Patient Modesty: Volume 61
The question becomes: will changing the medical
system's "bedside manner" be
what is necessary to make most of the folks who are writing to this thread more
comfortable with regard to their patient modesty issues? In other words, is it a fixable issue and all that is needed is simply
presenting the medical profession with a different communicating
"script"? Or is the patient
modesty issues not just a script but a
significant underlying structural issue.
An example would be: there just are not enough male nurses to care for
male patients who would desire male nursing.
Another: there is no organizational way to run an operating room
effectively with restrictions on the gender of the participants and changes in
protocol. What I am getting at is that
solutions to the issues discussed here may be more complex even if highly desirable.
What do you think? ..Maurice.
NOTICE: AS OF TODAY JANUARY 3, 2014 "PATIENT MODESTY: VOLUME 61" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 62
Graphic: GIF file from Google Images and American Broadcasting Company
posted by Maurice Bernstein, M.D. @ 10:37:00 AM
165 comments
165 Comments:
I can only speak for myself. What makes me most uncomfortable is a lack of trust of any medical institution and the fact that the people you are dealing with are strangers and you have no idea whether they will adhere to your wishes.
The above comment goes across the board but on this, modesty is the issue.
Secondly, I am uncomfortable withe lack of admission that there is a serious flaw ignoring the issues of modesty (from it's absence on consent forms to the attitude of gender neutrality).
Third, that "To Do No Harm" when it comes to the issue of privacy and dignity is ignored. The fact that it's usually the second item on the Patient Bill of Rights posted in the hospital AND the fact that it is the most ignored item on that list just enforces the feelings of mistrust.
Fourth, No procedures are put into place for accountability, responsibility when medical professionals behave in an unprofessional way. Whether it constitutes abuse or not isn't the issue. The issue is...Are behaviors having a damaging effect on patients and if so, why is this issue ignored?
What's needed? Addressing all of the above. Acknowledgement that there is a problem with misconduct, the reporting and background checks needed, listening to the patient, and accountability. Until that happens, and with feeling that you are in a trusting environment, nothing will change.
belinda
On the matter of how many times in a day a man thinks about sex, the most recent data available quotes numbers between 13 and 19 times per day, which would mean that during his waking hours a male thinks about sex hourly. (I assume these numbers are the median, not the mathematical average.) Researchers found a wide variation: some men seldom and others hundreds of times each day. Apparently some men have sex on the brain, fantasizing every few minutes. All this is supplemented by some other provocative realities - from puberty onward men have 3 - 5 erections nightly and spontaneous erections during the day. Adding to the erotic state of mind, there are stimulus-driven erection occurring throughout the day, perhaps some created by the male gynecologists at his workplace.
DES
DES, numbers are meaningless as statistics, I mean meaningless, unless it is known where these numbers are coming from and the details of how they were obtained. ..Maurice.
I apologize for not documenting my facts. The subject seems to be a touchy one. On the question of how frequently men think about sex each day - the Journal of Sex Research is quoted online in CNN Health on Dec. 15, 2011, and similar results were found in a Psychology Today article on the internet. The methodology used is available in the online articles.
My information about nocturnal erections is from the website Medicine Plus which is a publication of the National Institute of Health.
As for documenting the phenomenon of daily spontaneous erections, any man can relate his own experience.
I am surprised that you would question these facts as I assumed they were generally known. And I am even more puzzled by the vigor of your response. Why would these numbers about the male obsession with sex be disturbing to you?
DES
Des most choose to ignore numbers including MD sex abuse cases. Little is seen or mentioned on the TV, no one accepts it happens,
or so it appears.
How can there be any modesty with so much going on!
I understand why some women fight against abuse exposure.
Time that gender choice was offered, it will be compulsary in a few years IMO!
DES, the numbers are not disturbing to me, as a physician who should be interested in psychophysiology as we should also be with regard to other relationships between mind and bodily function, Think about obesity which we as doctors deal with obese patients. It would be of interest to know how often these patients think about food and eating and consequently arousing their gastro-intestinal motility. This would be analogous to penile and clitoral vascular engorgement secondary to sexual thoughts. So, nothing unusual or "disturbing" about the numbers themselves.However, I am nevertheless just curious about where and how the numbers came about. ..Maurice.
@DES, I don't question your numbers, just your point in citing them. Yes, men think about sex, as do women. I doubt that comes as a surprise to anyone.
We are all sexual creatures. I'm sure that some male medical personnel have erotic thoughts while at work, as you state. But the same would be true for female medical personnel, as well.
Given this, I'm curious as to your purpose in mentioning these statistics. I'm also curious why you seem to have omitted similar numbers for women.
Psychology Today, The sexual Continuum, Dec 6, 2011 Dr. Brian Mustanski. Don't know if that was the Psychology Today reference but here were some interesting findings and statements: "Even so the previous research that examined actual frequency found daily sexual thought frequency is not even double digits. In addition research has not always consistently revealed gender differences in frequency of thoughts". Also noted in their study the difference between men and women on frequency of thinking about sex was the same as the difference in frequency in thinking about eating and sleeping. So if we draw the same conclusions men are sex addicts who eat all the time and sleep, so that would make them lazy obese pervs? Then there was this statement "We can't know from our study if men really had more thoughts about sex, food, and sleep than women or if they were just more likely to recognize and report it". It seems to be plausible that since men have been more freely able to talk, acknowledge, and engage than women for generations they would also be more free to acknowledge it without guilt. It was even a badge of achievement for males. While it is not right, there is still is a different stigma when it comes to sex and gender. A man says I love sex, he is normal, a woman says I love sex she is what loose, slutty, is it considered as acceptable as the male. If a man says I have slept with 50 women, dude what a man, a woman says I have slept with 50 men, does she get the thumbs up as easily. It isn't right, it is changing, but it still exists. So, would in not be plausible as the researcher stated men might just acknowledge it more freely? Then they stated did the actual act of counting increase the frequency because they were being made aware and focusing on it?. So now where does that leave us Ollie? (showing my age there)...don
Dr. B – We’re close to agreeing. You note, 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.
I hesitate to define a concept by its cause. Therefore, to me, “bedside manner” refers, by definition, to behavior, both verbal and nonverbal, the necessary precursor of which is “a physician looking at his or her” patient as a” human being “and not a clinical object.” I replaced “human subject” with “human being” because the former reeks of impersonality which, it seems to me, is inconsistent with effective “bedside manners.” “Subject” is also commonly used to refer to someone who submits to the power or authority of another. I venture to suggest that physicians who master and employ “bedside manners” ensure that the patient-physician relationship is a democratic one rather than the traditional asymmetrical one. The consequence of doing so for the patient may be, among other things, the augmentation of trust, a feeling of having some control of the situation, and a belief that “the two of us are in this together.” As for the causal placement of the physician being “made aware,” or willingness of the patient to be candid with the physician about his/her physical modesty, I think it is better conceived as an effect of “bedside manner” than a precursor to it. And, let’s not forget the physician in this model. It also seems reasonable to hypothesize that patients’ made “happy” by the physician who employs principles of “bedside manners” has a salubrious effect – cognitively and affectively – on the physician.
Were I to read all of the posts you’ve written over the years about how you teach medical students, I might be able to tease out the principles of “bedside manners” that you embrace. Short of that, could you briefly list these principles?
Ray Barrow
Dr. B – I would like to contact John Macionis and see if he will give his two cents about what you and I wrote a couple of days back, but first I would like your consent. I’d like to send him the message below, if it’s okay with you. Modify it in any way you see fit.
