Patient Modesty: Volume 60
On November 27 2013, Anonymous wrote in part " There is a culture of dismissal, negativity, and a refusal/inability to acknowledge the issue of sexual abuse within the medical community that prevails. It is this type of prevalent attitude of denial and dismissal that is so dangerous because it perpetuates the abuse.
To comment on Bernstein’s blog feels similar to what it might feel like for a Jewish person to enter Auschwitz and expect to be treated as a human being. It just is not going to happen. There is a culture of dismissal, negativity, and a refusal/inability to acknowledge the issue of sexual abuse within the medical community that prevails. It is this type of prevalent attitude of denial and dismissal that is so dangerous because it perpetuates the abuse."
And from Hexanchus November 27 2013:
"OK, let's talk statistics.
Referring to the book:
Sex Offenders : Identification, Risk Assessment, Treatment, and Legal Issues ...
edited by Fabian M. Saleh M.D. Assistant Professor of Psychiatry Harvard Medical School, Albert J. Grudzinskas M.D. Assistant Professor of Psychiatry in Law University of Massachusetts Medical School, Division of Forensic Psychiatry University of Ottawa John M. Bradford M.D. Professor and Head, Toronto Daniel J. Brodsky LL.B. Criminal Defense Lawyer, Canada University of Ottawa
"In the 1980's an attempt was made to estimate the lifetime prevalence of misconduct among various professional groups. A questionnaire study of psychiatrists found that 16% of responders acknowledged at least one sexual contact with a patient (Herman, Gartrell, Olarte, Feldstein & Localio - 1987)."
"Similar studies found that the frequency of self report of sexual misconduct ranged between 8% and 16%, a range that has also been found among most physician groups (Gartrell, Millikan, Goodson, Thiemann & LO - 1992)."
"During the early 1990's, physicians in family medicine, OBGYN and psychiatry were the most common brought board attention for sexual misconduct in Oregon (Erbonn & Thomas- 1997)."
"Both forensic and questionnaire data agree that approximately 90% of offending professionals are male."
Now from me
So it would appear that this thread has changed its direction set by my visitors from discussion about the patient's modesty issues to one of presumably wide spread medical criminality. But is such criminality so widespread and so frequent and the consequences on patients so profound (including PTSD) that it has become a failure in the medical system and the political system not to explain to the public what is occurring and what changes in the medical system and law enforcement are going to be made to put a stop to this behavior. All we currently hear about is providing more medical care to more of the population and the costs of medications and medical care but nothing about the crimes in medicine except very rare news items of specific cases. So, Hexanchus, what does your research tell you about what should be done to spread the word about medical criminality and to rein it in? And Anonymous, what would be the solution to prevent the "denial and dismissal" attitude suggested as present in the medical profession? Is just a general "stepping on" the medical profession with harsh words the proper approach or are there more constructive approaches to preserve a profession and skills which presumably is still needed by everybody? ..Maurice.
Graphic: "Stepping on the Medical Profession"-Created by me using ArtRage and Picasa 3. The idea was developed from an image in Google Images.
NOTICE: AS OF TODAY DECEMBER 13,
2013 "PATIENT MODESTY: VOLUME 60" WILL BE CLOSED FOR FURTHER
COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 61
posted by Maurice Bernstein, M.D. @ 10:23:00 PM
155 comments
155 Comments:
OK Dr. B., I'll take a swing at it....
There are certain professions that by their very nature imply a level of assumed trust by the society we live in. These include specifically, physicians, clergy and police officers. Because of this implied level of trustworthiness, they need to be held to a higher standard with regard to their conduct.
When one of these professionals crosses the line, it reflects not only on them individually, but on their profession as a whole. Unfortunately when a breach does occur, the tendency of their professions are to close ranks and shield the offender, rather than supporting an open and honest investigation of the facts. Of course when the facts eventually come out, it makes them look like idiots and further erodes the trust in the profession - you need only look at things like the Rodney King incident, or the Catholic Church's cover up of sexual abuse of children by priests to see this.
There are numerous records of health care professionals documented to have committed sexual abuse that are still allowed to practice medicine.
So what do I recommend:
1. The profession needs to clean up their own act. Every allegation of abuse needs to be investigated in a fair and unbiased manner by the medical board. In fairness, most have gotten better at this.
2. When abuse is found to have occurred, steps need to be taken that insure the professional will never again have the opportunity to take advantage of a trusting patient.
Towards this end, Illinois has enacted a law which prohibits a health care provider convicted of a sex crime, forcible felony or patient battery from practicing in Illinois.
The law requires the Illinois State's Attorney Office to notify the professional regulation department within five days of any criminal charges against a licensed health professional involving sexual misconduct, patient battery or a forcible felony.
The department then will issue an administrative order requiring the charged individual to have another licensed health professional chaperone all patient visits until the case is resolved. Patients would have to sign a written notice explaining the reason for the chaperone, according to the law.
The law mandates that the licenses of physicians, dentists, nurses, optometrists, physical therapists and other health professionals convicted of such crimes be immediately and permanently revoked upon conviction without a hearing by the Illinois Department of Professional Regulation. Those with convictions in other states who apply for Illinois medical licenses will be denied.
I'd like to see this type of law enacted in all 50 states.
I would agree with the Illinois law to be applied in all states, but I don't think that awaiting for criminal charges is soon enough for administrative action to be taken by the medical board of the state. I would say, if sexual abuse of patients by medical practitioners is so extensive or even if it wasn't, it still would be better for all patients who feel sexually intimidated or more to at least notify their state medical board for investigation. At least statistics will be able to be obtained and the board can be more aware of the problem generally but also be able to cone down on specific physicians. And it should be the patients themselves who do the reporting of their own experiences. If a patient told me about their implied sexual experience with another physician, their referral to the state board as a minimum reaction if not law enforcement would be my response. Notwithstanding what others might say is inertia of medical professionals in this issue, I am in no position to personally investigate my patient's experience. There is so much more responsibility in the practice of medicine that these "sexual issues" must be directed to administrative resources by the patient themselves. So, again, my advice to those who feel or find themselves sexually abused by a healthcare provider, "SPEAK UP!" but not to this blog thread as a site of resolution and punishment but to the police or medical boards. ..Maurice.
Here is a posting referring to the topic of "locked doors" by "amanthatcares" to Volume 59 after it was closed yesterday. ..Maurice.
i am inclined to think a lock would be appropriate for exams that require nudity, for the same reason one would like to have a lock on the bathroom door. just because the examiner 'feels ok' doesnt mean that the pateint doesnt have anxiety about random people coming into a room without warrant.
amanthatcares
Dr.Bernstein wrote:
"Medical practice never is and will never be a sexual experience for the healthcare provider regardless of all the propositions to the contrary here and all without statistical verification. In fact, medical practice makes every effort to make the examination and procedures asexual. Any professionals who are exceptions are statistical outliers and should be removed from practice."
One would think, given his apparent interest in the topic, Dr. Bernstein would take the time to acquaint himself with some of the data. Even the most cursory internet search reveals that self-reported sexual misconduct by doctors occurs at a rate of around 10% (see the material kindly furnished by Hexanchus). With about 900,000 doctors practicing in the US that makes quite a few "outliers!"
While Dr. Bernstein maintains that intimate exams are non-sexual for the doctor, there are quite a few doctors who find them sexual enough to risk their careers and reputations by gratifying their sexual desires.
Just one of the the large school districts in the city where I reside has over 5000 teachers. Dr. Bernstein, wouldn't you be outraged if 10% of those teachers admitted to sexual contact with their students? It would be scandalous!
Consider the following "back-of-the-envelope" analysis:
At any given moment, according the the U.S. Dept. of Justice, some 200,000 men are incarcerated, or on parole or probation for offenses that fall under the broad category of "sex crimes". Bear in mind this includes everything from violent rape to exposing oneself, to hiring a prostitute. Now let us suppose (and this is just a guess on my part) that there are an additional 200,000 men who are guilty of a sex crime but have never been caught, or have been released from prison, etc. The adult male populaton of the U.S. is about 100,000,000. So, there is only a .004 chance (1 in 250) that an average man is a sex offender. According to the various reliable studies the rate of self-reported physician sexual misconduct is around 1 in 10. So the big question is why does physician sex offense occur at a rate 25 times greater than the average male population, and more importantly, why is it tolerated?
Doctor Watchdog
While sexual abuse is prevalent in institutional care, it's extremely important to recognize that psychological trauma happens when there is nothing abusive being done (according to standards of care), so you be the judge.
Scenario #1: You are in the ER conscience and extremely upset as you have been in an accident. The EMT's, police and extraneous person(s) are there. They have positioned you so that you cannot move. They are cutting off your clothes and you are very aware that there is a crowd and you are naked. You lose the ability to fight or flee (the natural stress response).
Scenario #2: You are in the OR and being prepped. You are not told what to expect. Next thing you know you are naked and being prepped with a room full of people.
Fight, flight, or freeze? What do you do?
Scenario #3 You are having an intimate exam. You are exposed and a room full of students knocks twice and proceeds to come in without waiting for a response.
The above are all in a days work at a hospital. All of these situations can be extremely traumatic to the patient. Medical procedures are not done with he psychological well being the patient in mind. Actually they are almost barbaric. And...it is harmful to put people in these positions without telling them (and that happens all the time).
Excuses that they don't have time to explain in an emergency is a cop out. I'm not saying not to do what's necessary but do it with humanity. The gawkers who are the ones who are causing patients to feel humiliated are entitled and still allowed to stand around.
The medical community has done nothing to correct what is so easily corrected. Every time someone is mistreated they become one of us. Maurice, please comment.
"To Do No Harm" is not what's being done.
belinda
Here's a doctor who apparently didn't get the "it ain't sexual" memo:
http://www.itv.com/news/central/update/2013-11-30/doctor-charged-with-a-further-10-offences/
Doctor Watchdog
Dr. Bernstein wrote "So it would appear that this thread has changed its direction set by my visitors from discussion about the patient's modesty issues to one of presumably wide spread medical criminality."
Actually, it is not so much about demonstrating criminality as it is to establish that the sexual urge is so strong that a significant number of doctors are willing to risk criminal prosecution, incarceration, often becoming convicted felons to gratify those urges. The point is, that for a large number of physicians, the male doctor/femal patient encounter is not nearly as non-sexual as you want everyone to believe.
Doctor Watchdog
While I agree every case of verified sexual abuse in a medical setting is tragic, comparatively they're infestitimal and overshadow the much larger issue of modesty, privacy, and dignity that we all face on a routine basis daily throughout this country. More importantly, when a patient makes sexual abuse accusations against a provider, the law requires a comprehensive investigation. Compare that to the response most of us receive when we complain that our modesty, dignity, and privacy has been violated in a healthcare setting, either indifference or ridicule.
Ed
I would agree with Ed. In my mind, sexual abuse in one form or another is an entirely different matter than patient physical modesty. Nobody except the sexual abuser would consider their acts professionally ethical or legal whereas physical modesty generally is understandable and accepted except to us physicians if we see it trumping potential curative and life-preserving medical or surgical management.
Shouldn't we give up on this thread on Patient Modesty describing criminality within the medical profession (leave that to the news media, medical boards and law enforcement and return to discussion of ways for the system to provide ample modesty protection satisfying for all patients? ..Maurice.
Yes please!
Ed
There are certain factors that cause psychological trauma.
Loss of control, the unexpected, extreme humiliation.
Nobody ever forgets when their dignity is compromised or they are put into a humiliating situation.
What's humiliating for some is not for another. It is safe to say, however, that behaviors that do not fit with our social norms would upset most people.
If patients were empowered to feel that they are making a difference to the medical community, they would probably tolerate some socially uncomfortable situations in order to "help" the medical community to achieve it's goals.
Positioning is the key. Dignity and self respect at the top. Treat patients as you would want to be treated (especially with informed consent, telling all that will happen, state of undress, who the medical community would want present, and wait for a response from the patient and then DON'T DO ANYTHING WITHOUT COMPLETE PATIENT CONSENT.
There's a start.
belinda
I could not agree more. No one denies the severity of the issue of sexual abuse in the medical community but it is a seperate issue. Yes there may be some outlier periphial overlap but they are seperate issues and to get locked in on actions everyone considers illegal activity it diverts from the focus of this thread which most of the medical community does not even consider a issue....don
Don, thanks for your comments. While sexual abuse is a different issue,(speaking from my own experience of medical sexual abuse), if the proper pre op, informed consent, and a flake of human kindness, none of what happened to me would have.
Sometimes there is a very fine line between the two situations. It's this grey area that can be cleaned up rather quickly but instituting some of the options in my last post.
So, from the eye of the medical personnel, stripping someone naked for examination would not be considered sexual abuse. However, if there is a room full of extraneous personnel watching, the patient is abused because they did not give informed consent.
People who come into trauma centers are focused on their accident, what will happen and how sick they are. Some won't realize they are in a state of undress. However, when you notice a room full of people staring at you, you become very aware, very humiliated very traumatized.
There should be something in the medical law or culture that reflects informed consent for these issues, the same as medical personnel assume people want their lives saved. Let's face it, they need to clean up their act and I'm still waiting for Maurice to acknowledge that "standard of care" needs some work.
belinda
Be;omda. first I must disagree when you wrote "So, from the eye of the medical personnel, stripping someone naked for examination would not be considered sexual abuse." First, I have never seen or heard of patient's being "stripped naked" by medical caregivers. Patients undress themselves and as I have repeatedly written there is no need for the patient to undress completely exposing their entire body and all its parts. As I have previously written, if some dermatologist do that for their skin inspection, we don't teach that in our medical school since sequential undraping (removing the drape from segments of the skin) is more likely to produce more accurate inspection by the physician. And in non-dermatologic exams, total nakedness is not taught because it would be of no value to the patient as well as the doctor and would only cause chilling, shivering (as well as modesty upset) with impairment for proper palpation and auscultation.
Yes, I have seen patients undressed by the staff in emergency rooms and operating rooms but it is also performed sequentially without my observation of total nudity.
Of course Belinda I have written and rewritten here that the medical system needs change to attend specifically to the modesty concern of any and all patients. And the change is only going to occur by learning those concerns by expressions of the patients themselves )"speak up") just as I have learned by reading my thread over the years. But don't wait for the few doctors who are aware to be able to change the system. It is the responsibility of each patient to make their doctor aware and patients together the medical system aware. ..Maurice.
Dr. B., I submit that the act of sexual abuse committed by health care providers can, indeed, be conceptualized in a manner that makes it an “entirely different matter than patient modesty,” but it cannot be conceived in a manner that makes it an entirely different matter than the act by health care providers of undermining patient modesty. Although they are different matters in some ways, they are similar matters in at least three ways.
First, sexual abuse committed in health care settings is likely to undermine patient modesty. Witness, for example, the words of a woman whom I interviewed for a research project conducted a few years ago: “I refuse to go to the hospital; I don’t want to be clinically raped.” Indeed, research I and my students completed suggested that those whose privacy and modesty were violated in health care settings tended to experience the same feelings and beliefs about themselves as those who were raped.
Second, sexual abuse and the act of undermining patient modesty are linked theoretically and possibly empirically. More specifically, some social psychological and structural theories of deviance and crime – e.g., differential association theory, neutralization theory, and social conflict theory – can explain both sexual abuse in health care settings and the act of undermining patient modesty.
Finally, I submit that the likelihood of sexual abuse among health care providers will diminish as action is taken that effectively increases the protection of patient modesty. This hypothesis is derived from those theories to which I allude in the last paragraph.
Maurice,
I have personally witnessed patients being stripped when they come into a trauma center after an accident. And yes, the gawkers are there in all their glory. Patients who are awake are traumatized because of their predicament and don't need to be humiliated on top of that.
The total responsibility for fixing this problem should not rest upon the shoulders of patients. Where is the responsibility and accountability of the healthcare system to stop abusing people? Anyone who has not had informed consent, exposed without warning and an audience is a victim of sexual abuse. Seeing it any other way is just kidding yourself.
What I would have expected you to say is that the responsibility to work on this issue rests on both halves of the system, patient and providers of care. This is the crux of the problem.
The only solution I have seen that works is to make things as difficult as possible for the healthcare system to function and then and only then will they try to fix it. This too, rests on the medical system for refusing to right the wrong.
belinda
Let's keep this thread on patient modesty. I request that those of you who are only readers to post a short message stating your opinion of this thread.
Dr. B. - Do you need any financial contributions to keep this thread operational?
BJTNT
Thanks BJTNT but no..no financial support is necessary for this thread nor all the other almost 900 different threads on my blog. Of course, the Patient Modesty thread is the one with the most visitors and the most comment contributors. However, all the other threads are visited at one time or another with occasional comments presented,
I also think that this thread should be kept close to patient modesty issues and divorced from implication of sexual criminality.
I would like to see how many cases of alleged criminal assault and battery or abuse toward a patient are taken by lawyers and the court system which occurred within the standard practices of physicians, nurses or other healthcare providers. I am not writing about that New Mexico urology lady doctor but I am writing about each of the examples presented here of unrequested observations of a patient's body despite it being accidental or part of an accepted current standard of professional behavior or activity. Does the court system accept the concept that such observation represents a criminal act, an act of criminal sexual behavior or would the courts look at this as a part of medical practice that needs attention and revision of practice but not a criminal act. For the present I think we should separate criminal conduct from the usual expressions here of patient modesty experiences. ..Maurice.
Also..lets not "step on" and "squash" our doctors or nurses.. we all need them around when we need them and we all will need them..and I am proud to have the opportunity to create new doctors for that very purpose. ..Maurice.
Hexandus, Doctor Watchdog, and Ray Barrow made excellent points about sexual abuse by medical professionals. We certainly cannot ignore this issue. I am tired of people trying to pretend that sexual abuse in medical settings does not exist.
I especially liked Ray Barrow’s comments: I submit that the likelihood of sexual abuse among health care providers will diminish as action is taken that effectively increases the protection of patient modesty. There is too much unnecessary stripping of patients. For example, there is no reason for hand surgery patients to be stripped at all. They should be able to wear underwear, surgery shorts, and shirts. Nude patients are much more likely to be sexually abused than patients who are clothed. This anesthesiologist would have had a harder time sexually abusing those women if their modesty was better protected. He fondled many of those women’s breasts. The policy at many hospitals about removing your underwear for any surgery is ridiculous. This is not just a patient modesty concern. This also puts patients at risk of being sexually abused. There are some nurses that remove patients’ underwear once they are under anesthesia though.
