".
belinda

 
At Saturday, September 28, 2013 3:10:00 PM, Blogger Maurice Bernstein, M.D. said...

Belinda, I think you are on the right track regarding what to be discussing here on this thread: changing the system so that which we now call "standard of practice" be converted to "standard of care" since all "practice" should really be "care for the patient". So now, those who feel there is a need for change, be active here and suggest and begin to start some effective way to make that change. ..Maurice.

 
At Saturday, September 28, 2013 3:19:00 PM, Anonymous Anonymous said...

Facebook.com/nursespage

The picture with the caption " Nurses see more
penises than prostitutes"

The comments number in the thousands with some
comments such as " we see a lot of butts too!

Does the caption suggest that a nurse is exactly that,
a prostitute off the streets?

PT

 
At Saturday, September 28, 2013 3:32:00 PM, Anonymous Anonymous said...

Maurice,

I work with a health psychologist and would be happy to do some analysis on current standard of care practices for most surgeries/procedures.

They need to be reviewed and have the potentially damaging parts for patients to be analyzed and processed from both the medical side and the psychological side to find common ground so that both sides can lives with new regulations.

Where do you feel I could get a copy of National Standard of Care Practices for American Hospitals.

As a financial analyst in another industry and my background of research and experience with my own issues, would create an environment to find the weakness, share with the health psychologist, giving a overall view of where the changes need to be made.
belinda

 
At Saturday, September 28, 2013 3:38:00 PM, Blogger amr said...

Dr. Bernstein,

Actually, you only restated your position, and have made no attempt to look at the shades of gray or to engage me with the questions I asked. Your response though, did attempt to pivot and change the subject.

Is it your contention that you have a RIGHT to have your students observe the operations at this “teaching hospital?”

--amr

 
At Saturday, September 28, 2013 3:43:00 PM, Anonymous María said...

It's not that I think Doug is wrong- maybe I feel he misses a bit the point. The reason I am so enraged is that those that accept caregivers of both genders are the only group catered for at all, and that's a situation that seems unlikely to change in the near future
Ed, please please consider this: some people are not willing to let any kind of healthcare that compromises their most basic values (and maybe sanity) get in the way of their modesty. (there, I said it!!!!) "At the end of the day it's just a preference" . Not so for many people. Respect for modesty might even determine whether or not they even seek care, and blatant disrespect for what is not a whim but a serious psychological necessity might change their view of the healthcare system for ever. So I don't think it's a fad, or even less indicative of mental issues. It's something I take seriously, and will make serious healthcare decisions about. Eventually it comes down to common sense, because some people are not willing to submit to healthcare from individuals that don't respect them and their most intrinsic values.
Surveys seem to point that as much as 50% of females have pretty strong preferences when it comes to intimate care,(wish similar statistics were available for men).
To the point of boring all of you with this, is any other crowd than the gender-neutral folks ever even noticed?. I also apologize for all the language problems (from Spanish).
María

 
At Saturday, September 28, 2013 5:34:00 PM, Blogger Maurice Bernstein, M.D. said...

In response to amr's --Is it your contention that you have a RIGHT to have your students observe the operations at this 'teaching hospital?'"

To be correct in answering: I have no RIGHT, I have a duty as their instructor to be there as support in case a student gets a vaso-vagal reaction to the environment in the operating room. That's my duty as prescribed by the school for me.

The students also have a duty to learn their profession for the benefit of society and their future patients within the opportunities available to them. These opportunities are set by standards of medical education within the United States and throughout the world. One of the standards is to simply observe activities relative to their future profession. This is a duty and not a right. If society finds this duty too expansive into areas of patient modesty, then I feel that society has a right to complain and attempt to change that student duty in that regard. So, in a direct answer to your question without any twisting: I have no right. ..Maurice.


 
At Saturday, September 28, 2013 6:14:00 PM, Anonymous Anonymous said...

The problem with students watching is the same problem with all of these issues. It's the lack of detail in the informed consent.

Students have a right to learn and observe when given proper permission.

If asked properly in a respectful way with full disclosure might empower patients to want to help educating students.

What's upsetting us all is that there is right of entitlement, we are not respected, not given proper informed consent and the medical system doesn't care if we are upset, traumatized or feel humiliated.