Dr. Macionis: I recently communicated the ideas of Joan Emerson to a physician-educator on a blog which he has run for several years now. I think I did a credible job conveying her points to him. I concluded my correspondence with him thusly: “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.” I then quote you as follows: 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.
We noticed that you did not cite the source for your assertion. This provided an opportunity for the physician to point out that your assertion might be correct when applied to the past but is not true of medical schools today when it comes to intimate exams. As evidence, he noted that medical schools employ patient simulators that undergo pelvic exams and male genital exams at the hands of medical students who have never performed pelvic exams in the past. These patient simulators “report to the examining students what is going on in the mind and the emotions and concern of a real patient.” The reason this is done is because medical school educators recognize “that genital examination of the patient is a special modesty and emotional issue and is no way similar to examining the knee or ear” and they want students to recognize this as well.
Will you please comment on what I have written?
Ray Barrow
Don, to your question "where does it leave us", the answer is "we don't yet know the answer to the question regarding the frequency of sexual thoughts in either men or women and even male physicians who might be under the same social "??stigma??" as women.
To Ray: I use the word "subject" nevertheless in a humanistic sense as compared to identifying patients and/or treating them as "objects" or "carriers of the disorder that the physician is required to diagnose and treat."
I don't recall myself or hearing other instructors using the words "bedside manners" to these beginning students. In our evaluation of the student behavior in interacting with the patient we look for and check on a checkpoint list factors such as the following (as taken directly from the list we use): "The student identified themselves and explained their role, demonstrated consideration for the patient's comfort (asking the patient if it was a convenient time to see the patient, insured patient privacy..and more.), assured the patient of confidentiality, maintained eye contact with the patient,asked questions about difficult topics in a sensitive manner, inquired into the patients concerns or fears, demonstrated awareness of what the patient was feeling, conducted the interview in a non-judgmental manner, made a personal connection with the patient beyond medical issues to get to know the patient as a person, maintained a respectful tone and did not talk-down to the patient..." and many, many more points to check off. We do not call this "bedside manner", we use the term "conduct of the interview". And on every learning checkpoint list for a physical exam, the Patient-Physician Interaction sets the following:
"Introduce self, wash hands before and after performing the physical examination, appropriately drape patient and attend to patient modesty during the physical examination, demonstrate concern for patient comfort." And what we look for in the student is NOT to simply ACT concerned but to transform that concern into a direct attempt to provide that comfort which is apparently needed.
That's it. That's what we all teach first and second year students. If this looks to the outsider as "bedside manner" then so be it..but to us, this is not a script to be "mouthed" but a behavior, a recognition of what the student is dealing with: a live, human being with many of the same emotional features as the student bears but who is also sick.
Ray, finally, write John as you want and perhaps invite him to directly participate in this blog thread, if he desires. ..Maurice.
My point was we can say all we want about this gender or that gender but all it really is, is speculation and enuendo so it does nothing for the conversation on modesty. Are guys worse than gals, does nothing and there is no proof that is even the case. What a person thinks has little to do with the issue, what they do and if they do it from the patient perspective and for the patients benefit is what this is about,,,,the male vs female leaves us right back where we started...don
I wanted to let everyone know that I received a sad email from a man who was sexually abused by his sister when he was younger. This man is very concerned about his modesty in medical settings. He wants to avoid female intimate care. He shared about how his uncle who had bladder cancer died because he refused treatment.
I was sexually abused by older sister when I was 4, she got in a lot of trouble from my parents and ever afterward projected her own anger and shame on me with physical and emotional abuse until I was twelve and could defend myself. Only then did the abuse stop. My worst fear is being naked and helpless in front of women - welcome to the healthcare system. I went into a deep depression after a previous hernia surgery - told myself it was due to everything but the real reason, I woke up naked with my pubic hair shaved off and also found that I had been catheterized without any knowledge or consent.
Sexual abuse is a gender franchise - granted (many women are victimized) but we totally ignore men like me. We die younger because we don't want invasive care from the largely female healthcare system. I had an uncle refuse treatment for bladder cancer after a cytoscopy. He could have added ten years or so to his life but chose to die at home with a box that emitted some kind of electronic waves as his only treatment. I miss him like crazy.
Misty
Misty, I understand that you get many sad personal stories on your modesty website but in view of all the many personal sad and upsetting stories we have been getting on this blog thread over the years but,instead,directly from our own visitors here do we really need to read even more but which has not even been directly written to this blog?
Misty, it now should be an analysis of the problems which have been shown to exist and discussing ways to mitigate them. Do we really need more "moaning and groaning" as I describe them? All who participate on this thread must be by now fully aware that there are patients suffering from not being able to resolve their modesty issues as they confront the medical system. Shouldn't we now stress discussing a specific therapy program for all rather than using this blog to broadcast concerns from folks who are not even here and cannot benefit therapeutically from simply their own direct ventilation of their stories on this blog? ..Maurice.
How many times a minute do women think about
sex, who cares. I once saw the staff bathroom of
a medical intensive care unit completely covered
with nude foldouts of men from playgirl magazine.
The female nurses decorated their bathroom with
that porn. Fair to say many times a day they
obviously thought about it. Imagine if you saw
a mammography suite staffed by males and their
restroom being completed covered with nude women
from playboy magazine. Wouldn't happen and never
will. It's called disparity.
If you went to an upscale clothing retailer to try on
clothing in the private dressing rooms and the sales
person came into the dressing room without
knocking,what would your reaction be? Acceptable?
If not, then why do we tolerate it in healthcare? It's
apparent airport travelers don't tolerate it with there
being 28 million complaints. I suspect many patients
have complained and maybe it falls on dead ears.
You now can punish facilities when you get a survey
from Press Ganey. Give them the lowest score and
watch there Hcap scores drop. You would be surprised how one patient complaint can affect their
overall score and thus their reimbursement in dollars.
PT
Maurice,
What do you mean by "a therapy program for all"?
belinda
Belinda, what I meant by writing " Shouldn't we now stress discussing a specific therapy program for all.." I mean discussing approaches to change the medical system which will hopefully diminish the possibility of further concerns and emotional distress for those who have modesty worries and bad past experiences. This I think would be more toward a curative approach to treatment rather than simply just written expression of ones personal concerns..what I call "ventilation". ..Maurice.
Belinda, wrote the following this evening but again was unable to get it posted here. Anyone else having problems? ..Maurice.
Maurice,
Thanks for clarifying what you meant.
The base of all concerns (there is much work on the side of the medical community reflecting upon those posts). is that the medical community come to the table with clean hands (valid issues of mistrust based on patient's own past hospitalizations) procedures, protocols for employees and patients who have either a disability, or deep avoidance issues, nothing can be done.
These principles have been laid out in some of my recent postings.
I know that this blog is about patient modesty and not about abuse. However, there is a large segment of the population that has been effected by these issues and then they all come to the hospital just like everyone else. They may have symptoms and yet not really understand what's happened to them. What could happen though, is an opportunity to educate the patient to recognize that they may have some issues and where to get more information. You cannot fix a problem without recognizing that there is one and what it is. Personal responsibility cannot be placed upon patients who have a disability due to previous abuse or sexual assault. It would be the same thing as telling a patient that they have to heal their own injury. It's the responsibility of the hospital to create a protocol on triage. Some patients will not readily admit to the hospital that they have a problem.
A great way to do this is to give every patient on triage an edited short booklet taken from Dr Van Der Kolk's book on ptsd outlining symptoms (slanted to modesty issues) and let the patient realize they may have a problem and who to contact in the hospital for assistance. If written and photographed properly anyone who is predisposed to these issues will be drawn to this booklet and won't even need to be told to read it. Protocols that have been put into place can then be initiated on behalf of the patient.