Medical Patient Modesty has received a number of cases from women who were sexually abused by doctors over the years. Patient modesty violation cases can also be sexual abuse cases. For example, one college girl had swimmer’s ears and the male doctor at her college infirmary coerced her to have pap smear. If this lady had refused to take any of her clothes off and walked away when the doctor told her she needed a pap smear, she would have never been abused by that doctor. We strongly recommend that women avoid male doctors for intimate examinations to prevent sexual abuse. A number of women who have been abused by male doctors have expressed that they wish that we could reach out to warn women to avoid male doctors for intimate examinations. One lady regretted her decision to let a male doctor who was filling in for her female doctor to do her exam.
Because of the number of people who have contacted Medical Patient Modesty about sexual abuse, we started an educational web site about Sexual Misconduct By Doctors at http://www.sexualmisconductbydoctors.com/. We provide tips to patients about how to prevent sexual abuse in medical settings at http://www.sexualmisconductbydoctors.com/importanttips.aspx.
Sexual abuse happens to women in medical settings more often. But some men have been sexually abused by doctors. I believe that it is actually higher than we can imagine because most men will not report abuse. For example, remember the case of the female ENT, Dr. Sparks. It seems like men are more likely to be humiliated than female patients when they express concerns about their modesty and ask for male intimate medical care.
Belinda also made excellent points. It’s awful when patients are stripped against their will and without their consent. The truth is it is often unnecessary to strip patients anyway.
Misty
Dr. Bernstein: I personally think you should rename this thread to Patient Modesty / Sexual Abuse and then create another thread devoted to patient modesty. I think it is important for you to have one thread devoted completely to sexual abuse.
Ray Barrow: I loved all of your points. I would love to talk to you about doing some volunteer work for Medical Patient Modesty. Can you please email me ? We are in need of volunteers to help us with additional articles. I agree with you that sexual abuse cases will go down as we work to decrease patient modesty violation cases.
amanthatcares I agree with your excellent points below:
i am inclined to think a lock would be appropriate for exams that require nudity, for the same reason one would like to have a lock on the bathroom door. just because the examiner 'feels ok' doesnt mean that the pateint doesnt have anxiety about random people coming into a room without warrant.
amanthatcares
I certainly think it would be nice for examining rooms to have locks for patients who want to be assured that they won’t have unwanted people coming in. Think about how this could be a problem for hearing impaired patients who could not hear knock at the door. There is one other option that patients could look into. They could look into having their spouse or someone else sit in a chair against the door so no one can come in.
Misty
I also agree that the focus of this thread should be on patient modesty.
The reason I posted the information outlined in the header to this volume was in response to the statement in volume 59 by Gerald that "I do not believe anyone can find scientific data that shows more than a very few male physicians being perverts. We must always rely upon scientific data as opposed to anecdotal stories."
He was wrong - the scientific data does indeed exist and the numbers are significant.
Documenting the invalidity of that statement was my only purpose - it was never my intent to change the directional focus of this thread.
Hex
Ray wrote: "Finally, I submit that the likelihood of sexual abuse among health care providers will diminish as action is taken that effectively increases the protection of patient modesty."
Yep, yep, yep!
It's no coincidence that the speciality with one of the highest rates of sexual misconduct is gynecology. Deny the sexual predator doctor the opportunity, and you prevent the misconduct.
Doctor Watchdog
While I agree that the focus on this blog is and should be patient modesty, it's difficult for many reasons to separate modesty and abuse.
The reason is that the patient experience may be traumatizing and experienced as abuse (when complete informed consent is not communicated and thereby a patient is exposed essentially against their will), while nothing abusive was done due to standard of care practices.
The problem is that standard of care practices especially with informed consent are sometimes not communicated. When that happens damage can and does occur in some patients depending on their life experience and how outrageous the situation seems in the eyes of the patient.
So..is it abuse when informed consent isn't given, a patient feels violated? My feeling is that it could be considered abusive, but probably fits legally into the category of negligence.
Either way, this is not helping the medical community in the long run. So, we have to look at why not? TO DO NO HARM carries heavy weight. Evidence of harm can be found in the assigned risk management departments of any hospital, on this blog, conversation with friends and family who have had horrific experiences.
Sometimes it's just a comedy of errors, everyone trying to do their job, forgetting to drape, where no harm is intended but the patient is still harmed. It's the same as friendly fire.
It's disconcerting to me Maurice, that you feel the burden is on the patient. The medical community wants to be in charge, run their system, quality control, patient satisfaction and patient safety.
These mental health issues are just as much about patient safety as medical mistakes.
Opinions please.
belinda
BJTNT, you want my opinion ? I have been reading this blog for years, but have only posted about 5 times. The reason is that I feel intimidated by some of the posters whose views differ from mine. You see, I don't have modesty issues. In fact, I am a female who has had the same male gyn for thirty years, and am outraged that some of you actually believe there must be something sexual about it. I also don't agree with the female poster who thinks only females should be allowed in that profession. Who is she to make that decision ?
Why am I even reading this blog, then? Because I also had a very traumatic medical experience (not about modesty concerns) that has caused me to lose trust in doctors, and I was hoping to pick up pointers about how to avoid something like that ever happening to me again.
LJ
Gynecology is also the specialty where the highest rates of unsubstantiated accusations of misconduct against physicians are made.
Enough with the sexual abuse rant; we can't fix this real or imagined problem here. Let's focus on those issues where we might actually make some progress. This blog has been a blessing for those of us who felt like our modesty, dignity, and privacy were violated. We're not going to fix this problem either but we can gain real insight from each other into how to prevent and deal with problems in future healthcare encounters. It starts when making the appointment and ends in the physician or hospital exam room 1v1. The only advocate you're going to find is the individual you see in the mirror!
Ed
I also think this blog should be confined to patient modesty and that the issue of sexual abuse in a medical setting is another matter and should indeed have a separate blog if so desired. While sexual misconduct does happen in the medical arena (and I do agree that it happens more often in specialties that require patients being unclothed) I think the incidences of it versus incidences of modesty violations/embarrassments are small. I, personally, do not have a fear of sexual misconduct when I approach the medical world but I do have a BIG concern about my physical modesty. Jean
"It's hard to imagine a man being asked to check his prostate via his boxers or briefs. He's cautioned to visit his doctor, undergo tests, and treated with dignity when faced with the embarrassing possibility of erectile dysfunction. There's no reason that women with breast cancer (a disease that also strikes men) shouldn't be treated with the same respect."
Treated with dignity, how would she know?
Complete Huffington Post article can be found here:
http://www.huffingtonpost.com/elisabeth-dale/whats-the-problem-with-se_b_4318439.html
Ed
The comments Doctor Watchdog made below are very true:
It's no coincidence that the speciality with one of the highest rates of sexual misconduct is gynecology. Deny the sexual predator doctor the opportunity, and you prevent the misconduct.
I encourage everyone to take time to read important information about sexual abuse in medical settings There are some very helpful articles on that web page. Look at how the second paragraph discusses how patients under anesthesia are very vulnerable. We all know how easy it is for patients to have their modesty violated once they are under anesthesia too.
Back to the patient modesty issue, I wanted to let everyone here know about an article that a law student wrote about legal options for patients who do not want an urinary catheter.
Misty
Maurice
If I didn't know better I might think you were
blind and lived in a convent all your life prior to
1825. The significance of that year, braille was
invented. I am assuming you took an oak to the
effect, I will respect the privacy of my patients.
Now, I believe many did not, perhaps they
missed class that day. You would think that would
be a requirement to graduate. My first question to
you, what does the oath mean to you? I will respect
the privacy of my patients!
Nurses took an oath as well,some of which are
in the nurse practice act. Sadly, most don't know what
comprises the act. Most state nursing boards have
guidelines for sexual misconduct. Finally, hospitals
have core values. On any given day you could ask
from the CEO down to the lowest butt wiper on the
totem pole what those core vales are. I seriously
doubt anyone could recite them verbatum.
As patients we play by the rules, pay our health
care bills and expect good care and respect for
privacy. Yet, physicians don't remember the oath
they took, I will respect the privacy of my patients.
Nurses don't seem to realize or care that it is
considered sexual misconduct by their state nursing
boards when they, disrobe or draping practices that
reflect a lack of respect for the patients privacy. By
deliberately watching a patient dress or undress.
Voyeurism by seeking sexual gratification by
looking at the sexual organs of others.
CEO's on down who have forgotten or don't care
about the core values of their institution. Yet, it seems
convenient to blame all this on the patient and their
MODESTY issues.
Recently, Connie Cass, a reporter from the
associated press wrote a rather interesting article
about Americans don't have trust anymore. One
of her comments that, only 50% of patients surveyed
trust those with their medical records.
PT
Ed wrote: "Gynecology is also the specialty where the highest rates of unsubstantiated accusations of misconduct against physicians are made."
Unsubstantiated claim noted. You might find it worthwhile to take a look at
http://www.tmb.state.tx.us/news/Spring02/spring02.php#%EF%BF%BDJustSayNo
especially the part that says : "The prevalence rate of sexual misconduct in physicians is estimated at 6-10 percent but this phenomenon is likely under-reported in physician surveys and by patients. It is believed that the number of false claims made by patients is very low."
Doctor Watchdog
Maurice said
" I totally reject the idea that operating rooms
are dens of sexual perversion. "
May I remind you of the case of Dr twana Sparks and what she did to her male patients in the operating room. Do you think this is an outlier event?
May I ask you how much time have you spent
in operating rooms? How many different operating
departments have you been to? I spent years
working in many OR departments Maurice and
what I have seen and heard OR staff say and do
on a regular basis would shock everyone on this
blog.
PT
PT,
I thought you’d be interested in this article: On Anesthesia, Assault, and Fear I would love for you to contact me about comments you heard OR staff say. I am hoping to do some articles about how patients can protect themselves in OR in the near future.
Misty
PT, in my previous posting I made a gross error in describing the lady doctor (who was Dr. Sparks) as a urologist. Her actions would have been bad enough in that specialty but it was even worse since she was actually ENT surgeon and should have nothing to do with male genitalia.
PT, obviously you have spent more time than me in operating rooms, hopefully as a working tech and not simply one of those "gawkers".
I can only report on my more limited experience in internal medicine and medical education. ..Maurice.
Does anyone writing here worry that what is written will lead to an unreasonable fear in the minds of the casual readers of this thread because what is written is disproportional to the actual risk of sexual misconduct or unneeded bodily exposure. Do patients who are having procedures need to add that fear to the worries they have about their underlying illness? Read the article that Misty referred to above and what the author and those who commented wrote. Is such fear really of therapeutic value to the patient? Is the increased release of adrenalin from the adrenal glands as the patient is wheeled into the operating room of value to the surgery? Isn't this unreasonable fear such as that of some individuals fear of flying just because of rare aircraft crashes?
In medicine, we have to weigh benefits against risks and so is the fears described here worth any and all consequences to the patient's health and well-being? This is a very important question to answer for our thread to be of value to the casual visitor here. ..Maurice.
Maurice
Her actions were worse since she was an
ENT surgeon. Actually in my opinion it was
troubling enough that she groped and assaulted
her patients. Even more troubling the nurses
never reported her behavior for years.
No Maurice, I was not a working tech and
not one of those " Gawkers" as you described
although there are gawkers in the OR. What
I felt more disturbing than anything were
the comments made about patients once they
were unconscious. Derogatory comments,sexual
comments and comments about patient's genitalia
both from the whole surgical team.
I believe operating rooms are unique and prime
for this kind of behavior in that the opportunity
exists. Patients are unconscious and vulnerable
to misconduct. To be honest I despised every
moment I spent in the OR and myself as a patient
experienced several incidents of unprofessional
misconduct when I had surgery both in pacu and
the or.
Incidentally, most people who work in the or
are not the kind of people I would want to spend
my afternoon at a barbecue with.
PT
PT, just for all of us to understand the basis of how your observations were made, can you tell us what was your purpose or role to be in the operating room. Was your observations made only in the role of the patient? ..Maurice.
Maurice
Said " what is written is disproportional to the
actual risk."
The overal probability that one will be killed in a single plane crash is 1 in 29.4 million. We would have much better statistics if and only if the risk management of hospitals shared information with the public on how many of their patients are sexually assaulted. Only a few states have passed laws that
require hospitals to report cases of sexual assault
that occur in the hospital over a 24 hour period.
Currently there are no requirements for hospitals
to report medical mistakes that result in death. Why
would we expect medical facilities to share any other
information. The times when we do hear or read
about unfortunate cases is because they were leaked
to the news media.
PT
Misty, I would be pleased to correspond via e-mail wih you. I don't have access to your e-mail address but have no qualms about posting mine if it is permitted on this blog.
A number of scholars have conducted systematic studies of healthcare, healthcare organizations, healthcare recipients, and/or healthcare providers. One of these scholars is Dr. George Annas, chair of Boston University’s Department of Health, Law, Bioethics, and Human Rights. He has spent years studying healthcare, patients, and healthcare organizations. In Judging Medicine, he dubs the hospital a “human rights wasteland” and writes:
Civil libertarians have little difficulty appreciating the plight of prisoners or mental patients. But tell the average civil libertarian that there are significant and unnecessary restrictions on the individual rights and liberties of patients in general hospitals, and you are likely to encounter a blank stare. There are a number of reasons for this. One is the general misconception that the problems are minor, or that certain temporary restrictions on individual liberty are essential if hospitals are to treat sick people properly. An unconscious desire not to perceive ourselves at risk may be another reason; we seldom seriously think we will ever be either prisoners or mental patients. But almost all of us have been hospital patients at least once, and each of us will be a hospital patient an average of seven times during our life. By not dealing with the issue, perhaps we are seeking to avoid thinking about our own future hospitalization, an event which is almost always traumatic and undesired.
Ironically, the descriptive contents of Annas’ book barely breach the proverbial tip of the iceberg. Were he exposed, between the publication of Judging Medicine and today, to research on patient-healthcare provider interactions, popular media publications on healthcare provider waywardness, and the publications on the several blogs (including this one) about the treatment of patients, he might very well have redefined the hospital as a “human rights abattoir.”
The dehumanizing events that occur in hospitals and in other healthcare organizations are not outliers but are institutionalized across healthcare organizations; they, in effect, transcend any particular healthcare facility. Using the words of Erving Goffman, these dehumanizing events “mortify the self” – they compel people to redefine who and what they are. Their aetiologies are historical, social-psychological, and structural. The locations in which they occur are more-or-less but invariably bureaucratic. The environment in these locations, as is true of all bureaucracies, is (again, more-or-less) impersonal and includes employees who occupy a hierarchy of offices and seek to operate in predictable ways. One disconcerting difference between these bureaucracies and many others (e.g., universities and corporate headquarters), however, is that “mortification of the self” frequently takes the form of undermining the bodily integrity of the vulnerable.
The institutionalization of mortifications that take the form of sexual improprieties was given some credence during an exchange I had a few years back with Dr. Peter H. Gott. At that time, he wrote a syndicated column for hundreds of newspapers around the country. He precipitated our correspondence with a newspaper piece on the chaperoning of male physicians by female nurses. I responded with a letter to which he responded.
I’ll end here before I go beyond my allotted characters. If you’re not bored to the core with what I’ve written and would like me to describe my correspondence with Dr. Gott, I would be happy to accommodate a request with another post. I don’t wish to add tedium to everyone’s boredom.
Maurice,
The incidence of unneeded bodily exposure and violations of patient modesty are rampant in hospitals.
Start asking your friends and family if they have ever had an experience they considered embarrassing and why.
How do you measure instilling fear against the possibility of psychological trauma when they don't know what could and does happen.
I wish I had known. Then, I might have been upset but wouldn't have been traumatized.
It's like going into a high crime area and not knowing it, or having the knowledge to take extra care.
How is informing patients of things that happen any different from telling patients the risk of procedures that many times include death but death rarely occurs?
belinda
Anonymous from 10:46 pm yesterday 12-3-2013, thanks for your interesting posting here. I am sure that our readers to this thread would be interested to read the arguments presented by both sides. You can write here your original words to Dr. Gott but since Dr. Gott is not here to defend his words and has not given permission for his words in a private communication to be publicized, I think his views should be only presented in a summarized form.
By the way, in your next posting identify yourself at the end of the text with some arbitrary initials or other pseudonym if you are not signing on with your given name. ..Maurice.
For Anonymous of 10:39 PM on December 3, 2013. I would advise going to Misty's patient modesty website contact page and initiate the correspondence there. Here is the url: http://www.patientmodesty.org/contact.aspx ..Maurice.
I agree with Dr. Bernstein the issue of sexual abuse and modesty are very different and this thread should be about modesty, I am sure if there is not one, Dr. Bernstein or someone could start one on sexual abuse. While there is some overlay on how a patient and the victim of abuse might feel violated,there is a vast difference on the providers side. Abuse is a criminal event, violation of modesty is not. An abuser intentionally inflicts pain for their self gratification. While some may differ with me providers commit what we feel are violations due to ignorance (though I still challenge this), following SOP, self protection of following SOP, or at worst indifference. While there may be incidences where it is the result of malice, I believe these to be isolated rather than material. To paint providers with the broad brush of perverts or abusers I feel is very wrong and inaccurate.
That said I am not willing to give them a complete pass on the issue of modesty violations. I do not buy a complete ignorance of the impact it has on patients as a whole. I might concede to some degree they might not recognize the depth for some but they have to know at a minimum it makes some extremely uncomfortable. I am going to follow up with a separate post on this on a recent change of provider and a discussion I had.
I really appreciate this thread and the contributors but I personally have a couple of concerns. First when we were lucky enough to attract a provider to the thread some chose to attack them rather than engage them in respectful conversation so we lost their insights and participation for the group. Big loss in my opinion and I wished Dr. Bernstein would moderate that but I also respect his decision not to. Second confusing abuse and modesty drives others away and perhaps creates anxiety as Dr. Bernstein suggested, a topic I would like to address later....don
I would love to hear more from Annom 10:39. Some of his/her comments strike to the very core of this issue and I feel run with the intent of the thread of modesty. It would seem the author has a significant amount of experience in our issue here. I would like to hear more.
I want to relate a recent experience that relates to your question as to concern about this thread creating anxiety to readers. My former PCP is in his 70's, he is the only PCP I ever recall having. My concern over provider shortages associated with obamacare lead me to the difficult decision I needed to make a change now that would increase my odds of having a provider long term. I called the office of different MD I told them why, they said they would set up an appointment and if I wanted to change they would have me fill out the papers to get info from my former PCP. I went and filled out the paperwork, was taken back to an exam room expecting to to talk to the MD. I live in a small town and knew all of the women in the office from intake to the "nurse' that took me back. The nurse took my medical history in private. I told her about only having one MD and she responded I know what you mean, Dr. X (my new PCP) is the only one I have ever had, other than when I got pregnant or for personal things,that would be just be to awkward. Then she said WE are going to do a physical on you as part of our SOP for new patients. I prepared myself for battle mentally. She took my blood pressure and said..is your bp always high like this? I take medication so it is normally good. My new MD came in and told the nurse she could leave now. He explained what he was going to do, did it with more consideration for my modesty than my previous MD and toward the end took my BP again and said, nice drop on the bp, you are back to text book, he said sometimes peoples bp are high from the anxiety of what they expect to happen....we had a nice chat about my comfort with him and my concerns with modesty and his nurses whom I knew.