Fixing this problem would benefit all.
belinda

 
At Saturday, September 28, 2013 8:13:00 PM, Anonymous Anonymous said...

My brother was given Milk of Magnesia every day. It caused him to poop his pants every day at school. He stank. No one wanted to be near him. He was severely bullied.

He was also given enemas 2 - 3 times a week. I can still hear him screaming.

When we consider the mental health of the child, does it matter why this was done to him? The people who were supposed to help him hurt him again and again. It only made the trauma worse that he was told that he should be glad, even grateful, for this doctor-proscribed treatment.

When we consider the mental health of the child, does it matter if the parent got some perverse enjoyment out of it or was doing it diligently, even though it hurt them, out of love? Can the child tell the difference?

Eventually my parents turned to "alternative medicine". He was put on a strict diet and given probotics. His physical health was restored. His mental health never recovered.

I don't understand why this thread is called patient modesty, when it's clear that's not what is being discussed. Over and over I am reading about people's mental health being disregarded in physical health settings.

It makes me angry when you say that observers in surgery don't matter when I've read so many stories of people waking up during surgery, and being mentally traumatized by... OBSERVERS in the room that they didn't expect. Or those who obtain their medical records and then feel violated.

WHY DOESN'T MENTAL HEALTH MATTER IN MEDICAL SETTINGS?

-RJ

 
At Saturday, September 28, 2013 9:17:00 PM, Blogger Maurice Bernstein, M.D. said...

RJ, of course mental health matters in healthcare provider-patient relationships and responses but for issues regarding mental health, unless the patient is unconscious and is unable to respond, it does require that the patient communicates the symptoms and issues to the healthcare provider. Doctors and nurses can't "read" the patient's mind. ..Maurice.

 
At Saturday, September 28, 2013 9:35:00 PM, Anonymous Anonymous said...

How can a patient object to having observers present if they don't know they are going to have observers?

According to the National Child Traumatic Stress Network, "Up to 80% of pediatric patients and their families report experiencing some traumatic stress following illness, injury, hospitalization, or painful medical procedures."

One of the keys we see across all mental trauma patients is the feeling that they had no control over what happened. Therefore, providing as much control to patients as possible should be a goal for reducing possible trauma. This should be true for patients even if they have no previous trauma history.

This includes allowing individuals to meet all people involved in their procedure and consent to their presence (immediate emergency might prohibit this, but most procedures seem to be scheduled hours, days, or weeks later).

-RJ

 
At Sunday, September 29, 2013 8:02:00 AM, Anonymous Anonymous said...

RJ, Healthcare settings (even without modesty violations) are a recipe for traumatic stress.

Things happen all the time that are unexpected both medically and psycho social aspects that are not mentally healthy for patients.

This is why it is so important that the mental health regarding nudity, a gender neutral environment, and other issues regarding control are addressed.

Apparently, Maurice, the medical community doesn't care quite enough.
belinda

 
At Sunday, September 29, 2013 9:28:00 AM, Anonymous Anonymous said...

doctors and nurses don't have to be 'mind readers' when dealing with issues of modesty or patients' mental health. by this stage in the development of medical care it is obvious to doctors that these issues are of concern to patients so for you to claim that each individual patient has to remind each individual doctor/nurse/whoever that they should be mindful of their patients' wishes is dishonest.

YOU should start from a position of assuming that patients needs should be met and not expect every individual patient to have to beg for decent treatment.

when we go to hospital we are on your territory. we are ill, frightened, naked, in pain but you still expect us to engage in a complicated discourse with you.

patients do not get a training course in advocating for themselves before they go to hospital. most of us do not want to be there. it is up to YOU to look after us, not for us to act as supplicants before you.

 
At Sunday, September 29, 2013 10:36:00 AM, Blogger amr said...

Dr. Bernstein,

I believe I can now posit that the “hidden curriculum” regarding patient rights to privacy actually begins immediately upon a student entering medical school.

Changing the discussion to “duty” to teach and learn does not directly or even indirectly answer the my queries. We are all old enough on this blog to remember Bill Clinton’s infamous: “Well it depends upon what the definition of ‘is’ is.”