Now we have a platform and not an individual case by case issue that bogs down the medical system.
Once the patient contacts the team, (now there is a feeling of empowerent and control for the patient). that means talking to the patient directly and letting the patient decide whether to share information with their family and not going behind their back to talk to the family. This would infuriate the patient further, further eroding mistrust. Patients who present with symptoms are not incompetent and should not be treated as such.
Not everyone who has been sexually assaulted has ptsd but they may have the trust issues and avoidance issues all the same. Any horrific experience changes who we are and how we feel about the world around us whether there is a disability or not. Some people find bodily exposure intolerable sometimes even with same gender care or...issues of mistrust that are so embedded they would never venture into a hospital at all.
Lastly, commercials are seen on TV not to be embarrassed and to take care of health. Yet the medical community (instead of addressing these issues by changing their system) try to push their agenda and guess what...men are still avoiding prostate exams and procedures when percentages would go way up if same gender care were offered for sensitive exams. Isn't it time for the medical community to look at what they are doing that can be improved upon?
This is a start.
belinda
To anyone having trouble getting their comments posted :
I have found that whenever I "preview" what I have written, even if I then hit the "publish" button, it doesn't always post. You just have to read what you have written and then send it. Hope this helps.
LJ
Thanks LJ for the handy hint. the contributor to the blog really does not need to use the "preview" function since one can simply scan the text field to re-read and after "publishing" if the field is empty you can be assured it was sent. If the text is still present there will be an explanation of the error just below. Anyway, that's how it is working for me. ..Maurice.
Dr. B – I sent this message yesterday, but it didn’t post. I’ll send it again.
Regarding your use of “subject,” although a curious use, your heart was in the right place. :) I’ve seen the two terms used as synonyms such as, “He was a subject of study” or “He was an object of study” meaning the same thing. Scientists have sometimes been criticized for using the term “subject” to refer to study participants because it’s “so impersonal.” Well, “That makes sense,” says the scientist. “As a scientist, I’m supposed to be objective and dispassionate.
I’ll see if I can get in touch with Professor Macionis. School may be out for the holidays, so I may not hear from him for awhile, if at all.
Thanks for information about how you approach measuring “conduct of the interview.” Following a stint as an inpatient at one hospital, I was asked to fill out a questionnaire, some items on which asked me to evaluate my experiences at the hospital. The questionnaire covered some of the “checkpoints” in your “conduct of the interview.”
Ray Barrow
Ray, to be a human or even an animal "subject" is still to be a living creature and to be an "object" is like defining the human or animal as a stone statue. Hopefully scientists will always be as "objective" as possible for their scientific study but to be "dispassionate" toward either their human or animal subjects is a totally wrong feeling or behavior. Remember, the scientist is one of them, too. ..Maurice.
Belinda: On 12/14 11:35pm, you wrote: “Lastly, commercials are seen on TV not to be embarrassed and to take care of health. Yet the medical community (instead of addressing these issues by changing their system) try to push their agenda and guess what...men are still avoiding prostate exams and procedures when percentages would go way up if same gender care were offered for sensitive exams. Isn't it time for the medical community to look at what they are doing that can be improved upon?”
Your hunch was supported by two studies in which I was involved. Prior to the first study, we derived a proposition from a theory which we wanted to test: The greater the social distance between those in positions of authority and their subordinates, the greater the depersonalization of the latter.
From this proposition, we derived a hypothesis: The greater the social status difference (Endnote 1) between patient and physician (social distance), the greater the gap between how patients expected to be treated and how they believed they were actually treated (depersonalization). The instrument we used to measure expected treatment versus perceived treatment included, but was not limited to, variables such as waiting time, being addressed by title (Mr., Mrs., Doctor, Judge) or by first name, whether or not permission was obtained before being used as a teaching subject, and whether or not unnecessary exposure occurred. Overall, we failed to find a statistically significant relationship between social status difference (social distance) and the gap between expectations and perceptions (depersonalization). When we correlated each social distance variable with each depersonalization variable, only one social distance variable was significantly related to our measure of depersonalization and it was not what we expected. Men were more likely than women to be depersonalized. The indicators of the gap between expectations and perceptions (depersonalization) most strongly related to the gender difference between physician and patient were exposure and being asked before being used as a teaching subject.
So, in summary, two of our findings were unexpected. First, we failed to find that social distance was significantly related to depersonalization. Second, we found that male patients were more likely to be depersonalized than female patients. We concluded that except on the variable gender, the social milieu of ambulatory clinics visited by patients were democratic in the sense that the degree of depersonalization (or personalization) in these ambulatory clinics was more or less equally distributed across patients’ occupation, education, income, and age.
“Strange, by my faith” ‘sez,’ I to myself. When it comes to degree of depersonalization in ambulatory care facilities, does it not matter whether one is a pauper or a prince, a physician or a construction worker, a high school graduate or a Ph.D. recipient?
A telling anecdote, although I recognize it has no scientific merit, can be found in the story of Dr. Edward Rosenbaum who wrote A Taste of My Own Medicine: When the Doctor is the Patient on which the film The Doctor, a tearjerker which ironically generates hope http://www.amazon.com/Taste-My-Own-Medicine-Patient/dp/0394562828 and stars William Hurt, is loosely (very loosely) based.
http://www.youtube.com/watch?v=Msgis8wPUmQ The film and paperback are about a physician turned patient who, tries as he might, fails to hang onto his status as physician and is ultimately relegated to the status of patient with all the mortifications and degradations to which that label is entitled.
MORE TO COME
Ray Barrow
Curiosity drove us to find out more about our second unexpected finding that men are more likely to be depersonalized than women. Remember in an earlier post I quoted a woman who said she would never visit a doctor because she did not want to be “clinically raped”? Well, we set about creating an instrument based on the typical rape victims’ cognitive and emotional responses to being raped such as feelings of powerlessness, humiliation, shame, helplessness, anxiety, vulnerability, guilt, anger, idiopathic fear, fear when in situations that remind the victim of the rape; inability to concentrate, tendency to dwell on the rape, self-blame, and belief that one is not in control of one’s life.
We distributed a questionnaire which contained this instrument to college men and women. We also included an open ended item on the questionnaire that asked subjects to report any experience they had in a healthcare setting that embarrassed them. Those who responded affirmatively were asked to check, on the aforementioned instrument, their cognitive and emotional reactions, if any, that followed the embarrassing experience. We called these responses “feelings of being raped.” (2)
We found that men were more likely than women to report having experienced embarrassing events. Men who experienced these events were more likely to feel “raped” than women who experienced these events. The intensity of this feeling was also greater in males than in females. Yet, in spite of all this, men who felt “raped” were less likely than women who felt “raped” to protest against the way they were treated, by, for example scolding the person responsible for the “rape,” expelling the offending parties (e.g., students), threatening to report the offenders, and so forth.
We were confused. Why would men who felt “raped” be less likely than women who felt “raped” to protest against their “rape”? It must be that cussed machismo getting in the way again. Our next finding raised some doubt about this stereotype. A little probing led us to the conclusion that it wasn’t so much that male subjects were macho but it was their belief that others expected them to be macho and if they behaved like “sissies,” they’d be ridiculed to their faces or behind their backs. (3) So rather than protest, they tended to pretend to stoically “grin and bear” the mortifications.
Is it true that healthcare providers tend to expect men to “act like men” when faced with events of the sort about which some contributors of this blog have written. And is it true that they are more likely to give a pass to women while responding with disdain toward men who “act out of character”? The research about which I have written didn’t answer these questions; as far as I know, they remain empirical questions.