I walked out with all sorts of things going through my head. My new MD was obviously more concerned about my modesty than my former whom I thought was pretty good. My nurse who did not hesitate to admit she did not go to this MD due to modesty issues apparently has no issues when she is on the other side. And to your earlier question about anxiety from reading this thread...I am sure it does create some anxiety but it can also be a tool for reducing it. The fear of the unknown I believe is worse than fear of knowing. Our minds tend to expand reality and jump to worst case scenerio. This adds to my belief that we should separate the issues of abuse and modesty. Creating the impression that there is a reasonable possibility you will be abused is not good nor do I believe accurate. That said, making people aware that their concern for their modesty is not weird, irrational, nor does it make them an outlier or minority is healthy. I will still contend that the majority of people have concerns about their modesty, they are not outliers. The biggest differences are how deep it runs and how they address it. This thread is empowering and empowered people have less anxiety. So yes I do have concerns people reading this will think abuse and modesty run hand in hand and be scared by what they read. Sexual abuse and violating modesty in a medical setting are very different in my mind, but that's my just opinion....don
Don
You said abuse is a criminal event, violation
of modesty is not. Clarify what you meant by
a violation of modesty.
PT
LJ made the following comments: "The reason is that I feel intimidated by some of the posters whose views differ from mine. You see, I don't have modesty issues. In fact, I am a female who has had the same male gyn for thirty years, and am outraged that some of you actually believe there must be something sexual about it. Why am I even reading this blog, then? Because I also had a very traumatic medical experience (not about modesty concerns) that has caused me to lose trust in doctors"
LJ, it is interesting that you mentioned that you did not have any modesty issues, but you came to this blog because you had a traumatic medical experience. Can you tell us about that experience in details? How do you feel this blog can help you when we pretty much talk about patient modesty?
You brought a good point about yourself. I guess we can say that women who go to a male gynecologist or men who go to a female urologist do not care about their modesty in medical settings.
Don
I am at a clothing retailer trying on some mens
clothing. As I am changing in the dressing room the
female attendant opens the door to the mens
dressing room and comes right in. Is this a
modesty violation?
If this were a young female patron and the
attendant male and if she called the police would it
be considered a double standard provided the roles
were reversed. In other words if the male called the
police would his complaint be taken just as serious.
If you are a male patient at a hospital
emergency room and the female nurse asked you
to change into a gown and rather than close the
curtain she watched you change. Would you
consider this a modesty violation?
The board of nursing considers this sexual
impropriety and could revoke her nursing license
for sexual misconduct.
A female nurse is giving you an im injection
into your gluteal region. She asked you to pull
down your pants and lie on the table. She does
Not close the door to the waiting room as there
are a number of patients seeing this unfold. Is
this in your mind a modesty violation?
The state nursing board considers this
sexual impropriety because she did not drape
properly and failed to provide you privacy. Her
license could be revoked.
Would it not be more productive for you or
Dr. bernstein to approach all mammography clinics,
L&D suites as well as post-op gyn floors and say
look, you have no males working in these areas,
these are simply modesty issues as no males have
historically worked in these areas. Thus, there are
no grounds to keep them out.
PT
Don,
With the nurse who wouldn't let her employer treat for intimate issues, it's just a matter of what lines people will cross, before the "ick" factor pops up. A doctor examining his own daughter has enough "ick" factor that even doctors consider it unethical, even though they say it's because there clinical judgment would be impaired. But the "ick" factor is not so great that an associate doctor might examine the doctor's daughter, and his clinical judgment not be impaired, no matter how well he knows the other doctor's daughter.
Had a friend who worked at a rape crisis center who was having some intimate medical problems. One of the directors of the center was a gyn, and he offered to examine her at no cost. Most women I've talked to agree there's a moderate "ick" factor there.
Most people would no doubt be appalled if a father showed his daughter how to use tampons, but most people would not be fazed if a male doctor did, but probably would be if a male nurse did.
Doctor Watchdog
PT perhaps I should have used sexual assault instead sexual abuse. The events referred to here appear to be sexual assault. Sexual assult such as rape, fondling, etc are against the law and criminal.
Modesty violations such as what I experienced are not against the law, are not considered criminal, and to one degree or another considered acceptable by the medical community and a segment of their patients.
I consider all of your examples modesty violations. they are not however criminal, try taking them to court. So what was your point with that part?
And no i do not feel it would not be more productive to insist mamography clinics employ men, it would be more productive to demand urology clinics employ male assistants. i would rather look for a win than equal infliction of pain..don
Dr. Bernstein: I am encouraged to see that you agree that Dr. Sparks examining genitals of male patients under anesthesia was wrong. There was no reason for her to examine their genitals since she was an ENT doctor. I think that if those male patients’ modesty had been protected that it would have made it harder for Dr. Sparks to access their genitals. Patients should be able to at least wear surgery shorts and underwear for surgeries involving nose, throat, and ears.
I think it is important for patients to be educated about what could happen to them once they are under anesthesia so they can take precautions. As you know, I strongly believe every patient should have an advocate not employed by the medical facility with them at all times. One of my friends who had her wisdom teeth extracted was stripped naked in a hospital. I was very shocked to learn about that because I did not think you would ever be stripped naked for wisdom tooth extraction. I had several oral surgeries when I was a teenager. The first one was to remove my baby teeth when I was 12. I was really out that time because they used laughing gas mask on me. Fortunately, my mom was always present with me. I got to keep all of my street clothes on. Once patient is under anesthesia, they cannot no longer advocate for themselves.
Patient modesty and sexual abuse concerns are not the only reasons for having an advocate present. My paternal grandmother died unexpectedly after an elective surgery because an inexperienced young doctor substituted the doctor who was supposed to operate on her at the last minute. He let her bleed to death. A nurse told my aunt what happened, but she would not testify against the doctor. If someone such as my aunt could have been present for the surgery, she could have immediately said this surgery has to be cancelled because we want the other more experienced doctor to operate on her.
I encourage all patients to fight for the right to have an advocate present for surgeries. Husbands used to not be allowed to be present for their wives’ C-Sections. My dad was not allowed to be present for my mom’s C-Section with me in 1979. But he was allowed to be present for my mom’s C-Section with my sister 4 years later. Some patients must have challenged that policy.
Misty
I received e-mail this afternoon from "The Uncomfortable Chaperone which I thought fits well with the discussion here, so I am reproducing it here followed by my e-mail response. ..Maurice.
Dear Doctor; I am a housekeeper, at a hospital, who has been told(among other housekeepers) that we must be the chaperone for the male ultrasound technician performing transvaginal probe examinations. We are all extremely uncomfortable with this, untrained and feel it unethical all the way around. Is this even legal?
Signed: The Uncomfortable Chaperone.
And next my response:
it is not unethical and it certainly would be legal but you should understand be given the option to perform this non-housekeeping activity. As your new responsibility to the patient, you should be there with the patient's consent and also you should be educated as to your full role and responsibility should be and educated into the procedure that you will be observing with regard to what the tech should be doing and what the tech should not be doing since without this education you would not be able to fully function as a chaperone. ..Maurice
I think the presentation of the data at the intro to this discussion is a little misleading.
The OP was talking about sexual abuse which, I assume, means medical professionals taking liberties without the patient's consent for sexual gratification.
The data presented refers to "sexual misconduct", which usually means the doctor had consensual relations with the patient. It is considered unethical for a doctor to date a patient. In some instances this can do real psychological damage to the patient. In other cases, a patient who dates their doctor is no more harmed than a client who dates their accountant, even if the rules are still being broken and the doctor still risks loss of licensure in the process. In the context of a modesty discussion, I seriously doubt that much of this sexual misconduct took place within the context of intimate physical exams, especially for the psychiatrists, whose work generally doesn't involve exposing the patient.
--RDW
Here is a posting from PT reproduced here without the link provided since the website no longer exists.
..Maurice.
Don
I suppose you consider this a modesty violation
and you consider this acceptable by the medical
community.
By the way he was awarded $250,000 and yes
the surgeon lost his job. Yet if they are not so
serious as you say and they are accepted by the
medical community one degree or another as you
say then why do state nursing boards have policies
against this behavior.
All the more reason you should convince all
the females in your family to ask for males, after
all these are just modesty violations and they are
accepted within the medical community. One
modesty violation may not be serious to you, but
to another could be construed as a serious privacy
violation.
PT
Dr. B – For the last several hours, I’ve been ruminating over your concern that “what is written will lead to an unreasonable fear in the minds of the casual readers of this thread because what is written is disproportional to the actual risk of sexual misconduct or unneeded bodily exposure.”
I’ve been so frustrated in my efforts to formulate a reply that my blood pressure, which normally runs about 130/75, increased to 168/91. And, that’s a fact. I think you could help me by specifying what in particular is written that you think would have the effect predicted. Surely, not everything written fits the bill.
Ray Barrow
Dr. B – If you recall, in my Tuesday 10:46 PM post, I noted that a column written by Dr. Gott about the chaperoning of male physicians by female nurses when patients were female captured my interest. Implicit in his publication was a belief that, although a need existed for female nurses to chaperone male physicians for the protection of both the patient and the physician, there was no need for female nurses to be chaperoned by male providers when patients were male. My intention for writing to Dr. Gott was not to convince anyone, including him, that there was a need for male chaperones to accompany female nurses who cared for male patients, but to challenge the fiction that male patients were never at risk of being victimized by female nurses in a way that undermined their bodily integrity. I wrote of the hundreds of interviews that I and nursing students conducted with patients and healthcare providers over the years. “Among our many findings,” I asserted, “have been reports of sexual improprieties committed by female nurses ranging from the sexual battery of male patients to off-color comments and gallows humor about male and female patients’ genitalia and female breasts.” I then offered some anecdotes that ranged from the dramatic, such as sexual battery of the sort reportedly committed by Twana Sparks, to the mundane, such as the unnecessary exposure of male patients during routine procedures.
I did not expect to receive a reply from Dr. Gott, and was therefore taken aback when I did. He indicated that he was flabbergasted by what I had written and was sufficiently awed by the contents of my letter that he planned to publish it in a later column, which he did. He may have rued the day that he published the letter for he wrote in another column that the responses to it were unexpected and many were viciously ad hominem. More specifically, he reported that he received a tsunami of responses from people who had experienced or personally observed the same or similar things about which I wrote. He admitted that he did not know how widespread the problem was but had to confess, given the many letters he received, that sexual improprieties committed by female nurses against male patients occurred with a greater frequency than he would have ever imagined.
I must continue this on another post due to length.
Ray Barrow
Nurses who responded to my letter and Dr. Gott’s publication of it reportedly ranged from dismissiveness to unveiled outrage. He was accused of being unjust for believing a word I wrote. One nurse was especially confrontational, accusing Dr. Gott of “yellow journalism.” She argued that by printing my letter, Dr. Gott revealed both his unprofessional side and his willingness to sever the unique relationship between physicians and nurses. She also claimed that publishing the dross contained in my letter was prima facie evidence of Dr. Gott’s lack of credibility and impure motives. She completed her diatribe by asserting that in her 20 years as a nurse, she had never seen or even heard of things of the sort about which I wrote, recommended that letters such as mine be censored, and demanded that Dr. Gott give up my identity. Dr. Gott pulled no punches in his response to this nurse’s diatribe. He denied overgeneralizing from what I wrote and from the corroborating correspondence sent to him, but suggested that the evidence clearly indicated that there was a problem in some locations. He wrote that if by printing inconvenient facts about healthcare provider deviancies made him a yellow journalist, then he would proudly accept the label and stand side by side with others so accused, such as Sinclair Lewis. He refused to give up my identity because to do so would be unethical and, therefore, unprofessional and he intimated that only someone who had little respect for professional ethics would demand such action be taken. He ended his defense by recognizing that it was the unprofessional behaviors reported in my letter and corroborating correspondences that necessitated censure and expressed a hope that his revelations would constitute the first step in this direction.
After Dr. Gott retired his column, he was replaced by Dr. Anthony Komaroff. I wonder what he would have to say about the matter at hand, if anything.
Ray Barrow
Ray, first, as a physician, if you were my patient, I would want to know when you last recorded a blood pressure of 130/75 and whether you ever were diagnosed with persistent high blood pressure and was started on medications for it. Also what method were you using to take your blood pressure and whether you had any physical activity prior to taking the 168/91 reading and whether the determination was made sitting or standing and whether you ever recorded blood pressure that high and under what conditions. All of this information is necessary to evaluate that reading in terms of it being caused by "frustrated" to find the right words to write since usually the blood pressure can rise with anxiety or fear though I can understand your frustration
With regard to my statement, I am simply writing about patients about to or being examined or undergoing procedures done under standard medical professional practices. I say that the actual risk of sexual misconduct or unneeded bodily exposure would be so rare that to instill fear into potential patients would be truly unreasonable. If such a risk was as prevalent as suggested, let's get rid of the medical profession altogether and try some other form of treating disease. How about Voodoo? (Maybe, there isn't a safe sexual risk with that either!) ..Maurice.
Anyway,
Just for the record: I agree completely with Don. He has many good points. I also think this blog should be confined to modesty issues and that the issue of sexual assault in a medical setting is entirely different and should have it's own blog. Sexual assault is a criminal act; modesty violations are not. I personally do not have a fear of sexual assault when I see a doctor but I do have a big concern about modesty. I do agree that the matter of sexual assault in a medical setting is not commonplace. Sexual assault is a matter that can be pursued in the criminal courts: modesty violations cannot (such as the examples PT wrote about). They may be brought to the nursing board but I can't see them ever being brought to a regular criminal court. And I also agree with Don: insisting that men be employed in mammography clinics isn't the best way to approach the medical modesty issue. Getting urology clinics to employ male assistants would be a lot more productive. Jean
PT I did not see the article and don't know what you are even getting at. There is a difference in sexual abuse and modesty violations. Both are wrong however different. Sorry if my not buying into your scorched earth solution but I disagree they are the same and I disagree punishing someone else will correct problem.
Dr. Bernstein I think you miss one important point, what you may consider "standard medical procedures" and "unneeded bodily exposure" are framed from the provider perspective and may be and are different than those of some perhaps many of your patients and surely our posters. Simple examples I have used before my MD did my vasectomy by himself, a friend's MD had his nurse stand there and do very little. If my MD could do it without a nurse, can we not agree then that the presence of a female nurse for such an intimate procedure might not be considered unneeded exposure by the patient. I have related how a "nurse" in our family talked about how disturbed she was as the "old timers" just left patients lying there exposed in surgery/post op while she felt the need to cover them even if they were out. I had to completely strip and wear one of those stupid gowns for an endoscopy at one hospital a woman in my office was allowed to leave all of her clothes including her bra on for the same exam at another. I had a female tech when a male was available for a scrotal ultra sound...I could go on and on but you get the idea. I am with you about the abuse issue, but the difference between what you and providers feel is normal and acceptable is completely different from the people on this thread. Most providers see no problem with the fact that almost all of the support people at urologist are female, after all they are professionals...most of us however feel that is completely unacceptable...so standard and unneeded are relative terms, and given it is the patients whom you are worried about getting worked up over nothing...aren't our views as patients just if not more relevant than providers?. Sorting out our own bias due to our point of perspective is difficult if not impossible. I agree I think abuse is rare, failure to address modesty issues to their fullest and per patients perspective and desire on the other hand I believe are common if not prevelant...don
Ray,
With regards to your comment that male doctors get chaperones, but female nurses don't: in my experience that trend applies to nurses in general -- both male and female.
I've worked as a CNA for three years. Every day, we have to clean vaginas and anuses on incontinent patients and shower patients of both genders. I always try to explain what I'm doing whenever a patient might get ideas (e.g. explaining that I need to lift the breast to clean underneath since that's a prime spot for bacteria and fungi to grow), but I've also felt like I was in a very vulnerable position if someone ever hurled an accusation. We have patients with varying stages of dementia who make false accusations of abuse all the time, usually that they believe to be true, and these are taken very seriously.
In general, men are under greater scrutiny when it comes to sexual issues, but I think the main reasons nurse don't get chaperones is not because they're beyond suspicion but because it would cost too much. It would take a lot of extra manpower to provide an extra body for every intimate procedure. It's a little more feasible for doctors because they make up such a small percentage of the staff and because the salary of the chaperone is a drop in the bucket compared to what the doctors getting paid (perhaps that's a bit of an exaggeration but you get the picture). Additionally, doctors get more power and clout along with their higher pay, so they're in a better position to demand a chaperone for their own protection. CNAs and RNs are more expendable.
On a related side note, I'll throw in my one story of female nurse abuse: I knew an electrician's assistant who got electrocuted on the job. He regained consciousness in a hospital and looked down to see a nurse playing with his penis, flopping it up and down. Yikes.
--RDW
Don, I wrote "standard medical professional practices" and yes,these is set by the medical organizations guidelines and are more based on clinical validation rather than simply opinions of either doctors or patients. With regard to "unneeded bodily exposure", what is unneeded or unnecessary exposure is simply a clinical decision, not a patient decision, and is based on the clinical need for exposure with consideration of general and expected patient modesty issues (issues of which we doctors were aware even before this thread started.) For example, as I have previously mentioned here, total nudity is not required for a thorough skin exam and can be effectively accomplished with segmental removal of drapings. ..Maurice.
I understand Dr. Bernstein but if providers followed practices as laid out, and if they lined up with reality and patient expectations this thread would still be on volume 1. In each of my examples there were options that would have aligned what providers see as needed from a clinical perspective and a patients need for comfort, yet they were not followed because of provider perception they were not needed. There is no doubt certain peroceedures require exposure, but how that exposure is addressed is in the eye of the beholder. The fact that we differ on what is needed and appropriate or not and who gets to make that call is evidence that there is a problem, When one doctor does a vasectomy without exposing a male patient to a female nurse and another has a female nurse whom provides little to no real benefit present, it shows what you consider clinically needed is actually often personal choice of the provider and could be done differently to address this issue. So to your original question, yes I am concerned the focus on abuse does have potential harm, however I also contend the anxiety generated by people reading of potential unneeded violation of a patients modesty is not only warrented, it is potentially helpful in fixing this problem. When providers stop defining what is warrented based on their biased perspective and start attempting to align it with patients wants, needs, and expectations the need for this thread will be gone and the anxiety reading this causes will start to become unwarrented.....don
Dr. B – Thanks for your comments re. my BP; I didn’t expect that. Although the BP readings were true (I’ve a ReliOn cuff ), I was really trying to add a little levity to the post, but I guess I fell short. Therein lies the limitation of written correspondence – one can’t read another’s nonverbals. From now on, I’ll use a smiley face or LOL when I’m not being serious, although I am reticent to do so (LOL).