Have you ever asked (not informed) a patient if it was ok for you (or your students) to observe.

It is your “duty” to get permission. It is your patients “right” to refuse (or not). Society in the form of this blog and others now appearing on the net are complaining about how you are conducting your profession.

Is it your contention that it isn’t your responsibility to get affirmative permission for you and your students?

I sincerely hope that you engage me directly and not pivot your answers.

Now regarding your contention about “observation”: Some have read the story of Art Stump and his book “My Angels Are Come.” Please see the posts on Dr. Sherman’s blog:

http://patientprivacy.blogspot.com/2009/06/cancer-rx-privacy-my-angels-are-come.html

Here the hospital allowed a teenage girl to observe his procedure. And I would posit that Dr. Bernstein, if he is remaining true to his position, would defend the right of the hospital to allow this to occur.

--amr

 
At Sunday, September 29, 2013 11:47:00 AM, Anonymous Medical Patient Modesty said...

Dr. Bernstein,

I agree completely with Belinda’s suggested solution . We are not saying that medical students can never observe or participate in procedures. We simply believe that all patients should be asked for consent and then if they decline medical student participation, their wishes should be respected. We need to show compassion to patients. They should be in control of who they want to be present for their procedures.

Most people who are concerned about patient modesty here do not care about the gender of their ophthalmologist. I was very impressed with an ophthalmologist who I went to last year because I had severe eye allergies. He asked me if it was okay for him to examine my eyes. I wish that every doctor would ask for consent before they do a procedure or examine you.

There certainly will be some patients who will decline medical student participation, but their wishes should be number 1 priority.

You have had patient modesty blogs for years now so I feel that all of the comments you have gotten should make you more sensitive as a doctor who wants to do whatever to accommodate patients to make them comfortable. I would like to challenge you to seriously consider doing things differently from the standard medical system and encourage your medical students to meet with the parents on Tuesday to ask them if it is okay for them to be present for their children’s surgeries. This would be a great opportunity to teach medical students how to be compassionate doctors and how patients’ wishes should be number 1 priority.

Just because something is standard in the medical system does not make it right or ethical. It is ridiculous that many patients are stripped for surgeries such as knee, finger, etc. that have nothing to do with genitals or breasts. For the article that I wrote about how informed consent is missing from urinary catheters, I did a lot of research including asking my cousin who was a nurse manager in the ICU at the local hospital questions. She confirmed that urinary catheter was standard for surgeries even though it was unnecessary most of the time.

Misty

 
At Sunday, September 29, 2013 12:34:00 PM, Blogger Maurice Bernstein, M.D. said...

amr, in direct response to your question "Is it your contention that it isn’t your responsibility to get affirmative permission for you and your students?": Yes, it isn't my responsibility. If permission is to be obtained from a parent for any medical student to be present in the operating room observing surgery on their child that permission must have been made in advance by the hospital staff who gave the medical school permission to attend. Beyond that, the logistics of the session are such that, it is true, I rarely meet a family member myself, I don't know where they are and which child in which operating room they represent. I don't know which student is where since they all can move independently from one operating room to another as the student desires. It is the surgeon and the operating room staff which is initially responsible for the student and the student's education at that point in their experience. I do wander from one room to the next to be available for my students.

I can assure all my visitors to this blog thread that there are no true modesty issues of these anesthetized children during the time my students are in their operating room. Yes, if one wants to define modesty from some philosophic existentialism for these children, then, yes I suppose that even if the children are asleep and not aware of their bodies and those in the operating room, all, regardless of age or experience,demand freedom of choice. ..Maurice.

 
At Sunday, September 29, 2013 1:02:00 PM, Blogger Maurice Bernstein, M.D. said...

To Anonymous from 9:28 AM today:
Of course, doctors "should start from a position of assuming that that patient's needs should be met." But each patient has their own "needs" and each patient has one "need" that would, in the particular situation,trump another (that is one "need" at that moment would be of more necessity to be met than another and the doctor, trying to meet "all needs" at once may not be possible or indeed degrade the ability to meet the most desired "need".