Not too long after the study was completed, a social psychologist was featured on, I think, 60 minutes (4). She spoke about the reticence of men to seek healthcare, claiming that they did so solely because of their macho self-perceptions which included an unwillingness to let others control their lives (5). I wrote to her and reported on what I found. Her response: “Interesting!”
ENDNOTES TO COME
Ray Barrow
ENDNOTES
(1) Social status distance difference was measured as the difference between patient’s gender and physician’s gender, the age difference, the income difference and the socioeconomic status difference. Socioeconomic status was measured using Hollingshead Two-Factor Index of Socioeconomic Status which includes ranking subjects on education and occupation. Only patients who visited male physicians in clinics were used in the analysis.
(2) By using the term “rape” in the present context, I don’t mean to imply that the feelings of the actual rape victim are in any way qualitatively the same as the feelings of those who experience humiliating events in healthcare settings. Whether that is so or not is an empirical question.
(3) The famous social psychologist Phillip Zimbardo calls this phenomenon “the power of the situation.” He speaks about it in the film on the following link.
http://www.learner.org/series/discoveringpsychology/19/e19expand.html
(4) I have a tape of the program packed away in a box in my garage in preparation for a move. I’m not inclined at the moment to dig it out. It may not fare well in the future anyway, given the below zero weather we are likely to get here this winter.
(5) This is called the single cause fallacy, fallacy of oversimplification, or causal reductionism.
Ray Barrow
Dr. B,
With respect to your question what approaches might be undertaken to try to change the medical system's understanding and accommodation for patient's modesty issues, I believe the most important one is for the patient to SPEAK UP.
1. It needs to start at the patient to provider level. The patient needs to be calm but firm in their position and not afraid to "call B.S." when they are responded to with the typical canned platitudes or dismissive remarks.
2. The patient needs to convince the provider that they are serious, and are willing to change providers or forgo medical care if a reasonable attempt isn't made to accommodate their concerns. If you aren't treated with a modicum of respect, you may need to take your business elsewhere.
3. Patients need to take control of their medical care to the degree they are comfortable.
Personally, I have relegated the role of medical professionals to exactly what they are - professional consultants. I make it clear that their role is to provide me with all the information that I will need to make any decisions concerning my care, including all options and the pros/cons of each. What they recommend is not enough, I want to know why.
I also make it clear that any decisions as to tests, treatments or procedures that may be undertaken are mine and mine alone - their capacity is strictly advisory.
My mantra is simple and can be condensed to eight words:
My body
My decisions
My consequences
My responsibility
First I want to sincerely thank Ray for coming and writing to the "Patient Modesty" tread. What has been missing from almost 8 1/2 years of conversation on this thread has been any professional attempt at sociologic or professional attempt at psychologic analysis of what has been written here. As is clear from Ray's writings, there is more to this topic of patient modesty and how it is handled within the medical system than raw emotional descriptions and accusations. Like so many other problems in life that need fixing, it takes some careful analysis or dissection (the latter term, as we surgeons and pathologists would call it). Again, many thanks, Ray.
However, Ray, with regard to the motion picture "Th Doctor", I find nothing, absolutely nothing wrong with a physician turned patient and then treated just as a patient and not as one might expect a doctor to be treated. As I have written many times throughout my blog, VIP ("very important person") treatment of a doctor may lead to unnecessary hazards in safe and effective treatment. When I have been sick, I have refused such VIP consideration by my doctors and nurses. And if there is "mortifications and degradations" applied to patients, this should be a valuable educational experience for that doctor patient.
And Hexanchus, I fully agree that doctors and nurses should consider themselves only as "professional consultants" and nothing more, with the patient setting their own autonomous course under professional "advice with guidance" after patient education about their illness. But for this division of responsibilities to operate properly, it is essential that patients are kept fully informed about their illness and options and that the doctor is confident that an ill patient has the intellectual, mental capacity to understand the facts presented and the options. If so, that is all that is necessary irrespective of whether the doctor is happy or unhappy with that patient's decision. Again, I agree. ..Maurice.
Thank you for the compliment, Dr. B. I'm afraid some others may find my posts abstruse and/or obtuse. I hope they'll humor me if not forgive me. My only excuse is that I've recently retired and wish to keep my mind active. I have found that participating in this blog helps me do that. Many of the contributions show considerable insight, bloggers seem willing to engage in reasoned discourse and avoid personal attacks against others with whom they disagree.
Beforfe I sign off, I’d like to clarify something for the reader. Dr. B, you write: “However, Ray, with regard to the motion picture "Th [sic] Doctor", I find nothing, absolutely nothing wrong with a physician turned patient and then treated just as a patient and not as one might expect a doctor to be treated.” Your use of the term “however” implies that the point I was trying to make by reporting our findings and using The Doctor as an illustration in support of our conclusion was that physicians who become patients should not be treated like a patient. This may not be your intention, but I want to make sure that the record is set straight.
I made no evaluative statement in my presentation. Our research demonstrated that there was no significant difference in the depersonalizing treatment of people in different occupational groups. My intention in referencing The Doctor and A Taste of My Own Medicine was to show that as much as they try to avoid it (by, for example, “throwing their weight around as Jack does in the film), even physicians, who occupy a high prestige occupation, is likely to be relegated to the status of patient, thereby experiencing some of the same types of depersonalizations experienced by some of those who occupy lower prestige occupations. There are other examples I’ve read (either in this blog, in Dr. Sherman’s blog, or both) of physicians who were humiliated by the actions of other healthcare providers. Thus explains my tongue-in-cheek use of the word “democratic” to refer to the equal distribution of dehumanization from one occupational group to another.
Also, I’d like to make a short comment regarding the message in your words: “I find nothing, absolutely nothing wrong with a physician turned patient and then treated just as a patient and not as one might expect a doctor to be treated.” I’m ambivalent myself, and I think I have good reason to be ambivalent. I’ll explain why later.
Ray Barrow
Ray, I will await you explanation of your ambivalence.
But now, to all my visitors, let's get on to one "nitty-gritty" issue and get that one out of the way in our further discussions here.
Should a requirement for medical professionalism be:
"Male doctors treat only male patients and female doctors treat only female patients"..except of course in an emergency. Failure to follow leads to revoking of license to practice. I presume none of my visitors are suggesting this requirement to mitigate patient physical modesty concerns. Right??
..Maurice.
Unsure if I shared the link on this blog, my complaint! here we are 2013, male doctors fail to offer gender choice for intimate exams.
Not only modesty but a down right cheek imo, most are under stress in medical setting, afraid to ask,
don't want to be pushed away from treatment.
http://www.thedailybeast.com/witw/articles/2013/12/09/are-male-gynecologists-creepy.html
Pailrider.
Maurice isn't man a hunter of women, as in all the animal kingdon, perhaps the answer lays there imo!
Pailrider on gender choice!
My experience has been that the women that refuses intimate exams form male Ob-Gyns are labeled as problematic, and even refused treatment.
O do take issue with Don?s statement about "moans". what do you mean?? that sexual misconduct, mean pronks and even harassment of females by male medical personnel of all ranks doesn't exist? Let me tell you it does, and when it happens, it is utterly devastating and depressing. What makes it awful is that when you realize it's happening you're deep into the thickets. If caregivers were more thoughtful, and not always wored about profits and the bottom line, they'd be both more respectful and respected.
(1) Ray am thrilled by you joining and feel it breaths new life into the blog that Dr. Bernstein had questioned several times was ready for a post mortum. Post away, being offended is a personal choice or perhaps trait.