Your second paragraph addresses, in part, the interest I had in finding out “what in particular is written that you think would” create an “unreasonable fear” in the mind of the casual reader because it is “disproportional to the actual risk of sexual misconduct or unneeded bodily exposure.” Since you used the article to which Misty referred, I am guessing that you believe at least some of the contents of that article instill “unreasonable fears into the minds of casual readers” as evidenced by those who commented. If so, can you address what in that article you believe has the effect you’ve posited? Are there posts with content that you believe have those undesirable effects? In truth, I had my suspicions regarding the posts to which you were referring, and I wanted to see if or the extent to which we saw eye-to-eye. It would be interesting to me to find out what other bloggers' assessments are of these posts.
Ray Barrow
Ray, first to your blood pressure. As you see I am reading like a doctor who also is also instructing medical students how to handle any expressions which a patient delivers to them and attempt to understand what the patient is trying express but with the help of the student's clinical knowledge. So I try to dissect what you are trying to express.
You are quite correct, blog posts, e-mail and texting provide very little to almost no understanding of in what way the individual is trying to deliver the message: literally,frankly or instead "tongue-in-cheek". And that is why, from a medical evaluation point of view, obtaining history by these means is weak. Getting history via the telephone (to hear the individuals voice and expressions) is somewhat better but to both hear and see the individual face to face is the very best in gaining understanding of the significance of history.
Now that this explanation is over, on my next post I will try to answer your second paragraph. ..Maurice.
Ray, with regard to your second paragraph questions, I found the main commentary author's concern impressive: "But the thing is, I am the one going under anesthesia. And I am still afraid. Because bad apples and outliers and statistics equal real people and real lives. And I am a real person with a real life and thus I experience real fear.
And I am afraid. Not of poor surgical outcomes or unexpected reactions to anesthesia but of this, the dark place where the dark things hide and there’s no lightswitch"
But of more concern, I think, to the "casual reader" was what a medical student identified as "Berry" in her clinical years (3rd and 4th years) wrote:"I am a medical student during my clinical years, and actually planning to go into anesthesia. And even so, I’ve often thought to myself that if I ever had to have surgery, I would be incredibly anxious about the vulnerability of being put under. I had never considered the sexual assault aspect, since I train at a busy academic medical center in a large city, so there is never an occasion when a patient in an OR is not surrounded by at least 5 staff members. .. Rather, I was thinking about something else you touched on, the idea of being made the object of mockery, especially since the people in ORs are my (soon to be) colleagues. I struggle with a lot of anxiety, which usually manifests itself as extreme self-consciousness; being out cold, naked, under bright lights, on a table surrounded by a room full of people, is terrifying
"
Think, if a medical student planning to go into anesthesia specialty has expressed to the public such fears..isn't that a bit disconcerting. It is like my previous analogy to flying and the rare crashes. If a commercial pilot expressed to the news media that he is giving up a career of being a pilot because of a fear of that rare crash, wouldn't that make an impression on some potential passenger? It sure would! "Gosh.. if a practitioner is worried about the outcome, shouldn't I?" That is my explanation of what might provoke "unreasonable fear" in the reader. ..Maurice.
RDW – I won’t quibble with anything you’ve written. What has been your experience has also been my experience; neither female nor male nurses are accompanied by chaperones. It’s reasonable to assume, as you do, that at least one reason is the cost that would be involved. However, as I wrote in my post, “my intention for writing to Dr. Gott was not to convince anyone that there was a need for male chaperones to accompany female nurses who cared for male patients, but to challenge the fiction that male patients were never at risk [seemingly assumed by him in his publication] of being victimized by female nurses in a way that undermined their bodily integrity.” I did not include the words that Dr. Gott used which gave me this impression because Dr. B asked me not to quote him directly. I should admit, however, that Dr. Gott’s assumption was actually broader than what I suggested. He seemed to assume that male patients were never at risk of being victimized by female healthcare providers in general. I limited my illustrations to female nurses because the research to which I alluded was with regard to female nurses only. And, the research focused on female nurses only because the students who carried out the research were female nurses, and wished to limit the study to female nurses.
You and some other participants may be interested in reading the case of Backus v. Baptist Health in which the issue of chaperoning is obliquely referenced. The arguments made in the case are pertinent to patient modesty issues. Arguments are presented by defendants in favor of and by plaintiffs against gender discrimination in OB/GYN wards. The decision of the judge included some powerful words in defense of insuring the bodily integrity of OB/GYN patients. Here’s the link. http://scholar.google.com/scholar_case?case=2210156281132062938&q=backus+v.+baptist+medical+center&hl=en&as_sdt=6,26&as_vis=1
One more point, I’ve seen the terms sexual abuse and sexual assault bandied about. In common law, sexual assault constitutes a threat of bodily harm, not the bodily harm itself, coupled with the ability to carry out the threat. What you describe in your last paragraph and what Twana Sparks committed were batteries. Battery involves deliberate, unsolicited, offensive physical contact (including touching) of another. If the intention of the offender is sexual, then the crime committed is sexual battery. Depending on its level, battery can be considered a very serious crime; it can be prosecuted as a felony and punitively punished and it can be litigated as a tort in civil court. Not only could Sparks and the nurse you describe be prosecuted, incarcerated in prison, and fined, they and the hospitals in which they worked could answer for these women’s actions in civil court. A tort could be filed against the hospitals under the common law doctrine of respondeat superior which means that employers are responsible for the actions committed by those who officially work for or in their facilities in the course of carrying out their responsibilities.
Ray Barrow
Oops! I accidentally deleted this evening's posting by Ray. But here it is. Ray, I am awaiting your metaphor in the morning. ..Maurice.
Dr. B – When I first read your question posted on Tuesday Dec. 3 at 8:30 pm (Does anyone . . . worry . . .?), I was reminded of a story told to me by a professor while I was doing graduate work at the University of Arizona
It seems there was a man diagnosed as paranoid and hospitalized because of an irrational fear that he was going to be rubbed out by hit men employed by the Cosa Nostra. In short order, the treatment he was afforded was successful; his fear along with the pathological behavioral and physiological consequences of that fear abated to the point at which the psychiatrists treating him believed he could be safely released as long as he attended regular outpatient counseling sessions. As he walked to catch a cab down the marble stairs of the psychiatric facility in which he had been treated, he was summarily shot to death by someone driving by in a fast moving vehicle.
You might see where I’m going here. But, it’s after 12:00 in MO, so I’ll address the relevance of this story as a metaphor later.
Ray Barrow
The example you use Dr. Bernstein goes to support the conversation on the abuse/assault aspects are a concern in creating anxiety, but it also supports to a degree validates the concerns for modesty. This is a 3-4th year med student, she stated "I have often thought to myself" which obviously had nothing to do with this thread, and one would assume being a 3-4th year med student she has had experiences in the medical settings she is referring to. Her concern was being out, naked, under lights, surrounded by a room full of people. If there were not an issue here would her experiences in the OR not ease her fear and anxiety? If this was all about nothing why would she not feel so when she sees herself as a patient? With that I stand by my position the concerns here are valid, the positions providers take as to how to handle this and what is required is self serving, and the anxiety created by the thread is justified and perhaps helpful if not beneficial to addressing the issue. Now I find myself questioning my original reading of your question, when you referred to the possibility of creating unwarranted anxiety were you referring to abuse/assault only or were you including the issue of modesty as well in that?....don
Outside of the rare (I hope) and unconscionable cases of direct sexual misconduct by practitioners (of either sex), I don't understand what all the angst is about, unless it is a product of North American puritanism. I am male and I have had a female GP and a female dermatologist for years, without ever having had any reason to feel "violated" or to feel the need for a change. Today I went for a colonoscopy (apparently a procedure that has caused many participants in this forum a lot of anxiety). Except for my gastroenterologist and myself, everyone else -- including the anesthesiologist, the nurses, and a technician -- was female. Everyone was professional and I had an interesting conversation with one of the nurses about travel, etc., with no self-consciousness. I was wearing the usual open-backed gown, and, frankly, gave little thought to who was going to be in the room or doing what while I was unconscious. Maybe people need to put things in perspective.
I just came across a great website and spoke to the owner regarding special garb designed with modesty in mind. She is welcoming to new suggestions for designing other options.
The name of the company is Spirited Sisters (after two had cancer) and The website is www.healingthreads.com
belinda
An author who wrote a book about how women can be sexually confident wives wrote an article about how women can have sex with their husbands in the winter wrote this tip:
Get creative with your covers, such as making a “tent” using your knees as tent poles, but draping the blanket such that certain parts of your anatomy are within reach. (If we can do it for the OB/GYN, we can do it for our husbands!)
What do you all think about this tip? If visit to the OB/GYN is not supposed to be sexual, why would this lady compare the visit to OB/GYN to sex with husband? It is bizarre that many women go to a male gynecologist and let him access their private parts in the same way as their husbands would.
The problem Peter is you have decided what is right for you is right for everyone. That your experiences and upbringing that make you feel as you do should apply to everyone because you define the norm for everyone with your personal norm. You also seem to think your experience in the medical arena is what everyone experiences. That, Peter is the main problem here, people including providers think they have the right to define what is right for someone else, someone whom they have absolutely no idea what they have experienced or how they were raised. I read about an organization in Calif. who is dedicated to legalizing adult males having sexual relations with minors. They define that as normal and think everyone should accept that. I know people who think we should legalize all drugs and what about nudist, should they not be allowed to walk naked in public since they are comfortable with that, shouldn't you feel comfortable walking naked in public? Good for you, glad that is comfortable for you, but do not try to define what others should be comfortable with because it works for you. That is the problem here, people chosing to define what others should be comfortable with......don
Peter, I was so pleased to read your comments from earlier this afternoon here. I was pleased because it showed that there are patients who can experience opposite gender medical management comfortably and without fear and anxiety simply because of gender and bodily exposure as long as what is being done for the patient is for the patient's health and benefit. I wish more would come and visit and write to help with putting the reality of patient modesty in as you say "perspective". ..Maurice.
Dr. B -- One of the issues you address in your 12/3 8:30 post is an issue of fact. You write, “[W]hat is written is disproportional to the actual risk of sexual misconduct or unneeded bodily exposure.” In your 12/4 9:43 post, you suggest that the risk is “rare.” In two of your posts, you equate the risk of misconduct and exposure to the risk of plane crashes. Implicit in your assertions is that you have quantitative evidence of the risk. Data have been collected by the FAA and other sources which allow one to quantify the risk of plane crashes. We have access to data collected by the FBI’s Uniform Crime Reports and other sources that allow for calculating the risk of being a victim of crime. There have been studies conducted that tell us what the risk of drug side effects are, and so on ad infinitum. But as far as I know there has been no systematic collection of data that can answer the question, “What is the risk to patients of ‘sexual misconduct or unneeded bodily exposure’”? If I am correct, then one cannot reasonably determine rarity, reasonably claim that the plane crash analogy is relevant, and assert with confidence that “[W]hat is written is disproportional to the actual risk . . .” Even if we knew the actual risk, we’d have to figure out a way to quantify “what is written” so we could test your proposition. Does “what is written” suggest that the risk is 100%, 70%, 50%, or some other percent? If I am correct, the statements you’ve made regarding risk amount to an opinion independent of facts. That's okay, I respect your and other people’s belief that the risk of sexual misconduct or unneeded bodily exposure at the hands of healthcare providers is rare, but I’m from Missouri, I won’t accept your belief as fact until you show me. :)
For readers who have not studied scientific methods, if I have not chased you away, I’ll preface an argument that I will present later (probably tomorrow) with one way I go about hypothesizing about or estimating the prevalence, incidence, or rate of some social phenomenon such as the risk of having ones bodily integrity compromised. The approach involves induction. Charles Darwin used induction to help him develop his theory of evolution. He first gathered data (e.g., on finches), noticed patterns in the data (e.g., Finches that live in rocky areas have short beaks while those that live in wooded areas have long beaks) and drew reasonable conclusions from the patterns observed (e.g., Long beaks are adaptive for getting insects in the wood and short beaks are adaptive for getting insects in stony areas.). If you’ve ever watched movies about Sherlock Holmes, you might recall Mr. Watson praising Holmes with, “Good deduction Sherlock!” In fact, Holmes was often using induction rather than deduction. He gathered data, recognized patterns, and derived a hunch or hypothesis from the patterns about “who done it.” He would then use a deductive process to test his hunch, such as orchestrate a sting operation. Of course, Holmes’ hunches were always correct, but scientists are not always so fortunate. I’ll later use a severely truncated form of inductive reasoning to derive an estimate of patients’ risk of having their bodily integrity compromised.
Ray Barrow
" If visit to the OB/GYN is not supposed to be sexual, why would this lady compare the visit to OB/GYN to sex with husband?"
And if you have read the thousands and thousands of reports of physician sexual misconduct that I have, you would see that the language often used to describe a doctor's sexual misconduct is "improper sexual contact with a patient," which obviously means there must be proper sexual contact with patient under normal circumstances.
Doctor Watchdog
Peter – You write (12/6 at 1:34pm), “Outside of the rare . . . cases of direct sexual misconduct by practitioners, I don’t understand what all the angst is about, unless it is a product of North American puritanism [sic]. . . Maybe people need to put things in perspective.”
Here are a few facts:
1. Historically, the only clothing worn by South American Yanomamo males is a string which they tie to the end of their penis and around their buttocks so that their penises are upright. As long as they are “clothed” in this manner, everything is hunky-dory. But if the string breaks in public and their penises drop, they consider themselves naked and tend to experience great humiliation.
2. Citizens of the Middle-East and Arab Americans, as you probably have heard, are very reticent about exposing their bodies to others. Some Middle Eastern males who have been compelled to expose their bodies in front of others have been so traumatized by the experience that they have become impotent.
3. Next to India, the United States is, arguably, the most culturally heterogenous nation in the world, with thousands of subcultures encompassed by larger cultures. When it comes to bodily integrity, the mores of these cultures and subcultures run the gamut from full exposure to exposure of eyes only.
4. Some U.S. courts have even given their two cents about the issue (in Backus v Baptist Health, EEOC v Mercy Health, Griswold v Connecticut, Shulman v Group Productions, and York v Story, among other cases), to wit:
“The human body involves the most sacred and meaningful of all privacy rights. Indeed, we cannot conceive of a more basic subject of privacy than the naked body. The desire to shield one’s unclothed figure from view of strangers, and particularly strangers of the opposite sex, is impelled by elementary self-respect, personal dignity, and the fundamental right to privacy. . .” Anyone who would usurp these rights becomes “the master of the other and, in fact, [such] intrusion is a primary weapon of the tyrant. . . It is a strange doctrine indeed that would decree that the sanctity of a right to privacy fully respected outside of a hospital is forfeited by the fact of falling ill and becoming hospitalized. It is no answer to say that the necessity for prudery to give way to medical necessity has always been recognized, even in Victorian times, so far as doctors themselves are concerned . . . The fact that the plaintiff is a health care professional, that he acted in a manner consistent with his traditional role, or that he is competent at what he does, does not eliminate the fact that he is an unselected individual who is intruding on the patient’s right to privacy.”
5. And, if you really understood Puritan culture, as is implicit in your first sentence, you would know that they really weren’t very puritanical. Read Kai T. Erickson’s The Wayward Puritans, if you want to know what I mean.
In short, when it comes to exposure of the human body, yours is not the only perspective, as you imply in your last sentence. The different perspectives are founded in the cultural values and norms of a people. It would be no easier for people of many other cultures to embrace the virtue of and act on your perspective than, as evidence by your own words, it would be for you to embrace the virtue of and act consistent with their perspectives.
Ray Barrow
Though I have always felt and have stated previously that "moaning and groaning" ones personal experiences and feelings on this thread was clinically therapeutic and of personal emotional value, I am truly pleased to read erudite commentary, irrespective of the writer's views, as a substantial contribution to a discussion which, of course, is part of title of this entire blog. Keep it up. This contribution to discussion is a means for providing documented facts and non-ambiguously expressed theories. On the other hand, I will not delete a "moan" or a "groan" since, as a physician, this is what I expect from the patients as I am being challenged to find relief for them. ..Maurice.
It is very clear that some of the people who have come to this blog lately do not care about having opposite sex intimate care. I would like to do some research to determine if any of those patients might be able to use any resources on Medical Patient Modesty’s web site.
I wanted to ask those who do not care about having opposite sex intimate care some questions.
1.) Do you have any modesty concerns in medical settings at all? If so, what are your modesty concerns?
2.) How do you feel about not wearing underwear for surgeries that do not involve your genitals such as hand, knee, etc? Do you have a problem with the ridiculous policy at many hospitals that you must remove your underwear for any surgeries?
3.) How do you feel about having an urinary catheter without your consent? I encourage you to check out this article about unnecessary urinary catheterizations and lack of informed consent. I know some patients may be concerned about the potential complications of urinary catheters rather than modesty.
4.) Are you okay with opposite sex nurse giving you a bath?
5.) Please take a look at Medical Patient Modesty . Do you feel that there are any helpful resources for you as a patient? If so, what articles do you find helpful? If so, why?
Misty
Dr. Berstein what you and Peter fail to acknowledge is that perspective is personal to the individual, Your perspective and mine are are different they are neither right or wrong because they are different. I am completely fine if Peter is comfortable with opposite gender, while not comfortable I am Ok with opposite gender when I am out, something others have chasitised me for, The fact is this is not a one size fits all issue as you would desire to make it. I have to say I find your insistance that your views should be my views, your comfort level should be my comfort level without even having a single inkling of how I was raised or what I have experienced to be somewhat arrogant. Do you tell the muslim woman to put perspective on it since it is a medical setting, to you tell a woman who has been raped to put perspective on it and let a couple of males handle the rape exam? You can argue these are extremes, but who are you to decide what is or isn't extreme and for who? The fact that some, lets go so far as to say many or most are comfortable with opposite gender, that doesn't change the fact that it doesn't mean it is right for the rest. I love to ride my Harley, some tihnk it is dangerous, I say put some perspecitve on it, there are 100's of thousands of riders, if you aren't comfortable riding a Harley you just need to put some perspective on it. Your perspective has nothing to do with mine....don
Don, what is my understanding of a patient's perspective is that it is the property of the patient just as the patient's history is the property of the patient and just as the patient's body is the property of the patient. And this is what we teach our students. We accept the patient's perspective as that of the patient if the patient has communicated that perspective to us and we should and will tailor our management of the patient's perspective within the limits and perhaps even a bit beyond not our personal perspective, but the perspective of ethical and standards of medical practice for that patient's illness. What I am getting at is that the perspective (the view, the personal feelings and concerns) of the patient is just an important element in treating the patient as the patient's medical history or information we discover on physical examination. But, as I have repeatedly written, the patient must "speak up" their perspective. We can't help without knowing. And don't say we won't make an attempt to help if we can know. To say that doctors intentionally don't listen to their patients is ignoring what medicine is all about--the patient. And if we doctors are only listening to our self-perspectives we are in the wrong profession. Maybe we should be authors. painters, photographers, music composers and what else?..but not doctors where the object of our work is not to express our perspective but to accept and use the perspective of our patients in our diagnosis and treatment of their disease. ..Maurice.