So, the question is what is the patient's most desired "need" and how will the doctor know if the patient assumes the doctor already knows that critical "need" and the patient fails to communicate. That is why I keep repeating: patients should "speak up" and, of course, their doctors should listen and then attempt to meet that "need".

A training course for the patient regarding "speaking up" is not necessary and should be permitted in every medical/surgical environment. Now how the doctor responds, after listening, to that "speaking up" that is another matter but whatever is the decision it should always be in the best interest of the patient within the current clinical situation. ..Maurice.

 
At Sunday, September 29, 2013 1:09:00 PM, Anonymous Anonymous said...

Dr Bernstein,

Am I right that in your most recent comment, you said that you "wander from room to room"?

I admire the way you seem to shift responsibly for the permission for your students to observe onto the hospital staff. Nicely done.

JT

 
At Sunday, September 29, 2013 5:12:00 PM, Blogger Maurice Bernstein, M.D. said...

It amazes me how this thread on patient modesty has continued to be populated by visitors but also commentators all these 8 years. It amazes me but also worries me. If the discussion here is about the interest of both the patient and the medical care provider in patient physical modesty and not about criminal sexual behavior or indeed any lesser form of activity of sexual stimulation (which all parties should abhor), I still can't believe that vast majority of the population of humans who are sick find that attaining and maintaining their modesty issues trumps (takes the place of) the goal of attaining a cure and return to good health. And yet, it is the body of the patient and not the patient's garment or covering which holds the diagnosis and allows a cure for the patient's illness. And yet it seems that some patients cannot accept that uncovering or degree of uncovering is necessary for diagnosis or treatment. Some patients find that being examined or nursed or treated by those who are performing their professional duty fairly, civilly, ethically and without any hint of criminal or unprofessional sexual behavior are still unacceptable because those professionals are of an opposite gender.

Where are the commentators to this blog thread who hold a view that while modesty, including physical modesty, may be an inherent feature of every human, but when it comes to diagnoses and treatment of a patient's illness, degrees of physical modesty must take a lesser concern to attempt to cure? They don't write, I fear, because for them to enter and provide a counter argument to this unilateral "discussion" would be too traumatic and yet I know they could provide the counter argument, supporting my view.

And my view is yes there is a problem in the medical treatment system including, yes, the medical education where the majority of doctors, nurses, hospitals and schools fail to take into account whatever are the modesty concerns of the patients in their institutions. "Taking into account" meaning providing practical changes in their systems for these patients, including education of both the patient and the professional participants of the patient's concerns and the practical changes that are possible. However, for this to begin, it is necessary, as I have written here multiple, multiple times, it is necessary for those patients with modesty concerns to the degrees expressed on this thread "speak up" to the system in as unified and emphatic way as is practical and possible. Turn your eyes away from this blog and move together with the hopeful goal to educate and change a system that is so disturbing to you all. ..Maurice.

 
At Sunday, September 29, 2013 6:57:00 PM, Blogger Maurice Bernstein, M.D. said...

A practical suggestion to all writing here.
The following is what Kathryn Teng MD (Cleveland Clinic's Center for Personalized Healthcare and Department of Internal Medicine) wrote in the 2013 edition of the Cleveland Clinic "Bioethics Reflections". As you may know, the Cleveland Clinic is a major and well respected medical center in the United States. My suggestion is for those with your strong views about patent modesty and freedom for healthcare provider gender selection contact Kathryn with your concerns and suggestions. She may be a stepping stone in the promotion of change.
Kathryn writes the following titled "Balancing personalized healthcare with public resources".

Personalized healthcare asks how we can integrate patient's individual biology, preferences and environment to provide individualized customized care. Although we are moving forward with more standardization, we know that the one-size-fits-all approach is really not working in terms of quality, metrics and healthcare costs.
How can we better identify the populations that require different tracks of evidence based care, and how can we use that information to activate and engage our patients toward better health? We know we can't do it alone--- we need our patients to participate in this journey with us.



So now you patients or potential patients "speak up" to Kathryn at Cleveland Clinic and let her know your concerns with the medical system and the need for change. You can refer her to this very blog thread for more of her education of your concerns.
Here is contact information from the Cleveland Clinic website.