(2) Dr. Bernstein, taking the position that males should only attend males and females attend females denies choice to those who do no care or prefer opposite gender and is hypocritical of those who complain they are not given their choice.
(3) Palerider & Maria Framing this as a problem caused by male providers abusing female patients focus's on a different subject, which is I think most would agree rare, and ignores the issue that female modesty is given more concern and choice than males. Ever heard of a female provider requiring a male chaperone for intimate exams on men? The only legal precedent I am aware of for legal discrimination on hiring is against males for females in OB. 90% of nurses are female with little apparent effort to change but it was a big deal to get more female MD's. Even so, the thread is modesty not abuse. ,,,don
From Belinda, this evening. She is still having trouble posting! ..Maurice.
Maurice, I agree with Don on the doctor issue but your idea has merit in other areas like the hospital.
Using a same gender team for intimate needs would greatly relieve many people from embarrassment if nothing else. What it also does is force the medical community to hire an equal amount of men in nursing. Now everybody gets what they want, men are protected, male nurses are working. I can't see anything wrong with this. It's a "win win" for everyone!
belinda
Dr. Bernstein,
I shared the sad email I received from a man the other day because I wanted to let the men on this blog know that many men indeed experience sexual abuse. Sometimes, it is helpful to hear about other patients who had bad experiences. Sometimes, patients who have had bad experiences feel alone.
Misty
Belinda, its not a "win win" if you take choice away from those who prefer opposite gender, and while I'm definitely not one of them, they are a significant percentage IMO. Follow the link:
http://www.city-data.com/forum/health-wellness/911358-how-much-does-your-doctors-gender-20.html
While the sampling size is small and far from scientific, I think the percentages are relatively accurate.
Ed
Ed,
The link does not mention ages of people responding to this survey. Look at the high number of young women who prefer female intimate care in Patient gender preferences for medical care By Dr. Joel Sherman. Also, do not forget that many men do not even have intimate procedures or exams until they are much older.
Misty
More from Belinda today. ..Maurice.
Ed, your link describes doctor preferences not that of support staff. I mentioned in a recent post that I agree with Don and Dr. Mo on this issue that doctor selection must be left up to the patient.
My statements were made about support staff in the hospital. Due to our sociological norms, most people would feel more comfortable with same gender intimate care for bathing, toileting, dressing and intimate procedures. A simple survey of hospital patients would clarify that. The tables on preferences would be much stronger than those on the graph for your link and there is strong reason to believe that patients who prefer opposite gender care for those duties would be in the minority.
belinda
We invoke many laws to protect people from their own poor decisions--motorcycle helmets, seatbelts, second-hand smoke, etc.
Sexual abuse by medical personnel is not rare in spite of the opinion of uninformed people. I believe that laws should also be enacted to ensure patient safety by criminalizing cross-gender medical care.
You say but what about emergencies? Patients are most vulnerable in such situations and are easy prey. Sexual assaults do indeed happen in the back of ambulances and emergency rooms.
Only in the most extreme situations should cross-gender care be condoned.
Belinda, I presume that if a patient has a gender preference for a physician, that is also their preference for ancillary staff. Why would a patients preference for staff gender be different and do you have any facts to base your assertion on?
Misty, what is your point with respect to the patient's age? Additionally, your obviously clueless with respect to "many men do not even have intimate procedures or exams until they are much older"; where is your supporting data? Finally, enough with the second hand sob stories. If those folks feel strongly enough, they can post themselves.
This blog is becoming tiresome with the neverending sexual abuse and "corrupt" claims against the entire industry! What planet do you people live on?
Ed
Don wrote the following...
Palerider & Maria Framing this as a problem caused by male providers abusing female patients focus's on a different subject, which is I think most would agree rare, and ignores the issue that female modesty is given more concern and choice than males. Ever heard of a female provider requiring a male chaperone for intimate exams on men? The only legal precedent I am aware of for legal discrimination on hiring is against males for females in OB. 90% of nurses are female with little apparent effort to change but it was a big deal to get more female MD's. Even so, the thread is modesty not abuse. ,,,don
__________________________________
Don that is far from reality, every day I receive news of male doctors charged with sexual abuse of women, I receive nothing about female abusing male patients..
Please read today's news from the UK, the tip of an iceberg.
An elderly doctor has appeared in court charged with child rape and indecent assault.
http://www.independent.co.uk/news/uk/crime/operation-yewtree-stoke-mandeville-doctor-aged-78-charged-with-child-rape-and-indecent-assault-9010412.html
DON Lack of modesty leads to abuse
easy for men in powerful position.
Pailrider.!!
There are those instructors in medical student education who are fully aware that there is such a thing as patient modesty in physical examination. Yes, "modesty" is a word we frequently use as we teach how to examine. I experienced this teaching word this morning as I sat in our year 1 faculty meeting and heard the head of dermatology talk about and demonstrate what his department teaches medical students and residents about how to examine the skin of a patient. He used a male standardized patient for demonstrating his words as the faculty watched. He showed how (and as I have already written about here on this thread many times) to examine using a technique of segmentally uncovering and each step is done with the direct assistance of the patient. No standing nude for the exam. And this is what is being taught. The same segmental uncovering is what we also teach for other phases of the physical exam. I can't speak for what is taught in other medical schools besides mine but I can't believe that this method is a "loner" to medical education. So this is what is taught. What is actually practiced is another matter and obviously patients are the ones who can tell the world their own experiences. ..Maurice.
Ed, there was some research done regarding labor and delivery departments. Patients felt very strongly about the staff gender, but not as much about the doctor.
That's because the doctor was selected by the patient based on several criteria, and while gender might have been considered, the medical factors outweighed it. The article also said that there was a big difference between these strangers in the hospital setting and selection of their own personal physician for delivering their child.
The planet that some of the people on this blog come from have been in the abuse area. I'm one of them and while I choose to focus on the medical and psycho social aspects of that result, nobody has the right invalidate anyone's experience, but I did want to tell you that it's important that you understand where some of us have been.
belinda
Belinda made excellent points about the survey Ed referred to. It only talked about doctor preferences. I know of some women who do not mind having a male gynecologist, but they would be very upset at the thought of a male nurse bathing them or participating in intimate procedures on them.
I have interacted with a number of people over the years and older people are more open to opposite sex intimate medical care. Let me share some very important points from Dr. Sherman’s article on gender preferences in healthcare. Based on some studies, younger people do prefer same gender intimate care.
The clearest example of preferences is in obstetrics and gynecology. Now that women are 90% of residents in training women have adequate choice in most localities and they do indeed express themselves. Women prefer female intimate care by percentages that vary from study to study from 50% to 70% with most of the rest having no preferences. Only 10-15% prefer care by males in one study. Variables include the age of the patient with young women preferring same gender care in higher numbers than older women who have generally become accustomed to care by males.
Dr. Sherman made some very important points in this article: Why Don't Men Visit Doctors, Is Embarrassment a Factor? that I wanted to highlight below.
It is well known that men see doctors much less frequently than women. The reasons are multifactorial and not all that well studied. It’s certainly not because men are healthier than women as they die on the average seven years before women. Clearly women are accustomed to seeing doctors at an earlier age than men for reasons relating to childbirth and birth control. Most accept the recommendations to get an annual physical with Pap smear. Men on the other hand typically don’t even think about seeing a doctor before the age of 40 unless they have a specific injury or acute illness. Routine annual physicals for men under 40 are a hard sell. A large percentage of men actively avoid seeing doctors even when they’re older.