Dr. B – In yesterday’s post (8:02pm), I promised, “I’ll later use a severely truncated form of inductive reasoning to derive an estimate of patients’ risk of [unnecessarily] having their bodily integrity compromised.” I’ll do that now.
It’s my claim that one could reasonably induce from the anecdotes on this and other blogs, Annas’ publication (which I’ve already cited), a publication by Kathleen Fenner, (Endnote 1) the “tsunami” of correspondences received by Dr. Gott (which I’ve already cited), and research conducted by Peter Ubel, et. al. cited by him on Dr. Sherman’s blog (2), among other scholarly publications that “unneeded bodily exposure” (which includes some instances of sexual misconduct) is quite common indeed.
I’ll add to this list in the last paragraph the findings of a study I conducted with students back in the ‘90s. We used a random digit dialing procedure to secure a sample of 82 city residents who agreed to speak about their experiences in hospitals (3) either as outpatients or inpatients. About two-thirds of the respondents either experienced unnecessary violations of their bodily integrity, witnessed it, or both. (4) Six reported experiences that could, by definition, have risen to the level of criminal sexual activity with patients. (5) The limitations of using random digit dialing and the moderate response rate rendered tenuous any generalization to the population from which the sample was chosen. Even if this were not so, there is no law of probability that would have allowed one to generalize from the sample chosen to a larger population. (6) Therefore, it seems to me that, unless other pertinent research has been conducted, the question “What is the risk to patients of experiencing unnecessary violations of their bodily integrity in healthcare facilities?” remains an empirical question. (7) Given the evidence, however, I submit that it is not unreasonable to estimate that the percent of people who have been treated in hospitals as inpatients or outpatients and have experienced unnecessary compromises of their bodily integrity exceeds 50% (8). But, truth be known, as far as I know, there simply is nothing published out there short of anecdotes, methodologically limited studies of the sort done by me and my students, and scholarly publications which are tangential to our interest in providers’ unwarranted violations of patients’ bodily integrity. So, what are we to do, if anything, to inform our ignorance? I’ll address that later for anyone who is interested.
ENDNOTES ARE ON THE NEXT POST
Ray Barrow
___________________
ENDNOTES
(1) Fenner, in Ethics and Law in Nursing notes that the rights of patients “that are frequently placed in jeopardy include the right to privacy (as separate from the right to confidentiality of personal healthcare information.). Follow this statement she gives a number of examples.
(2) Dr. Ubel and his colleagues found, among other things, that gratuitous pelvic exams were conducted by medical students at the 5 medical schools in the Philadelphia area.
(3) This figure represented somewhat over 50% of subjects who had been in hospitals.
(4) I cannot recall the breakdown of the frequency in each category. The likelihood that the results were due to chance was well under .05.
(5) Pre-law criminology students and nursing students were used to distinguish between violations of bodily integrity that were not criminal and those that were. The level of interrater reliability was high.
(6) I recognize that there were a number of other methodological limitations of this research, but I won’t get into them.
(7) Several years ago, I read about the results of research out of Vanderbilt University that involved asking physicians to report whether or not they had ever engaged in sexual misconduct with patients. I’m going by memory, which is not the greatest these days. But, if I recall, about 10% admitted to sexual misconduct (8% of women physicians and 12% of male physicians). The specialty with the largest percent of male offenders was obstetrics (somewhere around 19% of respondents) and the specialty with the largest percent of female offenders was psychiatry (I don’t recall the percent). Nor do I recall how the researchers conceptualized, defined, and measured sexual misconduct; I think it was pretty broadly defined. However, this research, at best, may give one an idea of the likelihood of physicians engaging in sexual misconduct, but it gives us no basis for estimating the risk to patients of being subjected by healthcare providers to unnecessary violations of their bodily integrity.
(8) We asked subjects about their past experiences in hospitals where they received outpatient or inpatient services. We didn’t gather data about the number of times they had sought services in hospitals. We didn’t ask them about their experiences during their last visit to the hospital or set a limit on the time period by, for example, asking subjects about their experiences in the last year. We did gather demographic data, including age, so could have estimated the lifetime risk of patients experiencing assaults on their bodily integrity, but we did not.
Ray Barrow
By the way, I am sure that some of statistics of physicians volunteering admission of sexual misconduct with patients is the known presence of the seductive patient (the patient who in one way or another initiates sexual misconduct) and such a patient we have to warn our students to be aware and discuss with them how to professionally deal with such a patient and the patient's behavior. Again, statistics regarding percentages of these patients are unknown but as patients (even on this thread) talk about the deviant doctor, we all should recognize that doctors also deal with deviant patients too. ..Maurice.
Some of my visitors here would be interested in the topic of sexually seductive patient. Back in 2007, I created a thread on that very subject which so far has a total of 22 pertinent comments (some my own).To go there to read and write, click on this link. ..Maurice.
Dr. Bernstein, I think their is a difference between what is taught, what is set as a standard, and what is delivered in the real world of business meets medicine. The military may have rejected don't ask don't tell but i think it is alive and well in the medical community. And while i agree with you to a high degree patients need to speak up and make their wants known, I would counter that providers avoid asking so they can practice in a false state of ignorance. Again I have a great deal of respect for you for what you are doing here, I can't help but feel you jumped on Peter's comments about perspective because it supported the providers position of perspective. I understand it goes a ways toward supporting the "gee whiz we didn't know " position providers want to occupy, but it does not eliminate the one size fits all works for providers scenerio. The court dialouge qouted above says it better than anything I have read. Can you honestly say providers do not ask so as to avoid the answer? Sorry i don't buy it. And the jump to support the put it in perspective seems to validate providers have the mindset this is not an issue so ingrained, any other thought or perspective is onviously wrong and I want to hear what you say so I can tell you why you are wrong...don
Don, you write "and I want to hear what you say so I can tell you why you are wrong." Don't jump to conclusions since in some ways I may agree with you. For example, I really do think that the "business" aspect of our medical system is badly affecting the ideal and most humanistic doctor-patient relationship. "Humanistic" meaning that a patient is a person in need and not a source of income to be moved on and out so that another patient can add to the daily seen population.
I disagree that most doctors know what I have learned from the 8 years of this blog thread about what a portion of the patient population's are concerned about in terms of modesty and gender issues. I didn't know any more than some basic points regarding breast and genital exams which we learned in medical school. So if the vast numbers of doctors are ignorant of the issues presented on this blog thread, of course, they will not be asking the patients about it and will only be aware if the patient speaks up. What the doctor does after the doctor learns..well, that is another issue. Hopefully, as the doctor is attempting to mitigate the consequence of the patient's disease, he or she will attempt to mitigate the patient's modesty and/or gender concerns. ..Maurice.
Dr. B – You write that you are sure “some of the statistics of physicians volunteering admission of sexual misconduct with patients is the known presence of the seductive patient.” You may be correct, but I find it odd that anyone would admit to sexual misconduct with a seductive patient if they did not engage in sexual misconduct with a seductive patient. On the other hand, the tool used to measure sexual misconduct (to which I do not have access) may have lent itself to this error. But in my experience, tools used to measure deviant, delinquent, or criminal behavior would not confuse a subject into falsely reporting that s/he had engaged in a highly reproved action.
Ray Barrow
Don – I appreciate the views you communicate in your contributions (Dec. 6, 5:54 and Dec 7, 3:45). They parallel, in part, what I wrote to Peter in my post of Dec. 6, 9:51. It is apparent from what you have written that you recognize the importance of culture in determining people’s perspectives on and reactions to bodily exposure. In the 12/6 post you suggest that both your and Peter’s reaction to trans-gender care is determined by social norms. In your next post, you recognize “that perspective is personal to the individual,” that perspectives are “neither right or wrong because they are different,” and that reactions to cross-gender care depend on how one is raised and the experiences they have had. The examples you give of Muslim women and rape victims are illustrative.
Rightly or wrongly, you scold Peter and Dr. B for insisting that their “views should be my views, your comfort level should be my comfort level.” You are, in effect, berating them for judging your culturally founded beliefs, values, and norms regarding bodily exposure using their own culture as a measuring rod. This phenomenon is dubbed “ethnocentrism” (“ethno” meaning culture and “centrism” meaning center of). Ethnocentrism has its functions (e.g., it fosters solidarity) but it is also a source of misunderstanding and conflict. Peter writes that he “doesn’t understand what all the angst is about” and, ironically, follows this statement with another that reflects a common misunderstanding about early Puritan Americans. In order to understand a culture different from one’s own, one must rise above his/her ethnocentrism and first recognize that cultural variations have causes and then walk the proverbial mile in the shoes of the other.
Ray Barrow
I am sorry to digress from the current discussion, but I would like to answer Misty's questions.
1) Yes. I don't want to be exposed needlessly to anyone, male or female. This means no medical students present during a procedure or surgery, and no non-essential people in the room.
I am especially concerned about what happens when patients are sedated or unconscious, because I know first-hand that they are treated differently when the medical staff *thinks* they don't know what's going on.
2) Prefer to keep underwear on.
3) Nothing should be done without true informed consent. This is actually a bigger problem for me than modesty.
4) Yes, as long as only one body part is exposed at a time, and no one else can gawk at me.
5) Your article about sedation. AWESOME !
To clarify my previous statements, I do not have modesty issues if I am treated respectfully and professionally, and gender of the doctor has absolutely nothing to do with that.
LJ
In my 12/5, 10:18pm post I tell the story of a poor, deluded, paranoid man who believed he was going to be gunned down by a Cosa Nostra hitman, who was “cured” by doctors of his “madness,” and who was then gunned down by a Cosa Nostra hitman as he left the hospital. I now wonder if those who read some subsequent posts (12/6 8:02pm, 12/6 7:13pm and 7:14pm), if anyone, have some idea of how the story is relevant to what I wrote in those posts or weather what I wrote is too abstruse and convoluted to see the relevance of the story. Would someone help me out and give me feedback? Do you see the relevance of the story and, if so, what do you think that relevance is? RSVP
Ray Barrow
LJ: Thank you so much for taking time to answer those questions! I am glad that you found the article about sedation and versed very helpful. There are certainly other concerns about operating room that patients also have to think about. A patient could be told that a doctor would do the surgery, but once she/he is under anesthesia, the doctor who is supposed to do the surgery could be substituted with an inexperienced doctor or medical student who would do the surgery instead. Surgeries performed by inexperienced doctors and medical students have caused some serious complications and deaths. We are also very concerned about unnecessary surgeries and procedures. For example, about 85% to 90% of hysterectomies are unnecessary. We have an article about concerns for modesty during hysterectomy. You will notice that there is a link on that page to another article about why hysterectomies are often unnecessary. I think it is important for all women to be informed the truth about hysterectomy. It is a big moneymaker for doctors and hospitals. It is sad about how women are often not informed about the complications of hysterectomy and the fact that most hysterectomies are not necessary.
I am very interested in hearing from others who are okay with having opposite sex intimate medical care. Look at those questions I asked yesterday.
Misty
Ray to me when applied to this thread the patients beliefs were seen as irrational and delusional and the medical community treated him as such. The reality is patients know, they know what is right for them but eventually they come to accept the medical communities thoughts and treatment as what is right and the accept it which is self destructive in the end.
I think the other part of this is the the providers are so sure they know, so sure they are right they unkownly do the damage with best intentions. They are so caught up in believing they know what is best for the patient they don't take time to question what they know or ask what they don't know...that is what it said to me, but then...that just my perspective.
And Ray you are exactly right I was scolding Peter & to a lesser degree Dr. Bernstein for making judgments on how others should feel. I do not judge Peter for not having these more concerns, he should extend the same to others....don
Don, as I have said before: physicians have no idea of the degree of emotional upset and concern that patients have regarding their modesty when they enter into a relationship with the doctor or other healthcare provider. You can't accuse doctors of ignoring something of which they have no knowledge. If doctors would only be referred to my blog thread they would finally be aware and then if they failed to discuss patient's concerns before exams or ignored the patients concerns without attempting to mitigate, they would be candidates for accusation of unconcern and non-responsive behavior. Speak up to your doctor and refer them here and then later ask them what they learned and their response. ..Maurice.
"Don, as I have said before: physicians have no idea of the degree of emotional upset and concern that patients have regarding their modesty when they enter into a relationship with the doctor or other healthcare provider. You can't accuse doctors of ignoring something of which they have no knowledge."
Dr Bernstein, the "no idea" is absolute BS and you know it. Although physicians, they're still human beings and their views of this issue, especially when patients themselves, encompass the full spectrum just as it does with the rest of society.
Ed
Ed, you have to write my entire expression to be fair and accurate in your evaluation. I wrote "no idea of the degree of emotional upset and concern that patients have regarding their modesty when they enter into a relationship with the doctor or other healthcare provider" not just the words "no idea". If I am representative of other physicians, I can tell you honestly (as I have many times on this thread), prior to reading this thread beginning in 2005, I, myself, though knowing general professional standards for attention to patient modesty, did NOT know the degree or magnitude of the concern by some patients. I was never taught about this and I was never informed by my patients about this. So there! Unaware. Ignorance. And though I am now aware and telling my students about what I read here, I am convinced most other physicians unless experiencing feedback from their concerned or already upset patients are also ignorant, unaware.
As a reminder of how to debate, you can't always argue against one brief expression, it may need some further detailing if you intend to present a valid argument. ..Maurice.
Maurice said
" Physicians have no idea of the degree of
emotional upset and concern that patients have
regarding their modesty."
I'm sure they don't understand the complex
social system of the trailer park either.
Just one more way the medical industry remains
non-transparent.
PT
Don and Dr. B – Don, on Saturday at 9:22pm, you expressed a belief that there “is a difference between what is taught . . . and what is delivered in the real world,” maybe in response to comments made by Dr. B about what and how he instructs students. Indeed, there tends to be some degree of difference or disparity between policy and practice at the organizational level and between ideal culture and real culture (or more precisely, between ideal norms and real norms) at the societal level. A focus on the disparity between the AMA’s ethical policy regarding treating patients with dignity (http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion1001.page) and “what is delivered in the real world,” whatever the extent of that disparity, may seem exceedingly mundane and certainly less dramatic compared to, for example, a focus on the degree of disparity between the AMA’s ethical policy regarding torture http://www.ama-assn.org//ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion2067.page and “what is delivered in the real world” as evidenced, for example, by Dr. Steven Miles’ 2006 publication Oath Betrayed: Torture, Medical Complicity, and the War on Terror. http://www.npr.org/templates/story/story.php?storyId=5516533 . Both, however, are worthy of attention, I believe.
A related phenomenon is the “hidden curriculum” found in academic settings, including medical and osteopathic schools. This hidden curriculum shows up as a disparity between what students are formally taught and what they learn informally. It is dramatized in a satirical novel published in 1978 by Samuel Shem called The House of God http://en.wikipedia.org/wiki/The_House_of_God which was the basis for a full-length film produced in 1984 http://www.youtube.com/watch?v=s22bLBu3FUQ .
Alas, as is oft proclaimed, truth is stranger than fiction. Dr. Melvin Konner, anthropologist turned physician (Endnote 1), confirms much of the disturbing aspects of the hidden agenda learned by medical students in his 1987 publication Becoming a Doctor: A Journey of Initiation in Medical School.
QUIZ TIME
Does anyone know what any of the following acronyms and words mean: AMF, CTD, TUBE, TUPE, LOL in NAP, and NTB? What is a crispy critter, a toasted toddler, a crock, a dirtball, a GOMER, a GOMERE, a dump, a FLK, a MUO, and a worm? Do you know, Dr. B.? If you know what any of these mean, then, rest assured, it is highly likely your students do too.
These acronyms and expressions are part of a unique language – a hidden curriculum or a subculture – that denigrates and communicates scorn for patients. According to Konner, their use, sometimes coupled with vulgar and gallows humor, “is part of the everyday scene of medicine.” This part of the hidden curriculum may help reduce stress, but at the same time it augments the social distance between medical student and patient and sets students (and later physicians) apart and above patients. Most disturbing, it opens the way for sanitizing and legitimizing the depersonalization of patients including the unwarranted exposure of patients’ bodies.
“But,” say some, “this is the 21st century; these things just don’t happen anymore.” There may be a modicum of truth to this statement and some change may be measurable. But try to convince Dr. Sally Mahood who, in 2011, published “Medical Education: Beware the Hidden Curriculum” in Canadian Family Physician, that the hidden curriculum is a phenomenon of the bad old days. http://www.cfp.ca/content/57/9/983.full
_____________________
(1) Or, more precisely, an anthrophysician – someone who views medicine through the lenses (or perspectives) of both an anthropologist and a physician.
I believe Anonymous from 8:25pm this evening is Ray. I agree that much of what we teach with regard to humanism in how patient should be treated is degraded beyond the second year of medical school by the "hidden curriculum" presented to them by their superiors.
Ray, my first and second year students do not yet know these acronyms. We even have to caution them about using clinical acronyms such as MI as an example (which could mean myocardial infarction or mitral insufficiency, two different entities) or acronyms which are common in one hospital but not widely used.
I have a blog thread on medical acronyms that should belong in the toilet and those interested can use this link.
..Maurice.
I quoted almost an entire paragraph where you said essentially that ALL providers have no idea and no knowledge of a patient's' concern for physical modesty issues.
Or, stated differently, since their not the nude one in the exam room with multiple strangers standing around, providers are obviously OK with it as long as the patient doesn't object. While you may actually believe that, you can't attribute such ignorance to all of your colleagues.
In the ideal academic environment you work in, you may actually practice ethical medicine where patient autonomy and informed consent reign supreme but it's not that way in the real world, and suspect you know that.
In my experience, these issues are not addressed up front and forthrightly because providers don't want to hear the answer. Medicine is all about the schedule, expediency, and billing; patients are a means to that end. Patients who raise these issues interfere with that, hence we're not asked, and your colleagues hide behind the silence is golden defense.
As a reminder of how to debate, read my complete post please!
Ed
In an excellent syndicated column, "Savoring the Gift of Life", Michael Gerson discusses his battle with kidney cancer. In describing his ordeal Mr. Gerson states, "At the hospital, cheerful young nurses ask you to pull down your pants at odd moments - which is not nearly as pleasant as it sounds."