Kathryn Teng, MD
216.444.5665
Location(s): Cleveland Clinic Main Campus
Department: Executive Board Office

Start the process and keep us informed on this blog thread. ..Maurice.

 
At Sunday, September 29, 2013 7:00:00 PM, Anonymous Anonymous said...

We are all a product of the life experiences we encounter, and the groups and segments of society we choose to identify oursleves with. Dr. Bernstein try as you might your decades of identifying yourself with the medical community is obvious and to be expected, Consider your title you are DR. Bernstein, to think that you would not identify yourself and therefore align with there thinking would be niave. As i think back over the past weeks posts I have many thoughts and reflections.
1. I understand and agree your contention that your duty is to your students, I does not however change the fact that it i the facility should have their paitents interest first and foremost, and coercied consent is not putting the patients welfare first. You can defend your position and condemn the medical community at the same time. Surely you cannot feel requiring consent to allow students to partcipate as a condition of recieving treatment is right. I ask you do you feel that is right? Do you feel requiring consent for treatment is not a form of coercion? Especially when some facilities state any change in the consent for will not be accepted?
2. You use a well known method of arguing by the medical community. You act is the question of modesty and treatement is an either or or propostion, like they are mutually exclusive, The arguments over the past week is about students observing surgery not about compromising care for modesty. This is typical of what we see from the medical community, using life and death in the ER to justify everyday nonlife threatening events.
3. Dr. Friedman asked the question, how has the pendelum swung this far where a patient enters for a routine proceedure and leaves feeling processed rather than embraced. You are one of the most compassionate providers on this issue i have encountered so when duty to students and rights and benefit for patients are seperated, one has a glimpse at why patients would feel processed rather than embraced. When facilities force us to sign a consent form to give up our rights that have nothing to do with our health and treatment....does not this anser the question as to why we feel procesed rather than embraced...the question is, does anyone care?....don

 
At Sunday, September 29, 2013 8:41:00 PM, Blogger Doug Capra said...

I've followed this blog since it's beginning, many volumes ago -- and I started posting probably in the third volume. I've stated my basic premise many times but I'll do it once more.
1. For a very few, the issue is serious bodily modesty, esp. with the opposite gender. These are the few that say they would rather die than expose themselves to medical professionals. I do find this position to be extremen, but I also believe that this population must be served with respect and dignity.
2. Another very few on the other end of the spectrum, almost delight in exposing themselves to the opposite gender. They may be exhibitionists.
3. The vast, vast, vast majority don't really have a modesty issue. The issue is one of poor communication within the medical system -- and, yes, Maurice, poor communication on their side, too. But it's a communication issue. Everyone assumes too much about what needs to be done and how it should or will be done and who will do it. It's also a matter of how medical delivery has changed dramatically within one or two generations.
The issue isn't modesty as much as it is how patients are treated. These days it's more common for patients to be "serviced" rather than "cared for," esp. in some facilities. I firmly believe that most patients will accept opposite gender care -- yes, even for intimate procedures, if they feel safe and that they are being treated with dignity and respect. Some of this involves knowing who will be treating them and who will be observing. Patients want shared control over their privacy.
You must admit, Maurice, that the medical profession, historically, has not done a good job with communication. It's been mostly a one-way street. Communication involves at least two. Yes, the system is improving and communication is getting better. But it's still not good enough. There is still enough of the old school around that wants to hold on to the way it used to be.
I would also say that some members of this majority group have had poor communication experiences that may have resulted in modesty violatons. As you know, once you lose trust, it's very difficult to gain it back.
These are the real issues, IMO.

 
At Sunday, September 29, 2013 9:22:00 PM, Blogger Maurice Bernstein, M.D. said...

Don, I hope you and the others writing to this thread have not ignored or forgotten that this is a bioethics discussion blog. Discussion usually represents a discourse with more than one view. So I have taken and described a view which may be considered to many as perhaps quite opposite or in some ways opposite to the majority (virtually everyone) writing to this thread. The fact that I have continued this thread for 8 years despite very little support (e.g.Gerald of Sept. 27 and often Doug) for my expressed opinions for debate should indicate that what I want for this thread is discussion and not just a sermonizing of my own single presented opinion. If I really felt that the medical system should not be tampered with, why would I repeatedly request my visitors to become activists to change the system to accept their significant viewpoints? So remember "Bioethics Discussion" is all about DISCUSSION. ..Maurice.