According to a recent survey published in Esquire (April 2011) only 37% of men have seen a doctor in the last year. Another third have not seen one in over a year. Ten percent can’t even remember when they last saw a doctor. Forty five per cent don’t have a primary physician. The comparable number for women is 20%. Of men in their 40’s, 20% have never had any preventative tests including prostate exams or blood tests, colonoscopy, diabetes screening and cholesterol measurements. The questionnaire didn’t ask about blood pressure which along with blood tests are perhaps the most important screening tests.
The above two paragraphs confirm my point that many men do not have any intimate procedures done until they are older.
Misty
Many Labor & Delivery units at hospitals have policies that only allow female nurses. I think this is very prudent because many women (even those who have a male gynecologist) are very uncomfortable with male nurses. It is best for the hospital to assign male nurses to other units that include male patients. We definitely need to increase male nurses to accommodate male patients. At a hospital about 30 minutes from my home, there are usually at least few male nurses on each unit except for Labor & Delivery.
Misty
Palerider check out Dr. Sparks, female ENT MD who not only routinely abused male patients in front of the staff while they were out, but it went unreported for an extended time. Do you think a male MD doing that to female patients so openly would have gone unreported? Obviously you have a different opinion about male providers and I suspect males in general than I. You have every right to your opinion. Without any basis for it I think the vast majority of this country think providers are good ethical people. I still do not feel this is an issue of malice be it abuse or modesty. All of the providers I know personally are good people. Now I fully realize in a population as large as the medical field there are going to be some bad people, but they are the exception not the rule. A MD in the UK abusing children while horrendous has little to do in this discussion which is about patient modesty. I have no idea what experiences you have had that have created this feeling. We are probably never going to reconcile our different opinions of providers, I think they are good people, male and female, I think they are carrying forward a tradition and agenda that is harmful or at a minimum uncomfortable and unacceptable to a significant number of patients. But I don't think it is done with malice. You evidently view all or most males in the medical field as potential predators and abusers, females are not. I just don't see that as a modesty issue. From the many pages of posts here I would guess Dr. Bernstein has been involved in many procedures most of the posters here would find unacceptable...do you really think given his concern for this issue he is a likely or even potential abuser? Sorry I don't agree, but more importantly I still do not see it as a major part of the discussion of modesty to the point where it keeps coming back and back....don
Don,
Everyone has a right to their opinion. There is, however, an undercurrent in institutional care where modesty violations are done on purpose to either make the patient submissive or to punish for failure to cooperate. It has been highlighted in elder abuse and nursing home treatment but goes across the board from the penal system, mental health hospitals, and yes, our medical facilities. This is not my opinion, it is a fact and you might want to do some research on the subject.
Personally, I feel, too, that these situations are in the minority, however, because they do exist and the situations do provide an erosion of modesty to patients, they are just as much part of the picture as negligence due to being busy, or distracted.
Modesty violations should not be discriminated against just because the majority of them may not happen due to abuse. The bottom line is the same. The patient suffers the same humiliation whether there is malice or none.
belinda
Here are three articles. The first deals with a patient who after having breast cancer surgery is subjected to cruel and degrading care for no medical reason.
The second talks about strip searching in mental hospitals.
The third is a paper written by a psychiatrist that talks about the harm strip searching does in eroding privacy. Whether the strip search is conducted for drugs or to assess a medical emergency, there needs to be protocols developed in the hospital to protect the mental health of the patient. This means excluding extraneous people from the room, eliminate observers of any kind and would recommend cutting off the clothing with one same gender person and then examining each part of that draped patient to at least give the patient the illusion of being covered.
After reading the articles, it seems to me that the line between standard of care, abuse, and modesty are blurred to a point where you cannot separate them.
Don, would be very interested in your opinion after reading the below articles.
This blog is so interesting because so many people are coming from so many different places.
Here they are:
http://www.nytimes.com/2005/08/16/health/16dignity.html?pagewanted=all&_r=0
http://www.currentpsychiatry.com/home/article/it-s-time-to-stop-strip-searching-psychiatric-patients/63bed88d2b1167b9761caf30e9c115b7.html
http://www.americanbar.org/content/dam/aba/publishing/previewbriefs/Other_Brief_Updates/10-945_petitioneramcusychiatrists.authcheckdam.pdf
belinda
The article, In the Hospital, a Degrading Shift From Person to Patient is heartbreaking. I wish that Ms. Duffy could have sued the hospital. It’s awful about how she was treated. I’m glad that she now works as a hospital volunteer, giving other breast cancer patients advice on how to avoid situations like her post-operative humiliation. This article proves that we cannot trust the medical system. This is exactly why patients and their family members must take steps to protect themselves.
Misty
I really appreciate the excellent points that Anonymous from December 17, 2013 at 1:27 PM made yesterday:
We invoke many laws to protect people from their own poor decisions--motorcycle helmets, seatbelts, second-hand smoke, etc.
Sexual abuse by medical personnel is not rare in spite of the opinion of uninformed people. I believe that laws should also be enacted to ensure patient safety by criminalizing cross-gender medical care.
You say but what about emergencies? Patients are most vulnerable in such situations and are easy prey. Sexual assaults do indeed happen in the back of ambulances and emergency rooms.
Only in the most extreme situations should cross-gender care be condoned.
I agree with your comments. I find it so strange that the medical industry is not held to the same standards as other industries. Sexual assaults and patient modesty violations often happen in the back of ambulances and emergency rooms. Medical sexual abuse is much more common than we imagine. Most patients do not even report sexual abuse.
I am not sure if you still read this blog, but I would love to invite you to contact me about the possibility of volunteering some of your time at Medical Patient Modesty. Please click on this link to contact me. We also have an educational web site about sexual misconduct by doctors.
A Christian male paramedic shared this with me a few years ago:
I am a paramedic, and I try to use female EMT's for female patients, and I try to use male EMT's for male patients. There are very few EMS people who seek to deal with the problem as I do. In addition, I often have to care for female patients, some of whom would die if I waited for someone of the same sex to arrive.
I appreciate this paramedic and I agree with him. I personally believe that if a woman is suspected of having a heart attack that her underwear should not be removed. Heart is not near the genitals.
Misty
Don I take your point, however!
1 Why do male doctors fail to offer gender choice.
2 Why is man the predator in the animal kingdom.
3 Why do I receive news on daily basis, doctors accused of sex abuse.
4 Why is there more female doctors training in gynecology.
5 Why do a lot of guys object to another pressing fingers into there partners sex organ,to prove nothing.
6 Why 50 years ago a male doctor would climax/orgasm a women with finger for treatment of hysteria.
7 Why in 2013 gender choice isn't offered.
8 Who holds high office in the medical field.
9 Why do think is ok for another man to receive all sexual signs from internal examination, vision,
smell, tough, eyes record events, testosterone flow.
10 Why did a male recently drug his patient for sex.
11 Why did a male recently take picture during pelvic exam with James Bond style camera.
12 Why are there groups of male doctor charge with sex offences remain treating women.
13 Why do they brainwash women that they do not become aroused, at the same time admit it.
14 Why is gender choice available in the UK,male doctors will never offer when doing a pelvic exam, don't you get it?
I can back up my comments with official links or court case.
How can you dismiss this, all connected to modesty or lack of it, a minimum requirement should be gender choice, there is no modesty with a man prodding a female sex organ, most of the time.
IMO in a few years male doctors carrying out this type of job chose from hundreds of other medical ones, will be looked back at, the same as hysteria orgasm treatment.
Pailrider.
It's time to close this blog down!