I think that sentence speaks volumes about the medical modesty issue. I t reminds us that many men somehow think that intimate male medical exposure to young women is somehow "pleasant" or "exciting" or even "humorous" until it happens to them. Then they realize that, in fact, for most of us such exposure is terribly, embarrassing and uncomfortable and leaves us with a sense of helplessness and lost dignity.
I thank all those who by contributing to this forum and also by their words and actions in their personal lives do their utmost to disabuse others about this commonly held belief regarding opposite gender intimate medical care for men.
MG
Can we get the answers to this quiz:
Does anyone know what any of the following acronyms and words mean: AMF, CTD, TUBE, TUPE, LOL in NAP, and NTB? What is a crispy critter, a toasted toddler, a crock, a dirtball, a GOMER, a GOMERE, a dump, a FLK, a MUO, and a worm? Do you know, Dr. B.?
I'm dying to know. I've read TUBE on this blog before (totally unnecessary breast exam). I was able to find GOMER (get out of my emergency room). A google phrase search of "LOL in NAP" yielded 6 results and all were non-medical language. I've read "crispy critter" only in reference to it's use by soldiers in Vietnam.
--rdw
The following comment was left this morning on the now closed Volume 59. I also would advise our visitors here to take a look at the link provided. ..Maurice.
Not before time IMO, I would like to think Misty and the guys using the boards, had tiny part to play with this article.
http://www.thedailybeast.com/witw/articles/2013/12/09/are-male-gynecologists-creepy.html
pailrider.
This is actually the first time I learned about the article, Are Male Gynecologists Creepy?
It does not look like this author used any information from Medical Patient Modesty's web site. I commented on the article.
I have seen Pailrider's comments on other forums in the past.
Misty
The creepy GYN thing is an Interesting read, more than a bit sexist but it adds to the discussion we are having Dr. Bernstein, if providers have no clue..why. I have no reason to doubt your statements that providers don't know but I hope you can understand why it is met with such doubt. I can buy no one spoke up, that I understand, most don't think they should or can. But there are so many inconsistencies in how it is approached, and then there is the question of providers have acknowledged their own issues and insecurities when they are patients (recall Dr. Kiegal), how can they not see it on the other side of the gown. So I do not challenge your position, but I question if not, why? How do providers reconcile the fact that male OB/GYN's are becoming extinct with their view that gender does not matter? We patients have heard providers joking, we read of providers saying they have preference but do not recognize it when they are in scrubs. Honestly I am not trying to challenge your position, but surely you can understand why people challenge that. I wonder if the question of why providers don't know lies not in what they werent taught as much as what they were. Are providers taught that because they are providers they have majically become gender nuetral (little sarcasim there), that the fact that people are patients changes the whole way they look at gender, that it doesn't matter to patients so don't worry about it as long as you do the dance be "professional" use medical terms etc. So the question is why would you have to teach students that patients can have modesty concerns when it is natural in every other aspects of our life to have them? Where do they acquire the mentality that it doesn't matter to most? Shouldn't that be a question as well, It is a difficult question to answer as we both find eachothers position so difficult to believe...,,don
Don, of course all doctors "by instinct" and by formal medical education have a "clue" regarding that patients may have varying degrees of modesty issues from "not much" to "a lot" but the "clue" they don't have is the whole magnitude of "a lot" and in which way all that modesty is going to affect the workup, treatment and the physical and emotional outcome of that relationship. It is this latter description, only provided by the individual patient, that will change a "clue" into hopefully attentive and effective knowledge.
My own "clue" has been expanded by reading my blog and now it is time for the other doctors to get their "clue" transformed into greater attention to the modesty issues of their current patient. ..Maurice.
OK I can buy that, not so sure there isn;t a healthy dose of self justification involved as well but i can believe that to a large degree...there are of course exceptions in both directions, but that i can accept..don
Interesting side note, the link above was obviously sexist but for another look at this check out the box on the side about Al Roker/Matt Lauers prostate exam segment, now substitute the women on the show going in for a pelvic exam and the guys making jokes like that or poking fun about breast exams...not trying to ignite the gender war here, more a showing of how what seems like common sense can become acceptable over time. The offense is still recognized but we come to accept it....don
In my 12/5, 10:18pm post I tell the story of a man who believed he was going to be gunned down by a Cosa Nostra hitman, who was “cured” by doctors of his “madness,” and who was then gunned down by a Cosa Nostra hitman as he left the hospital. I then asked if anyone had some idea of how the story is relevant to my 12/6 8:02pm, 12/6 7:13pm, and 7:14pm posts.
Don 12/8, 1:59pm responded “Ray to me when applied to this thread the patients beliefs were seen as irrational and delusional and the medical community treated him as such. The reality is patients know, they know what is right for them but eventually they come to accept the medical communities thoughts and treatment as what is right and the accept it which is self destructive in the end.
I think the other part of this is the the providers are so sure they know, so sure they are right they unkownly do the damage with best intentions. They are so caught up in believing they know what is best for the patient they don't take time to question what they know or ask what they don't know...that is what it said to me, but then...that just my perspective.”
You pretty much hit it on the head, Don. However, I am loath to generalize to all physicians or healthcare providers.
I’ll share my take on the matter.
Our poor, deluded, paranoid protagonist had probably picked up on certain cues in his social environment (such as a threatening letter) and concluded that his risk of being assassinated by the Costra Nostra was pretty high. Physicians got hold of him and used their considerable skills coupled with the power of credentials and authority to inveigle a cure. Now cured of his phobia-induced paranoia, our protagonist failed to take preventive action and was gunned down in the street, the victim of an iatrogenically induced assassination.
To what is this story analogous? We blogposters are informed by Dr. B and other healthcare providers that the fear we have of our bodies being unnecessarily exposed by healthcare providers is unreasonable. In good faith, the providers collectively use their considerable acumen and skills at argumentation coupled with the power of credentials and authority to disabuse us of the notion that unnecessary exposure occurs often enough to warrant fear. The frequency of occurrence, we are told, is rare.
We are thereby cleansed of our iatroheteronudophobia and, like our unfortunate assassination victim, we let our guard down; we trust without preparing for the worst. For example, we fail to question the woman at intake who hands us a “Conditions of Admission” form and instructs us to sign the form to give the physician permission to treat. Because of our newfound trust, we do not read the document and thereby fail to notice that we are also agreeing to do things we really don’t want to do, such as serving as teaching subjects and permitting the hospital to audiotape and videotape us not only in public areas but also in places were we have reasonable expectations of privacy, such as patients’ rooms. By not reading the document and negotiating a change in those parts to which we take exception, we increase our risk of experiencing humiliating events that we’d prefer to avoid – to being gunned down in the street, so to speak.
Thanks for responding, Don.
Ray Barrow
But, in fact, does the medical profession really set as a goal to manipulate any patient's concept of their own physical modesty? We have so much more to do and in so little time than attempt to perform a modesty metamorphosis of our patients. As physicians, we are aware of the issue of patient modesty in general terms but since we are not aware of the magnitude within each patient.
Yes, we are not taught or inclined to bring up the issue of physical modesty with the patient but are taught simply to explain to the patient what is to be done and to get the patient's consent. It is before or after this information that it is the responsibility of the patient to inform the doctor their concerns about what is about to happen. No mind-reading on the part of the physician but hopefully only attentive listening and attempt to mitigate the patient's concerns. ..Maurice.
rdw – According to Konner, AMF stands for “adios, mother f - - - - r” and is used in place of AMA (“against medical advice”) when the patient who leaves against medical advise is, for example, a dirtball (a patient who is dirty and infested with insects), a worm (a patient who is threatening or dishonest), a crock ( someone who is psychosomatic; stands for a “crock of s - - t”), or some other type of patient who is held in contempt. Crispy critter and toasted toddler mean the same thing – a child who has been badly burned. FLK means “funny looking kid” referring to children who have physical anomalies that distort their features. TUPE means “totally unnecessary pelvic exam.” A MUO stands for “marginal undesirable organism” including a dirtball and worm. NTB refers to patients who are “not too bright.”
GOMERE is said with a French accent and stands for a female GOMER As you suggest, GOMER stands for “get out of my emergency room” and generally refers to the elderly patient, usually those who are turfed (transferred, hopefully permanently) from nursing homes. LOL in NAD stands for “little old lady in no apparent distress.
Implicit in my post (12/8 8:25pm) was the message that words, especially pejoratives, can harm. Just as the use of pejoratives to denigrate the enemy helps the solider dehumanize him, pejoratives used by healthcare providers that denigrate patients open the way for their dehumanization.
Ray Barrow
I read “Are Male Gynecologists Creepy?” Made me think of how hysteria disorder was treated by 19th century physicians.
MEDICAL MASTURBATION: HYSTERIA AND THE VIBRATING DILDO
It is rare that one hears the term “hysterical” used with reference to the actions of a male. Indeed, I never have. In my experience, the term “hysteria” has been used to refer to the aggregate behavior of people who overreact to some crisis or perceived crisis in their social world such as the “mass hysteria” that followed H. G. Wells’ radio program “War of the Worlds” in which Wells posed as an announcer reporting on the invasion of Earth by Martians.
Otherwise, I have heard the term “hysteria” only with reference to the behaviors of women. To understand why that is, one might refer to an etymology dictionary where one will find that the term is Latin for “of the womb” or “suffering in the womb.” Hysteria was “originally defined as a neurotic condition peculiar to women and thought to be caused by a dysfunction of the uterus.” (Endnote 1)
There has been some scholarly writing on what, until the early 20th century, was the preferred and most common treatment for hysteria, the most recent among which was published by Rachel P. Maines entitled The Technology of Orgasm: “Hysteria,” the Vibrator, and Women’s Sexual Satisfaction. This recommended treatment logically followed from what was believed to be the cause of hysteria; viz., excessive sexual tension which was manifested in disturbing sexual fantasies and dreams, excessive vaginal lubrication, irritability, and pelvic discomfort. The cure – masturbation.
Unfortunately, Victorian women, being a highly religious lot, were socialized to believe not only that sexual fantasies constituted adultery, a mortal sin, but that the best way to purge themselves of these fantasies – masturbation – added to their waywardness. So, in droves, they visited physicians who sexually aroused them manually to the point of “paroxysm” or “release.” The use of these terms as euphemisms for “orgasm” in physicians’ professional literature was the way they desexualized the treatment thereby sanitizing and legitimizing it. Of course, medical masturbation did not really cure women’s hysteria, so they found themselves compelled to return for frequent treatments.
Apparently, most physicians did not look forward to manually treating hysteria. It was time consuming, taking upwards to an hour or more to complete. They reportedly breathed a sigh of relief when Joseph M. Granville, an English physician, patented his electromechanical vibrator at the end of the 19th century and marketed it to physicians as an alternative to manual masturbation, for it significantly cut down the time before “release.” Maines suggests that physicians at the time conceptually distinguished between sex – which required penile-vaginal intercourse – and medical masturbation with a machine. “Since the external use of vibrators didn’t involve the vagina, it could not be considered to be sexual contact, and thus was a purely medical encounter.” Maines refers to this conceptualization as the “androcentric model of sexuality.”
As the Victorian era came to a close and the U.S. moved toward an encounter with its first sexual revolution of the 20th century – the 1920s, age of the flapper – advertisements for vibrators moved into the popular media, including the Sears and Roebuck catalogue, and the vibrator became a widely purchased product now used more frequently by women in the privacy of their own homes than by physicians.
By 1930, the vibrator as a household gadget lost is legitimacy as it entered the underworld of pornographic photography and films. By then, most physicians had already stopped using them, an unintended consequence of the sexual revolution of the ‘20s when people began to come to terms with the idea of women as sexual beings.
(1)“Online Etymology Dictionary” www.etymonline.com/index.php?term=hysterical
Ray Barrow
Don made some excellent points. I wanted to address the issue about male gynecologists becoming extinct. Some smaller towns have no or almost no female gynecologists so male gynecologists are still powerful in some areas of the US especially smaller towns.
For example, look at two hospitals in towns with population of over 16,000 people.
1.) http://www.blueridgehealth.org/Obstetrics-Gynecology -physicians.html - 8 of the 9 OB/GYNs are male.
2.)
http://fairviewparkhospital.com/physicians/index.dot?specialty=obstetricsAndGynecology – 6 of the OB/GYNs are male.
Women who have their babies at those hospitals certainly cannot be guaranteed that they will have the only female ob/gyn for the birth of their babies.
Bigger cities usually have at least one all-female ob/gyn practices. Sadly, all-male urology clinics are rare. I encourage all men who are concerned about modesty to contact their local urology clinics asking them to hire male nurses and CNAs. I really would love to see more all-male urology clinics and urology clinics with more male nurses and CNAs for male patients.
As the founder of Medical Patient Modesty, I am not happy with modern medicine even though there have been many wonderful advances in modern medicine that have helped to save people’s lives. I wish that more doctors and nurses would be more sensitive to patient modesty. I was well aware that many medical and nursing schools do not teach their students about patient modesty. Even if medical and nursing schools taught a class on patient modesty, I believe that some doctors and nurses still would not be sensitive to patient modesty. I do think that a class on patient modesty would be helpful, but it will not change the whole medical system. That is why we often encourage patients in articles on MPM’s web site to take steps to protect their modesty. One man contacted us earlier this year with concerns about modesty for colonoscopy. He wanted an all-male team and colonoscopy shorts. He found a wonderful clinic that was willing to accommodate his wishes. If he had not spoken up and taken those steps, he would most likely have not gotten his wishes.
Misty
I encourage everyone to check out Beth's comments on the article about male gynecologists being creepy:http://thebea.st/1iTmoHh She also addressed female medical professionals doing intimate procedures on men.
I have also pasted her comments below in case you all cannot go to that link.
The issue here is that we have separate restrooms for males and females, separate dressing rooms for males and females - and the opposite sex is not normally allowed in those rooms. Why then do we just shrug it off to have men studying for years of careers that we would not usually accept ANY man to be doing that intimate of a thing without being in a committed relationship with him.
These male gynecologists may be professionals, but they are STILL men. Average men fantasize about sex several times per hour. A recent survey showed that 9% of the physicians responding to it said that they'd had sex with 1 or more patients in the past year - which violates all professional guidelines for doctor/patient relationships. Some cases are infamous, while others are quietly settled out of court, but inappropriate behavior DOES happen. While no one can determine the percentage of doctors who fantasize about their patients, it's certainly pretty high.
As examples, several have been in the news recently: http://www.itv.com/news/central/update/2013-11-30/doctor-charged-with-a-further-10-offences/ and some involving doctors who photograph patients and keep them for their later viewing or distribution, such as Dr. Levy who was found to have 10 hard-drives full of such images! http://articles.washingtonpost.com/2013-02-19/local/37180910_1_hard-drives-baltimore-police-patients
And women physicians, nurses, or other therapists should not be intimately examining men either. Yes,many women have damaged or verbally assaulted men - ESPECIALLY young men/teen boys with erections. It's no better when a women does it.
The key to outpatient intimate examinations is to bring someone with you. Someone you trust who can be your witness should anything out-of-line happen. Having a "chaperone" in the room will not protect you. She depends upon the doctor for her job and livelihood. She is there as the doctor's witness and to testify on his behalf if it were to come down to that.
Misty
I do have one question about the colonoscopy procedure and personnel (see my post from Friday 12/6), since I was sedated and not aware of what was going on. As I said, there were four practitioners in the room: my GI guy, the anesthesiologist, a nurse, and a woman described by the nurse as "the doctor's right hand [assistant]". I'm curious as to what that person does during the procedure; the nurse too, for that matter, if anyone familiar with the protocol (New Jersey) could chime in.
Dr. Bernstein I don't see the goal of providers so much as to change a patients perception of modesty as to get them to accept the providers definition, which allows the system to work as they want it to. Changing their perception is not as important as accepting. Your quote "we have so much more to do in so little time" is the driving force. I am rehashing a bit but if a provider was to acknowledge the concept of modesty was individualistic, they would to a degree be forced to consider abandoning the one size fits all approach to patient modesty. In a profession where the patient is supposed to be the center of concern, where the cornerstone of care is "do no harm", and where providers strive to help the patient, how would you reconcile the time constraints you deal with everyday with the providing individualistic care which will likely drastically increase the amount of time needed. I don't think there is a conscious effort to get patients to change their perception, just accept what is being offered. If the patient changes their perception that is great, but it is more of a tool or a by product of trying to get to the real goal...accepting the protocol that works best for the institutional part of any medical setting, it is still a business. Dr. Bernstein I think you are remarkable for doing this and at times taking a lot of abuse as the lone defender of the profession. You must have an incredible amount of self confidence not to get ticked and say the heck with it I am done. So I hope you don't read to much in what I am going to say next. I went to college with my small town Indiana mentality guiding my way and thoughts. I was stunned by the diverse thoughts and people I met. I met a guy whom was what I now consider a racist. We had numerous discussions and his thoughts really disturbed me. One day I challenged him on how can you think like that? He looked at me and said, think like what, where I am from everyone feels this way, I was just wondering the same thing about you. We tend to accept our part of the world for what it is and as normal. I would question if over a period of time providers have developed the mentality and practices of manipulating patients view of modesty or at a minimum, manipulating them to accept what the provider wanted them to, who would be able to recognize that in the medical community? There are exceptions of course, but the racist saw himself and his actions as the norm and justified them to me and to himself. If providers were doing their version of the same...how would you know? I think the medical communities rise to a position of all knowing and to a degree elevated above question has created some of that. Objectivity is difficult on long established norms in our own communities, especially when one is under attack. Thanks for all the effort....Don
Don, just as in so many other areas of medical practice, all doctors must think of their patient's illness and psyche as "individualistic". One cannot lump all patients and their issues together. But for the finest "individualistic" approach to patients from their doctors, the doctor must first have from the patient a description of their wants. For doctors to take a view that all the issues about physical modesty and gender selection that is written on this blog is something that all doctors should be considering is the "wants" of every one of their patients is NOT in any way "individualistic". It is essentially painting all patients with the same brush and the same color: unbridled modesty despite the clinical situation and unbridled concern about the healthcare provider's gender
Again, to be "individualistic" in attention and attempt at mitigation requires receiving a specific understanding of the patient's concerns and desires and not putting the patients all in one pile.
"Manipulation" of the psyche patients is not a goal of ethical medicine unless it is to inform about healthier behavior or to treat those who are have psychiatric illnesses. But "manipulation of the body parts"..ah! that is part of medicine WITH PATIENT CONSENT! ..Maurice.
I wanted to let everyone know that a man who had open heart surgery shared about how a medical professional told him to get over his modesty issues. You can find this man’s story at http://thegospelcoalition.org/blogs/tgc/2013/12/06/scowling-at-the-angel/.