 
At Sunday, September 29, 2013 9:30:00 PM, Anonymous Anonymous said...

Thanks Maurice


I will be sure to share with Dr Teng the
facebook nurses page. Over 600 nurses commented
with one female who said " I can't wait to finish my
nursing so I can see more penis". I just don't see
anyone fixing stupid on such a grand scale.


PT

 
At Monday, September 30, 2013 7:33:00 AM, Anonymous Anonymous said...

Wow, what a disturbing read on Facebook. The fact that this is the mindset of the people taking care of us when we are at our most vulnerable is worrisome. So much for the "Ivory Tower" ethics courses and "professional" training. I realize that most of them probably maintain a certain professional composure during patient care, but apparently find much hilarity in our bodies behind the scenes and enjoy their access to our genitals. This brings about the question as to whether we as patients should care about the mindset of our caregivers and the things they say about us among themselves (or on Facebook) if they treat us professionally at the moment of care? Would be interested in what bloggers here think. LKT

 
At Monday, September 30, 2013 8:12:00 AM, Anonymous Medical Patient Modesty said...

I got a disturbing email from a man who was forced to have a genital / rectal exam by a medical student this morning. I have recommended he file a complaint about this doctor to the medical board in his state. He had to go to therapy because this experience traumatized him psychologically. You can see some of the information he shared below. This case shows how important it is for medical students to always get consent before participating in your exam or procedure.


I was recommended to meet a new Doctor by two family members. I was taken into the exam room immediately and after my EKG was left sitting one hour listening to the Doctor thru the walls talking to other patients. Finally I heard him at the door and I heard him say oh its a physical. The Doctor did not walk into the room or introduce himself instead he pushed a student into the room laughed about it held up his pointer finger and told the student to remember the finger and walked away. I did not know what to do, do I make a scene, the student was soft spoken and I was more concerned about his feelings so I endured a 50 minute of exam. I realized during the exam he was doing it like a student practicing what he learned in school, I was appalled that a student was allowed to practice a male genital exam and a rectal exam, a complete internal without my consent and with out a doctor being present. When the Doctor finally came in 50 minutes later he sat with his back o me checked off the forms and said :well you have been poked and prodded enough you look healthy take care I am now in therapy dealing with the fact I was reduced to being a specimen for training pictures


Misty

 
At Monday, September 30, 2013 11:12:00 AM, Blogger Doug Capra said...

Here is an article that exemplifies the problems with communication within our health care system. Modesty violations can be the result of these communication problems. Read this and then ask yourself how important you think modesty issues are to healthcare professionals when this kind of communication failure exists with basic medical care.

http://www.kevinmd.com/blog/2013/09/improve-health-care-patients-eyes.html

 
At Monday, September 30, 2013 12:36:00 PM, Blogger Maurice Bernstein, M.D. said...

Doug, when I read the story I ended up with the same questions and conclusions as this reader commented: "so what's the ending of this? What did the CT show? Would this have changed the course of his care? Or is the article written to give us just the flavor of how confusing and jolting the experience was?"

Though it is reasonable and proper for the bumps and jolts or even worse patient experience to be publicized (and I am all in favor of this to show what the patient is experiencing being a patient in the medical system) BUT.. for complete and fair understanding of the situation should be also the clear detailing of the facts of the scenario both relative to the patient but also the facts regarding the administrative and procedural issues that burden the hospital and the hospital staff. None of the latter was presented to the reader of the article...just the impact of what occurred on the patient and the family.

In all our discussions here, remember..we are complaining about the system but we are not getting any facts or rebuttals by the system. And that information is essential for a complete understanding of problems by all parties engaged in discussing and hopefully mitigating those important problems. ..Maurice.

 
At Monday, September 30, 2013 12:50:00 PM, Blogger Maurice Bernstein, M.D. said...

NOTICE: AS OF TODAY SEPTEMBER 30, 2013 "PATIENT MODESTY: VOLUME 57" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 58.

 

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