Ed
Ed, I fully understand your disgust with the direction many of the comments are leading..moving a discussion about a very definable issue of how patient modesty can be better handled by all those participating in the medical system (including the patients themselves) to one (criminal sexual abuse within medicine as defined by those who are writing about it) which though certainly is of social significance but is not really an issue of modesty but one of criminality.
One can hardly think that criminal sexual abuse within medicine should provoke any sort of ethical argument and certainly doesn't present any ethical dilemma which requires discussion.
Physical modesty in medicine is an issue of the patient and for the doctors and nurses and techs. Criminal behavior is an issue for law enforcement.
We are all aware that physical modesty in medical practice exists so now lets devote this thread to suggestions regarding how to deal with the modesty issues of patients and the responses of the healthcare providers so that the ill patient is not worsened by their interaction with these providers and that the goal becomes now only how to cure the illness. ..Maurice.
Dr. B – I earlier expressed my ambivalence about agreeing with your assertion: “I find nothing, absolutely nothing wrong with a physician turned patient and then treated just as a patient and not as one might expect a doctor to be treated.” There are two reasons I am ambivalent. First, it is my opinion that, taken as an aggregate, the experiences detailed in this and other blogs violate a number of universal ethical principles. In short, I believe that people who are treated in some of the ways described are victims of unethical behavior, whether the victims are physician-patients or lay-patients. In other words, I find it equally unethical to treat physician-patients in these ways as to treat lay-patients in these ways. And I believe that to violate ethical principles is morally wrong. Since I believe these things, I would be hard pressed to, at the same time, believe that there is “nothing, absolutely nothing wrong with a physician turned patient and then treated just as a patient. . .” Sometimes assertions such as this reflect what I call the “fraternity hazing syndrome” – “I was hazed. Do you think you’re special or something that you don’t have to go through the same thing I did?” Of course, it’s evident that your reasoning is less specious and more sophisticated than the reasoning of those infected with this syndrome when you write: “VIP treatment of a doctor may lead to unnecessary hazards in safe and effective treatment. . . And if there is ‘mortifications and degradations’ applied to patients, this should be a valuable educational experience for that doctor patient.”
I recognize that ethical principles are not absolute in the sense that sometimes they can be neutralized under circumstances which, at first blush, appear unethical. For example, some defend what, on the surface, appears to be unethical by arguing from the viewpoint of the pragmatist: If the benefits of violating ethical principles outweigh the costs of not doing so, then the unethical nature of the violation can be properly neutralized. Your words I quote above appear to suggest that this is your argument: The benefits of physician-patients and lay-patients having the same risk of being unnecessarily humiliated outweigh the costs of deliberately reducing that risk for the former but not the latter. I wouldn’t be so ambivalent if I thought this were true.
CONTINUED
Ray Barrow
First, I’ve no good evidence that exposing the lay patient to the sort of experiences described in this blog while ensuring a more favorable experience for physician-patients leads to “unnecessary hazards” (1). But I do have considerable evidence provided by scholars (beginning in 1950 with Adorno, et. al’s famous The Authoritarian Personality) that the effects of the “mortifications and degradations” described will most likely not have the desirable educational outcomes that you probably anticipate; indeed, the best evidence seems to suggest that adversity of the sort described in this blog tends to lead to frustration, aggression, and scapegoating or displacement rather than empathy, patience, and compassion. In other words, the “valuable educational experience” you predict may increase rather than decrease the likelihood that physicians will treat patients with disrespect, especially in the case of physicians who are high in authoritarianism.
By way of summary, I am ambivalent about approving the exposure of physician-patients to the same unnecessary humiliations experienced by some people in this blog because to do so would mean approving what I believe to be the violation of universal ethical principles. Although I do value democracy in the form of equal distribution of opportunities, it is unsettling to me when democracy means the equal distribution of phenomena I consider undesirable.
Second, I’m willing to concede that sometimes the value of neutralizing an ethical principle to achieve a greater good may be warranted. However, I’ve no good evidence that exposing physician-patients to unneeded humiliations of the sort experienced by some lay-patients warrants such neutralization. Indeed, the evidence instructs me that such experiences would most likely be counterproductive by increasing the likelihood that the offended physician would treat patients disrespectfully.
_________________________
(1) If you are suggesting that wholesale VIP treatment of physicians leads to “unnecessary hazards in safe and effective treatment,” you’re begging the question. The pertinent question is: “Does treating physician-patients differently from lay patients by ensuring that physicians are not exposed to the unnecessary humiliations described in this blog lead to unnecessary hazards“?
Ray Barrow
I agree with Ed, this blog should end.
PT
Don: You write: "Ray am thrilled by you joining and feel it breaths new life into the blog that Dr. Bernstein had questioned several times was ready for a post mortum. Post away, being offended is a personal choice or perhaps trait." Thank you for the reassurance, Don. I have learned a considerable amount from your and others' contributions to this blog. There's a lot insight out there.
Ray Barrow
Ed and PT, you write this thread should "end" because...
I presume you both are not satisfied that all conversation about resolution of patient modesty issues have been completed but that further commentary about the separate topic of criminality in medical practice is only distracting and really not pertinent to patient modesty itself.
And I would agree, we should stick to the subject of this thread "Patient Modesty", if this thread is to continue. Unless, you both also think that everything that needs to be said about patient modesty has been said and there is nothing further to add for education of my visitors or suggestions to resolve the modesty issues presented.
All my visitors here: let me know what you think regarding this matter of closing down "Patient Modesty". I have almost 900 other topics for consideration and hopefully more coming. ..Maurice.
Ray, I am not a naturist and I have physical modesty like others but when I am in a medical situation as a patient effective diagnosis and effective therapy, to me, are more important than my modesty. So, therefore, "safe and effective treatment" to me is my primary concern and will trump my modesty. It is known that VIP treatment toward physicians or others provides hazards to such safe and effective treatment.
This is my view and obviously some writing here will sacrifice treatment for protection of their modesty. I just disagree with that decision but I am aware that many reading this thread will disagree with me. However, despite this view, after educating my patients about their illness and my evaluation of the importance of further workup and treatment, the decision of whether or not to continue is up to the patient. I hope this explains my view. ..Maurice.
Don: You wrote: “I think the vast majority of this country think providers are good ethical people. I still do not feel this is an issue of malice be it abuse or modesty. All of the providers I know personally are good people. Now I fully realize in a population as large as the medical field there are going to be some bad people, but they are the exception not the rule. . . I think they are good people, male and female, I think they are carrying forward a tradition and agenda that is harmful or at a minimum uncomfortable and unacceptable to a significant number of patients. But I don't think it is done with malice.”
Aside from your critique of what Palerider wrote, your points remind me of a recent book published by Philip Zimbardo entitled The Lucifer Effect: Understanding How Good People Turn Evil. Everyone on this blog who has taken a course in basic psychology, social psychology, or sociology after 1975 has been introduced to Zimbardo’s works, most likely his Stanford Prison Experiment, which is unlikely to ever be replicated again because of its ethical problems. Zimbardo is arguably the best known contemporary social psychologist in the world. Were you to read his book or even watch his lecture online and couple that with a study of other publications, including those by Stanley Milgram, I vow that you would conceivably have the knowledge necessary to staff a health delivery organization with “good” people most of whom would behave in “evil” ways against patients. Conversely, you would also have the knowledge necessary to staff a health delivery organization with “good” people most of whom would behave in “good” ways toward patients.