I have bolded the sentences in this story that got my attention:
The man in black said, "If you have any modesty issues, now is the time to get over them."
He spoke as though I'd done something wrong and was about get my comeuppance. I don't know why he did this.
He continued, "I'm taking you to the pre-op ward. The first thing they're going to have you do is strip down to nothing."
What he lacked in bedside manner he made up for in accuracy. A nurse met us at the door and led me to a room filled with beds separated only by curtains. He gave me a hand towel and told me to strip down so he could shave me.
"Um, what?" I asked.
"I need to shave you from your neck to your toes. Standard procedure for open heart surgery," he said. "I'll be right here on the other side of the curtain. Go ahead and lie down on the bed when you're done. You can cover yourself with that towel. Holler at me when you're ready."
With no option but to comply, I played my only card: "You're going to bring me a sedative soon, right?"
He said, "Just as soon as I'm finished your surgical team will pay you a visit and set you up with an IV. They'll give you something then to help you relax."
I did as instructed, and after he at last clicked off the electric shaver, my nurse draped a white cotton blanket over me, and then a second one, tucking them in tightly under my legs and sides, as if to say, "Sorry, friend. Here's a little of that modesty back."
I hadn't been that vulnerable since the day I was born.
This patient was very vulnerable. He did not feel that he could speak up about his patient modesty. The fact that this medical professional told the patient that he needed to get over any modesty issues he may have indicates that this medical professional must have been trained to encourage patients to give up their modesty. Many doctors and nurses will tell patients to get over any modesty issues they may have. This indicates that many medical professionals do actually think about patient modesty. Why would they spend time encouraging patients to get over modesty issues if they did not think about patient modesty? For example, when my grandma expressed how she did not want a male nurse to see certain parts of her body, he replied by saying, “Don’t hide it. I’ve seen everything.”
It seems like some medical professionals are trained to encourage patients to give up their modesty in medical settings by saying certain things such as “We all are professionals. We’ve seen everything”. I feel the medical industry tries to “train” patients to give up their modesty and that it should not matter in medical settings.
Why do so many medical professionals often encourage patients to let go of their modesty in medical settings? It seems like it is more for their own convenience.
Dr. Bernstein: I have some questions I’d like to ask you. You shared that you were not taught about patient modesty in medical school.
1.) Did they not talk about how some patients might be embarrassed for their private parts to exposed in your medical school?
2.) Were you taught that patients should not worry about their modesty and that they should be focused on getting medical care? I remember you mentioning that you were shocked that patients seemed to be willing to give up their health due to modesty concerns a while ago.
3.) Were you taught that private parts were just like other body parts in medical school?
Misty
Misty, I don't know the words I previously used that you are referring to but when I was a student in medical school in the mid 1950s, there was no such concept of patient autonomy and professional paternalism was what had been going on for ages. Therefore, I don't think there was any detailed description or detailed protocol regarding patient modesty to medical students. As an instructor of medical students now, as I said previously, we teach students to consider patient modesty as they take a history (e.g. sexual history) or perform a physical exam. We also stress the need for covering and sequential uncovering the patient's body in order to prevent chilling and to be thoughtful of any patient physical modesty issues. Beyond additional instructions regarding chaperons for genital exams and the overall need for informed consent, that is about it. Of course, with my year 1 group of 6 students I have referred them and they are aware of this blog thread.
Misty, I hope this fully answers your questions. ..Maurice.
Dr. Bernstein,
Here is the statement you made about how you were shocked that some patients would give up medical care due to modesty concerns.
“It is with this view in my mind that I have been shocked to read threats of some visitors here of abandoning their attempts to clear themselves of disease, even potentially fatal disease, if their modesty issues are not strictly followed.”
Do you teach your current medical students that patients may not be comfortable with opposite intimate examination?
Misty
Now Dr. Bernstein you are thinking like a Dr., what I am saying is every patient is different, that means they may run the range of don't care about opposite gender, perhaps even like it for some, to no way, no time, never. I am saying it is the medical community who take the one size fits all when they intentionally act like this is not an issue that they even need to acknowledge exists though the do in the actions. I got a kick out of Misty;s comment, if they don't know there are modesty issues why would they say get over them, why do they take certain steps that indicate they know but still claim they don't? So I stick by my post, we are looking for providers to acknowledge we are individuals be that not caring at all or extreme. If the medical community acknowledged that individual goes beyond the physical attributes of our visit, this thread would have been done long ago, but they don't even ask so it is the medical community who paints with the broad brush, and I still believe it is self serving more so than ignorance.,,,don
Misty, as I already mentioned, the general issue of patient modesty is discussed with my first year medical students but they will not be involved directly in "intimate" examinations (if you mean "genital") until year 2. And, yes, I know that the issue of the gender of the examiner is discussed as part of the experience in that year when they have the opportunity of examining the genitals of both male and female teacher subjects. This is when the matter of use of chaperons is discussed by those teacher subjects and the issues not only of the patient's reactions to the exam (such as including reactive penile erection) but also the students' (and as doctors') reactions themselves. ..Maurice.
Don, I have to disagree. We don't teach and doctors, if they are educated and aware, should not be identifying all the needs of individual patients with a "broad brush". Medical systems might do so because of financial or logistic issues but not the individual thoughtful physician. We teach that each patient is an individual regardless of known gender, race, ethnicity or occupation and more and requires history taking and physical examination performed and interpreted as that individual patient. It seems that what physicians are taught and the professional principles of practice is still a mystery to some patients. However, I will admit that how their physician behaved to them is not their mystery but an experienced observation and reaction. ..Maurice.
Dr. B writes,““But, in fact, does the medical profession really set as a goal to manipulate any patient's concept of their own physical modesty?” We have so much more to do and in so little time than attempt to perform a modesty metamorphosis of our patients. As physicians, we are aware of the issue of patient modesty in general terms but since we are not aware of the magnitude within each patient.”
Don rebuts, “I don't see the goal of providers so much as to change a patients perception of modesty as to get them to accept the providers definition, which allows the system to work as they want it to. Changing their perception is not as important as accepting.”
Dr. B rebuts the rebut thusly: ‘“Manipulation’ of the psyche patients is not a goal of ethical medicine unless it is to inform about healthier behavior or to treat those who are have psychiatric illnesses.”
Now, I personally don’t know about any of this, but I know of someone who, I vow, could speak with authority and uncanny perspicacity about the matter. Her name is Joan P. Emerson (at Berkeley now, I think) and in 1970, she published what is now considered a classic in social psychology “Behavior in Private Places: Sustaining Definitions of Reality in Gynecological Examinations.” In H.P. Dreitzei, ed., Recent Sociology 2: 74-97.
To understand what Dr. Emerson wrote requires understanding her perspective. She and I were trained to view the social world in different ways. In fact it is my impression that, ironically, Emerson and Dr. Joel Sherman’s daughter were similarly trained. Dr. Sherman and Dr. Doug Capra run the Patient Modesty and Privacy Concerns” blog
I was trained that the best way to understand the observable world, including the social world, is via rigorous scientific research. But, although it has been difficult for me because of my training, I’ve come to realize that understanding human beings requires more than the impersonal approach of science of the sort we might use to study the fauna of Sri Lanka. After all, humans are unique in the animal world in, among other ways, the level of their sophistication at creating and manipulating symbols.
Adherents associated with the school of thought in which Dr. Emerson was trained tend to believe that the best way to understand the social world is by viewing that world through the eyes of those who are studied, to, in effect, walk a mile in others’ shoes. Unlike scientists, who understand “reality” to be whatever is the outcome of scientific research, those who are likeminded with Dr. Emerson define “reality” as the meaning people attach to the world around them.
I’ll use a later post to tell you what Dr. Emerson has to say about how the social milieu is manipulated during pelvic exams by male physicians, female nurse “chaperones,” and patients in order to balance two disparate definitions of the situation* in order to minimize the embarrassing effects of modesty while at the same time humanizing the patient .
* These disparate definitions include: 1) the clinical definition founded in the medical model that female genitalia are no different than any other body part and carry with them no meaning of sex and 2) the non-clinical definition which recognizes that female genitalia are unique among body parts and carry a sexual meaning –
Ray Barrow
Ray, you wrote "These disparate definitions include: 1) the clinical definition founded in the medical model that female genitalia are no different than any other body part and carry with them no meaning of sex and 2) the non-clinical definition which recognizes that female genitalia are unique among body parts and carry a sexual meaning "
In medicine we teach and practice only one definition: "the definition which recognizes that male and female genitalia are unique among body parts and carry a sexual meaning"
Yes, we do know the difference between inspecting these parts and inspecting the pharynx where just opening the mouth, sticking out the tongue and "say ahh.." are our only requirements for that exam. ..Maurice.
The truth is many doctors and nurses actually claim that body parts such as ears and knee are no different from private parts. They pretend that private parts are not sexual organs. For example, Oprah Winfrey asked several male gynecologists on her show, "Do sexual thoughts ever enter your mind during the exam?"
One male doctor said, "No. It's no different from examining a knee or an ear."
Misty
I have a challenge for all people here who feel strongly about patient modesty. The medical system often tries to “train” patients to lose their modesty. I encourage each of you to consider setting up time to speak to teenagers, college students, young adults, and parents in your community about how they can speak up about their modesty in medical settings. You could look at reaching out to public & private schools, churches, and colleges. I know some of you may have a fear of public speaking, but each of you should do whatever to do overcome your fear to help people especially teenagers and young adults to know their rights because the medical industry rarely tells patients they have a choice for same gender intimate care or the maximum amount of modesty they can have for certain procedures before they fall to the medical industry’s notion that you must submit to everything medical professionals ask you to without questioning. While there are some good doctors and nurses who are sensitive to patient modesty, we cannot trust the medical system because it is so corrupt and untrustworthy. A small number of doctors and nurses who are sensitive to patient modesty cannot change the medical system. The winnable strategy is to do whatever we can do to educate others about how to stand up for their wishes for modesty in medical settings. I believe that we will see many changes if so many patients spoke up and refused medical care if their wishes are not honored. I am impressed with how Belinda spoke up when that male technician came in the examining room without knocking on the door. It is exciting that Belinda is going to take advantage of this experience to educate medical professionals about how to be more sensitive to patient modesty. It is also impressive that Don was able to get his male doctor to do the vasectomy on him without assistance of a nurse. I am really concerned about how many teenagers and young people are being taken advantage of by medical professionals. Sadly, many parents fail to realize how unnecessary intimate examinations and opposite sex intimate care can damage their children emotionally. Teenagers and young adults are more likely to be sexually abused by medical professionals also.
A college student, University Student From BC who is 22 years old now submitted her case to Patient Modesty Violation Cases on MPM’s web site last week shared about how she is still traumatized by how her mom took her to a male doctor when she was 14. She had unnecessary genital exam. She shared that she thought her mom had good intentions, but that she shared that many parents may not realize how important modesty is to their children. I believe that many parents have been “trained” to give up their modesty by the medical industry that they do not realize how opposite intimate exam or unnecessary intimate exam can hurt their children. This is exactly why we need to educate parents about protecting their children.
Misty
Dr. Bernstein, I stand corrected...sort of. I agree it is the institution that approaches this as a one size fits all issue to modesty, in theory. We tend to hold providers, especially Dr.'s accountable as part of or an extension of that institution. We don't know who would require us to strip naked and don those stupid to short, open backed gowns for a cataract surgery while we are awake, minimally sedated, and done in a few minutes. Same with minor wrist surgery. But the Dr. is whom we see in charge. Same with support people, we tend to lump the MD in with violations of nurses and techs. So to a certain extent I agree, I can believe you do teach the individual nature of the patient, but it is apparent that is abandoned in the institutional setting by providers whom were trained as such. While it may be the institution that creates this, it is the individual provider who execute it. Apparently what is taught, and what is practiced, are often two different things. The institution can also include private practice where a vasectomy is treated like just another procedure by some for ease and efficiency. I used some intentionally.
On teaching and knowing the difference that genitalia is unique, I would like to know what that means for modesty. Beyond the clinical of draping and protecting ones self from accusation, what does it mean if the in practice they are treated with the same focus of efficiency. I think almost everyone here has heard or read that after awhile a penis is no different than an elbow to a nurse. I realize often this is with the intention of calming the patient, making them feel more comfortable, and or justifying opposite gender but it seems to conflict with the recognition it is different. It does not appear the recognition creates a difference in practice in many cases. Then there are the inconsistencies. A woman has a pelvic exam and is draped to give the feeling of being covered to a degree. A man gets cystro laying naked from the waist down for everyone in the room to see. I do believe providers are taught to recognize it, but are they taught to acknowledge it, especially to the patient?...don
I was very disturbed a few weeks ago to find this article: Instilling Sexual Confidence in Our Daughters . This author believes that all mothers should take their teenage daughters (even if they are virgins) to OB/GYN before they graduate from high school to prepare them to go to the OB/GYN every 12 months for the rest of their lives. Most of us know that pap smears are usually not necessary for virgins who have never engaged in any type of sexual activity. Also, ACOG does not even recommend start pap smears until 21 years old. The guidelines at ACOG are also misguided because they do not take into consideration not all women are at risk for cervical cancer. Dr. Sherman did a wonderful job unveiling the truth about pap smears in his article about how informed patient consent is missing from pap smears.
Number 5 in Instilling Sexual Confidence in Our Daughters really disturbed me:
5. Confidence in Her Sexual Health (ages 12+)
Sexual health is a matter that women can’t take lightly, including your daughter. I’m shocked at how many girls get their periods but have never received instruction from their mothers about proper feminine hygiene. I’m also shocked by how many teen girls are sexually active but tell me they’ve never had a gynecological visit. How many adult women struggle with infertility because of the STD they contracted years before? Mom, before your daughter graduates elementary school she needs to be prepared for the changes taking place in her body. Before she graduates high school (and prior if she becomes sexually active), escort her to your OB/GYN. Help her establish a good relationship with the doctor she’ll need to visit every twelve months for the rest of her life. Teach her how to do breast self-exams. Teach her how to be a sexually healthy woman.
Look at number 2 about how she encourages mothers to teach their daughters to not let anyone touch their body parts that are covered by a bathing suit. I feel this contradicts with number 5.
I suggest that everyone consider using the below articles as references in talking to teenagers, young people, and parents.
Are Breast / Genital Exams Neccessary For Sports Physicals? We used a lot of references to Dr. Sherman’s article about sports physical. He did an excellent job unveiling the truth hernia exams do not help to ensure the safety of playing sports.
Tips For Parents of Teenagers
Misty
Misty, with regard to the question posed to gynecologists by Oprah "Do sexual thoughts ever enter your mind during the exam?" That is a bit different than asking "Do you personally have sexual arousal when you perform a pelvic exam?" Hopefully, all physicians have thoughts and concerns about sex during the exam-- how the patient is interpreting what the physician is doing from a sexual aspect and how to preserve a strictly professional behavior. But, as important, make that pelvic exam as short but also as clinically valuable as possible to compensate for the pain and perhaps emotional upset of the patient.
It is my observation that medical students starting out on their first pelvic exams have more fear than anything else related to causing pain and distress to the patient. But,to those visitors here who are relatively new to this thread if you really want to read a detailed personal experience and research on this very topic written by a formed female medical student named "stressed student" just click on this link to Volume 42 written in the Introduction section. It is a long piece but very interesting and gives one an insight into this student and maybe insight into the entire topic of medical education. ..Maurice.
Strange that Doctor Bernstein posted, Patients Modesty should be excluded from this board.
Like myself fight against gender choice for intimate exams and expose the lie doctors do become aroused, enough proof in the media, posted several hundred times myself..example below!
On Tuesday, Smith, 60, had nothing to say before a Cook County judge sentenced him to 18 years in prison.
The Tribune review found that at least 16 registered sex offenders held physician or chiropractor licenses and none had their licenses revoked after being convicted. One doctor convicted of sexually abusing a patient was not disciplined by the state at all.
http://www.chicagotribune.com/news/local/ct-doctor-patient-rape-prison-met-1211-20131211,0,1116218.story
Pailrider...
Pailrider, I suggested that the topic of criminal sexual assault is not a modesty issue in anyway one wants to describe the definition of modesty and it was sexual assault that should be excluded from a thread concerning patient physical modesty. Now if there are ethical issues to be debated regarding criminal sexual assault by physicians (such as the behavior of medical boards) then we should create a different thread for that debate. ..Maurice.
Dr B – You credit me for writing, "These disparate definitions include: 1) the clinical definition founded in the medical model that female genitalia are no different than any other body part and carry with them no meaning of sex and 2) the non-clinical definition which recognizes that female genitalia are unique among body parts and carry a sexual meaning.” I indeed wrote that, but I won’t take credit for the idea; the idea belongs to Dr. Emerson. I placed that idea, using my own words, in a footnote signified by an asterisk. Also, she is not writing about what is taught in the classroom (which may constitute the ideal) but what is (or was) practiced during pelvic exams (which may deviate more or less from the ideal). As I confessed in my post, I personally don’t know about any of this. That’s because I’ve never been in a room in which a pelvic examination has taken place, nor do I wish to ever have that experience. :)
Ray Barrow
Ray, I apologize, I should have been more specific that the footnote was a description/conclusion by another.
I would disagree with Dr. Emerson to even suggest that there is a clinical definition founded on any such "medical model" as what she describes. What we in medicine would consider as any sort of a "clinical definition" or even "anatomic definition" of female genitalia would be what we are teaching our medical students today. And we are certainly not teaching them that the genitalia are "no different that any other body part" and has no sexual connotation or implication. That just isn't true. So that is not the medical model. The goal of setting professional guidelines and limits to the work of medicine would be to teach and expect future remembering that genitalia inspection or manipulation by a professional is of special significance in it being a part of sexuality and sexual activity for all patients both men and women and that care should be taken to attend to such examinations with that in mind and follow the professional limits and guidelines. Any deviation from those teachings, the model we all teach "doctors-to-be", can be uncomfortable or emotionally harmful to the patient or in the extreme a criminal offense. Again, my apologies. ..Maurice.
A typo correction from my 12:02 pm posting today:
the "a formed student" should read "a former student". I hope those who haven't read her piece go to Volume 42 and read. Very interesting! ..Maurice.
On (12/10) I promised that I would “tell you what Dr. Emerson wrote “about how the social milieu is manipulated during pelvic exams by male physicians, female nurse “chaperones,” and patients in order to balance two disparate definitions of the situation* [and] in order to minimize the embarrassing effects of modesty while at the same time humanizing the patient.” What I write below, except where I use quotes, is my take on what Emerson wrote.
Emerson observes that there is a dominant definition of reality that prevails during pelvic exams when the physician is male. This definition is that the events that occur during the process are purely clinical and carry no implications of sex. However, this definition of reality is inherently precarious. The more convincing reality is that a woman’s pelvic area is special; it carries sexual implications and is “out of bounds” in the sense that it should not be viewed or touched by anyone except possibly sexual intimates. This more convincing reality presents a countertheme that potentially threatens the dominant definition but is none-the-less present during pelvic exams.
The patient, male physician, and nurse each possess a “typology of responses” to the situation designed to sustain a balance between the dominant definition of reality and counterthemes. “The physician guides the patient through the precarious scene in a contained manner: taking the initiative, controlling the encounter, keeping the patient in line, defining the situation by his reaction, and giving cues that ‘this is done’ and ‘other people go through this all the time’” (p. 77). An effort is made to define the situation as a medical one. “If it is a medical situation, then it follows that ‘no one is embarrassed’ and ‘no one is thinking in sexual terms.’” By their action, words, and demeanor, the medical staff communicates to the patient, “Of course, you take this as matter-of-factly as we do” and “in the medical world, the pelvic area is like any other part of the body; its private and sexual connotations are left behind when you enter the hospital” (p. 78).
According to Emerson, one “implication of the medical definition is that the patient is a technical object to the staff” (78). . . It would be a shocking and degrading invasion of privacy were the patient not defined as a technical object” (79). To treat the patient as a technical object requires that “the staff disattend the connection between a part of the body and some intangible self that is supposed to inhabit that body. . . The scene is credible precisely because the staff act as if they have every right to do what they are doing,” and the patient validates this interpretation by her very nonchalance (78). Thus, “the patient needs the medical definition” to minimize the threat to her dignity; the staff need it in order to inveigle the patient into cooperating” (79). At the same time, however, counterthemes that exist right along side the dominant medical theme must be addressed. This is because to define a patient as being a mere technical object “constitutes an indignity in itself” (80). Therefore, “some gestures acknowledge the pelvic area as special; other gestures acknowledge the patient as a person” (79). These counterthemes “provide an opportunity to show deference to general community meanings at the same time that one is disregarding them” (80). They must be balanced with the medical definition in order for a pelvic exam to be carried out smoothly. Indeed, suggests Emerson, “what is to be sustained is” not merely the medical definition but “a shifting balance between medical definition and counterthemes” (80).
CONTINUES IN NEXT POST
Ray Barrow
Emerson then explains how procedures and participants’ demeanor help sustain this balance. She does this by interpreting (or identifying the symbolic meanings of) the words, actions, and “props” that are typically present during pelvic exams. She lists the “props” such as décor and medical equipment that help sustain the medical definition. She writes about indicators that recognize the special nature of the pelvic region including rituals that demonstrate respect for patients’ dignity such as draping patients, allowing them to dress and undress alone, and the presence of the nurse “chaperone.” She writes about how the patient is expected to act to help maintain the balance between the medical definition and counterthemes. She notes that it is the patient who most frequently threatens the precarious balance between the medical definition and counterthemes by, for example, blushing and making “an ‘inappropriate’ show of modesty” (87). She explains how the physician and nurse cooperate to neutralize this threat. “The foremost technique” of doing so, she writes, “is to sustain a nonchalant demeanor” (88). She ends her piece by noting that if the patient is persistent in her efforts to threaten the balance between the medical definition and counterthemes, the physician and nurse may “collude” to “exclude” the patient by, at the extreme, defining her as emotionally disturbed.
Assuming I understand Dr. Emerson’s publication correctly, if she were asked to instruct medical students on the delivery of pelvic exams, she would advise them to actively participate in manipulating patients’ definition of the situation in a manner that helps balance the dominant definition (that the exam is purely clinical and carries no implication of sex) and counterthemes that recognize just the opposite, rather than focusing on one set of definitions at the expense of the other. John Macionis in Society (2011: 436) writes “Managing situational definitions is rarely taught in medical schools. This oversight is unfortunate, because as Emerson’s analysis shows, understanding how medical personnel construct reality in the examination room is as important as mastering the medical skills needed for treatment.
Ray Barrow
And now a bit of reality for Maclonis and Dr. Emerson to know.
Why do medical schools use "subjects" who function as teachers be the subject of students first attempts at pelvic and male genital exams. Think of it: teachers who are not physician instructors themselves but who are human subjects as patients whose genitalia will be inspected and manipulated by students. Why are these teacher subjects utilized? They are not there to instruct the students into the details of anatomy, pathology or surgical techniques. They are there as simulated patients who are reporting to the examining student what most likely is going on in the mind and emotions and concerns of a real patient who will be examined by the student. I know what they are teaching: "Don't put in your finger again this way because it will be painful" or "touching me this way is unnecessary and makes me uncomfortable" or "don't grab my penis like that". Why are these teacher-subjects hired by medical schools from companies providing them? Why are they not hired to talk to students as they are examining (the examples given by Misty from a male doctor on Oprah) "a knee or an ear". It is simply because, genital examination of the patient is special modesty and emotional issue and in no way similar to examining that knee or ear. I have a feeling that those who write about teaching medical models are in no way the teachers doing the teaching and may be ignorant of what goes into teaching students about genital examination.
Maybe those of you who want to contribute to the medical education and provide more attention to those issues which trouble you should join these companies who provide these teacher-subjects and be one yourself... and I am sure that they are well paid too. ..Maurice.
No apology needed nor expected, Dr. B.
Now that I posted what I believe to be Dr. Emerson’s major points, you may have concluded as I have, that she was not writing about how students were taught but about their efforts in the field. In the 1960s, research left little doubt that the dominant approach to medical education was consistent with the medical (or disease) model. One gets the impression from reading all of Emerson’s publication that successful gynecologists at the time were those who developed the balancing act skill she describes on the job rather than in school.
It may also be the case that, in fact, your approach to teaching students is consistent with what Dr. Emerson would recommend. It seems that your approach is consistent with the humanistic model of medicine, which, in contrast to the medical/disease model, is holistic. If I am correct, and if you are correct that the humanistic model is today the dominant model in medical schools, then Dr. Macionis owes medial educators an apology. I’ve spoken to him at professional meetings several times; he’s one fine fellow. He teaches at Kenyon College in Ohio and his e-mail may be accessible via the internet. I think he would be amenable to purging the statement I quoted from his book or at least modifying it to better reflect what’s going on in medical schools, something I think is important, given his book is used by thousands of college students a year. Although Dr. Macionis is remiss for not providing the reader with the source of his belief that “managing definitions is rarely taught in medical schools,” he nevertheless might request that you provide him with evidence that, although it may have been true in the past, it is no longer the case.
Ray Barrow
Dr. B – I posted my last statements before I read your 9:16 post. I can’t directly speak to how Drs. Emerson and Macionis would respond to your questions. But I think my last post may have addressed the gist of your questions. If you would like me to elaborate, I will try. It'll have to be tomorrow since it's almost 12:30 here and I'm pooped.
Ray Barrow
Belinda sent me the following comment by e-mail this morning since she was unable to get it posted...Maurice.
Maurice, you raise an interesting point regarding participating as one of these teaching patients.
First, it seems unlikely that someone who has had a poor experience would participate. This being said, the shift from patient to instructor gives the patient power over the student providing an opportunity for a patient to be the one controlling and instructing the medical students.
It is also an opportunity for someone to grow beyond their apprehensions and by participating creates an environment of exposure therapy that is healthy and not abusive, whereas exposure therapy for these situations are not available.
Unfortunately, it must also be noted that the mindset of such instructors have no modesty issues or may be exhibitionists, thereby eroding any teachings regarding a subject they cannot relate to...modesty.
belinda
Pailrider, I suggested that the topic of criminal sexual assault is not a modesty issue in anyway one wants to describe the definition of modesty and it was sexual assault that should be excluded from a thread concerning patient physical modesty. Now if there are ethical issues to be debated regarding criminal sexual assault by physicians (such as the behavior of medical boards) then we should create a different thread for that debate. ..Maurice.
IMO it is all connected, especially considering my previous post, which isn't visible on the blog. Repeat Male doctor in charge of students attending pelvic exams, quote' you will only feel your oun body doing your first hundred, in your opinion does that not include modesty or a lie?
My posts are to highlight this and that male doctors fail to offer gender choice, women under stress of medical setting, not wanting to miss treatment fall for it, hook line and sinker! Have to defend any comments against the procedure, because they have been there and done it.
Pailrider.
An interesting question might be, how do students go from mainly having more fear than anything else for causing pain or distress to the patient in this case a pelvic exam, to not knowing the depth of the issue of modesty of their patients. This is not intended to be sarcastic. From the starting point that most of us feel is obvious to not realizing, what causes this tranformation? Is it desensitation over time, is it the education process, what causes this change?...don
It is impossible for a male doctor to stay pure in thoughts when they examine female patients’ private parts 100% of the time. Average men fantasize about sex several times per hour. If it was true that male doctors never had sexual thoughts, why do we hear of so many male doctors who have sexually abused women? Male doctors that do not abuse female patients still have lustful thoughts. In fact, I heard of how some medical school professors instruct their medical students to keep their lustful thoughts private.
In the article, “Nudity and Christian Worldwide” by Robin Phillips, the author makes some very powerful points that I feel apply to the medical settings. Here are the points that were shared in this article that I feel apply to how medical and nursing schools work to desensitize students.
Points from article that are relevant:
a.) When I hear Christians say that watching sex scenes in movies does not affect them, I sometimes wonder if the shoe isn’t actually on the other foot. If someone can honestly claim that viewing erotic nudity does not affect him, then this seems the clearest evidence that such content has already had a marked effect. This is because such a person is admitting to having become so desensitized that viewing a body that is bare, or partially bare, has become merely commonplace like looking at someone’s elbow.. It is not a sign of maturity to be unaffected by cinematic sex, or even plain nudity, since there is a hardening up process that must occur before a person can view such scenes detached and non-sexually.
This reminds me so much of the desensitization process that medical professionals go through.
I am familiar with the stressed student. In fact, she emailed me a few years ago and we talked some. I really admire her for her stance. I wish more medical students would stand up and refuse to do intimate procedures. There was no point in her participating in intimate procedures since she was going into a specialty that did not require her to do intimate procedures. She would have made an excellent doctor. I received an email from a male medical student last month who wants to go into family practice. He shared with me that he did not want to do any female intimate procedures and wanted some advice about how he could refuse to do them.
Some medical and nursing school students are forced to give up their moral convictions in schools because they receive threats that they won’t pass medical or nursing schools if they won’t do certain procedures. I wish those students knew their rights. They have the right to decline anything that goes against their convictions. In fact, we have several articles about medical professionals standing up for their convictions.
Misty
Ah ha Don! You asked a great question:"how do students go from mainly having more fear than anything else for causing pain or distress to the patient in this case a pelvic exam, to not knowing the depth of the issue of modesty of their patients." A major part of the answer to your question for only some of the students is "the hidden curriculum". This "hidden curriculum" well-known and well-described in the literature (Google it) is the "teaching" 3rd and 4th year medical student receive as they enter their clinical clerkships and are taught not by teachers like me but by their superiors (interns, residents and the attending physicians) and they learn how to become medically efficient which involves some ethical misbehavior and some loss of humanistic concern for their patients. The students and interns and residents all are in difficult situations where they are being graded by their supervisors and to complain about what they are doing, how they are doing it and how their superiors may be ethically misbehaving will impair their own progression up the education ladder. But this happens only to some students and some interns and some residents, not all since some are strong enough to fight back. And then what we teach the students in their first two years may also be altered by exposure to the stresses present later in their medical career. If this "hidden curriculum" is responsible for the professional behavior described on this thread, that behavior is unlikely to change without attacking that "hidden curriculum". ..Maurice.
Belinda made an interesting point that instructors who choose to let medical students to do intimate exams on them have no modesty issues or may be exhibitionists. I am sure that many nudists would not mind letting medical students practice genital exams on them. I would not even accept that job even if I was offered $1 Million. My modesty is too important to me and I know other patients feel the same way as I do.
Misty
Don,
You made excellent points. I agree with you that medical professionals often uses an one size fits approach for patient modesty. While is true that there are patients who do not care about modesty or having opposite sex intimate medical care, the medical industry needs to realize there are many patients who do care. I feel the medical industry and medical associations such as ACOG often use one size fits approach for many issues. For example, ACOG recommends that every woman has pap smears so often. They fail to take into consideration that women who are at zero to low risk do not need pap smears.
I agree with you that it is ridiculous for patients to be stripped naked or required to remove their underwear for all surgeries. Patients should be able to keep their underwear and shorts for many surgeries that do not involve their genitals such as hand, finger, knee, etc.
I like how you have taken some steps to improve patient modesty. I think it’s awesome that you have provided some scholarships for male nurses. I encourage you to consider the challenge yesterday. I think you would be an excellent speaker on male patient modesty issues. I am sure there are a lot of young men or teenage boys in your community that need to be educated about how to stand up for their wishes for modesty in medical settings.
Misty
Misty, you write "Average men fantasize about sex several times per hour". Where is the reference to such a seeming fantastic statistic. I would like to know how such fantasies within the man's brain is transformed into a statistic of presence and frequency to be recognized by others. And who exactly is the "average man"? Generalizations are easy to make a point but should they be part of ethical discussions? ..Maurice.
Dr. B – I first became aware of “bedside manner” training in medical schools and the employment of patient simulators in the late ‘80s or early ‘90s when I met several college graduates who were employed as patient simulators to help pay their way through college and when I read several articles in popular journals that attributed this “new” trend to research that demonstrated an inverse relationship between the communication skills of physicians and the likelihood of suit. The writers defended what they wrote via interviews with a few physician-administrators and by assuming that the research findings, which preceded the educational change, caused a rethinking of the traditional approach to teaching medicine, a belief still promulgated by some people today.
Aside from the physician-administrators’ opinions, I recognized that the popular journal writers’ committed two logical errors, the first being the post hoc ergo propter hoc error (after this, therefore because of this) and the error of single cause or oversimplification. Regarding the latter, having known several healthcare providers who had been influenced by Emerson’s and other similar publications to lobby for courses founded on humanistic criteria, I suspected that the desire to reduce the likelihood of law suit for economic reasons was not the only cause, if a cause at all, for the addition of “bedside manner” training. But what interested me the most was finding and reading the scholarly publications on the effects of physicians’ social skills and the likelihood of being sued. The findings were telling. Researchers found, among other things, that the poorer physicians’ social skills, controlling for other possible causes, the more likely they would be sued or complaints filed against them, even when they did not make medical mistakes, while the better the social skills, the less likely a complaint or law suit, even when physicians’ made medical mistakes. The most impressive of the publications, I thought, was by an attorney who did an excellent job incorporating social psychological theory, relevant research, and principles of law in her report.
Dr. B, if you or anyone else would like the source of this publication, I can try to find it.
Ray Barrow
To me, "bedside manner" by a physician is nothing more than a physician looking at his or her patient as a human subject and not a clinical object. Bedside manner should not be a script to act out towards the patient but a true understanding of the patient and the patient's concerns and then hopefully providing a therapeutic response. If this "understanding" is missing with regard to patient physical modesty, I agree that the physician should be made aware. ..Maurice.
Observation a couple of my posts haven't been posted to the blog, I wonder why, perhaps I hit the odd nerve..hey ho I understand.
OK a different angle, patients modesty, isn't this the way it should be, the way intended instead of creating a full medical procedure, just my opinion!
http://www.radio.cz/en/section/curraffrs/ministry-introduces-changes-to-improve-health-care-during-and-after-birth
Pailrider.
Pailrider, I have not deleted posts by anyone written to this thread and none are shown on blogger.com as pending. Interesting article in that url you presented. ..Maurice.
I was listening to a talk show the other day which was discussing what the presenter called the "myth of male sexuality", the jest was there was a commonly accepted belief that males had sexual thoughts and I forget the number but it was almost once every couple minutes. He said the myth came from studies where they just asked. When they approached the issue scientifically by monitoring brain activities, pulse, bp, etc. remotely the number was no where near what was commonly quoted and accepted. On the other hand, when they monitored females the same way, they found a higher level of activity than commonly believed. Males were still higher, but the discrepancy between males and females were no where near as far apart as is commonly believed. As I said it was a talk show so I have no reference material to verify anything. Now, to me the point is, to often we make decisions and statements based on commonly accepted myths and apply them to the general population. This shows on both sides of this thread. I'm sorry but I do not believe in general we are at risk of being molested or sexually abused by providers, I just don't. I think the Dr. Sparks and those people are a small small minority. I also do not believe that it is only a small minority that have modesty concerns, and I believe the percentage that have significant concerns could be large. But hose are just observations not irrefutable facts.
Dr. Bernstein, your comments on the hidden curriculum goes to what I still feel is the main cause here. The need of the institution for efficiency forces the provider to compromise what they want to provide, what the patient wants, and what the institution wants. There are not enough male nurses, the case loads are to heavy, there is not enough time, staffing is not gender balanced. While we are most commonly attacking the provider I think we should be attacking the institution. I mean really, how many people when faced with choosing to please their superior, be it teacher, supervisor, boss, or employer would not to one degree or another cater to the power. Now that doesn't in my mind excuse providers completely but I think to a degree we are misplacing our anger. Then there is the case where the provider is the institution such as private practice, I don't know a single MD that has a male "nurse". That to a degree is supply but I also assume it is a lack of effort. Years ago my daughter was injured playing sports. We got called back to the exam room of the ortho we were seeing, instead of the young female taking us back an older gentleman came and got us. I struck up a conversation, turned out he was retired and needed something to occupy his time, asked the ortho if he had anything he could do, took a couple night classes and waa laa the unattainable male office assistant was born. It can be done but there has to be a little effort and I don't see that happening....don
David Campbell wrote the following Comment today on our now closed Volume 59. ..Maurice.
This blog has been incredibly fascinating to read. I have learned a tremendous amount about myself reading the articles and reading through the discussions. However, I believe that I might be somewhat different from many of the folks who have posted comments here.
I generally tend to seek out female practitioners. There are certain exams and procedures that make me uncomfortable to the extreme regardless if they done or witnessed by male or female health professionals. Why, then, do I seek the service of largely female practitioners? Two reasons, one functional and the other philosophical. First, as far as genital/urinary exams and the perfunctory DRE at my age (55) is that women tend to have much smaller digits. That simple. The second reason is that women MOSTLY tend to be a lot more gentle in their approach to the patient. Not always so, but there is a tendency.
Are these exams and procedures incredibly uncomfortable under any circumstance? Yes, of course they are. But I have chosen to play the percentage of getting more caring and less physically distressing exams.
I think that the most I have taken away from reading this blog is a feeling that we all have our own ways of coping with things we don't like.
NOTICE: AS OF TODAY DECEMBER 13, 2013 "PATIENT MODESTY: VOLUME 60" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 61
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