I challenge everyone on this blog to take the time to watch the video that is on the following link and see if you can make an inductive generalization from Zimbardo’s explanation for why some “good” people at Abu Ghraib did “evil” things to Iraqi civilians to why some “good” people in health care settings do “evil” things to patients. http://www.youtube.com/watch?v=9xpsVlY3QQc There are other shorter videos available online that might be just as educational as this one.
Ray Barrow
Dr. B -- Regarding closing down "Patient Modesty," I have not seen much in the way of efforts to explain why modesty violations occur, what has to happen before sweeping actions to curb its rate occur, and what structural changes need to take place to reduce its rate.
Regarding your other post, yes, I understand your view. But I'm confused as to why you felt compelled to explain it to me. Was it something I wrote? If so, what exactly is it I wrote?
Ray Barrow
Ray Barrow
Conversely, you would also have the knowledge necessary to staff a health delivery organization with “good” people most of whom would behave in “good” ways toward patients.
Maurice,
Have you considered a separate blog topic related specifically to sexual abuse (and sexualizing patients) within the medical system? I have to tell you that as someone who was sexually abused by a physician, it has been my experience that no one wants to know about it. What I experienced should have risen to a criminal level, but at times behavior that is sexually inappropriate wouldn't rise to a criminal level, at least in a practical way. How do you prove an inappropriate action occurred short of a rape. It is the patient's word against the doctor's.
It as been my experience that doctors don't seem to want to know about misconduct on the part of their peers--even caring, capable doctors whom I would expect to listen. The tendency is to blame the patient for the problems they (patients) have as a result of sexual abuse. I have been chastised on multiple occasions for not dealing with my problems (at least not in perception of the doctor) related to the abuse I experienced and not just getting over it. I have seen no sign that the medical system feels any responsibility to patients who have been abused. They seem to think this is not their problem, but the patient's. I have seen no sign that the medical system is willing to deal with their own when they act inappropriately. Not medical boards--at least in the state where I live. Not hospitals, except to take steps to protect the doctor so they can avoid litigation. In my case, the hospital protected a doctor whose license was already restricted because he had volunteered the information about his inappropriate sexual contact with a patient to the aforementioned medical board. I don't know the circumstances of his volunteering the information to his licensing board, just that he got a slap on the wrist and he was allowed to continue practicing in the same setting as that where he previously acted out.
As I'm sure you know, much sexual acting out is hard to prove. There are actions that are inappropriate that could never be proved in a court even if a victim could convince someone to investigate. When I started acknowledging what happened to me, I was repeatedly asked if I didn't just misunderstand what was happening. No, I didn't. I understand there are exams and treatment that could be misinterpreted as inappropriate. Maybe that is where the abuse and modesty topics overlap. I'm not sure.
When I was working as a health care professional, I heard far to many stories of abuse by doctors to believe it is rare. I'm sure the number of healthcare professionals who are sexually inappropriate across a range of actions is a small minority. That doesn't mean it isn't a problem.
I hope everyone can agree that in addition to being criminal, sexualizing interactions with a patient is unethical.
I was shocked to learn via this blog that women who were anesthetized and undergoing surgery were routinely given gynecological exams by students for practice, and that this was done without their knowledge or consent. How is that not sexual misconduct, and does anyone who told students to do this, not to mention the students themselves become guilty of sexual assault? I know if I learned that happened to me, my last concern would be modesty. I would want to file assault charges.
How does this relate to a blog on ethics? I wish doctors would take a serious look at how they deal with their colleagues who are compromised. I also think it would be useful to look at their attitudes toward victims of sexual abuse within the medical profession, and think about how they might better deal with this problem.
AB
AB, Your points are well taken and my comments and articles are coming from the same place.
It is extremely disappointing and quite frankly almost expected that there are those that don't believe things like sexual impropriety happen more often than one might think. I have repeatedly suggested that individuals interview the risk management departments of the hospitals and will find these complaints rampant.
I did and found that 40% of the complaints at a major city hospital were of this ilk.
Yet, 34 years after my experience, the mindset is still the same.
All those who don't believe that there is a problem would change their mind in a heartbeat after experiencing sexual impropriety.
It's too bad that those who haven't had the experience can't have empathy for those who have and who don't believe that this is common place.
Talk to healthcare professionals "off the record" and you'll get an earful. TO DO NO HARM goes out the window.
So, to all of you who think that this modesty issue and losing your dignity for whatever reason aren't related would all feel differently if you experienced it.
Sexual impropriety isn't as serious an issue as sexual abuse, however, the damage caused by it is very similar and the lack of undertaking measure to prevent this type of behavior is non existent to this day.
And, yes, sadly, there is no accountability, responsibility, empathy or any desire for the healthcare system to remedy the situation.
belinda
Maurice
I have to agree with Belinda's comment regarding
sexual impropriety and the large degree that it takes
place. This is one of the problems I have with this
blog, that somehow all of this will go away if we
get therapy. Second, you comment repeatedly about
what you teach your medical students. Your medical
students mean nothing to me.
A brief reminder about an incident with Dr Adam
Hansen whom you all may recall was the 5th year
resident at Mayo who took a pic of his patients penis
with his cell phone and showed it to other staff. The
media got ahold of this and when the dust cleared
Dr Hansen was fired and reprimanded by the
Arizona state medical board. The patient was awarded a $250,000 settlement. Remember, this
was considered a Hipaa violation.
Dr Hansen took the photo because the patient
had a tatoo on his penis. The point of bringing up
this story revolves around the conversation on the
student Doctor forums. The consensus among the
medical students were that if you do something,
careful who you tell, don't trust anyone. Never
mind that this is considered a class 6 felony, never
mind that the patients privacy rights were violated.
Are we to assume your students are better than
any other medical students anywhere else. The
"Stupid" factor is hugh and will only get worse. My
only advice to the visitors on this blog is this. The
only thing medical facilities understand is money.
Therefore, if you want to get their attention and
you had a bad experience do 2 things. Don't go
back to that facility, give the lowest score possible
when you get a survey in the mail or by phone. The
lowest score possible on all questions. This directly
impacts their Hcap scores and will reduce their
reimbursement.
PT
Palerider, obviously you have some strong feelings about male providers, males in general, and abuse vs modesty. We are not going to change each others minds so lets just say I disagree and would encourage you to find a thread that addresses abuse in the medical community.
Ray I intend to review your links when I get a chance. but the conversation brings a couple questions to mind.
(1) do we have a common agreement on what is a modesty violation, sexual inappropriate, abuse, and assault. I am guessing there is a lot of distance in our definitions of each. The whole issue of sexually inappropriate behavior has just surfaced. To me that would include things like nurses joking about a patients anatomy, issues, or procedures yet many in the medical community have justified this as just stress relief. There was a post on allnurses that was quoted here where nurses were taking a peak at a young man's abnormally large penis while he was out. Abuse, inappropriate, assault, or no big deal, the opinions ran the gambit. So in the eye of the beholder appears to be in play. That means we don't have a common definition of these to debate from.
(2) Ray touched on the Lucifer Effect and the study of the prison/prison guard really has implications on WHY providers do these things and seem to be oblivious to the obvious to us. There is also the mob mentality where we see people in a mob acting out as they never would alone. I think to me drawing similarities from Prison Guards, Abu Griefm and the medical community has a bit of a difference. Do you think the personalities of people seeking employment is the same between a prison guard and a MD or nurse, between a teacher and a cop. The environment and goal of a prison of controlling and a hospital of helping are vastly different..I want to touch on the other side, the patient mentality but have to run for now....don
I think it’s great that Dr. Bernstein allows people to post comments on this blog even if he disagrees with them. I realize that none of us will ever agree on everything. I think that all of us should agree to disagree on some things. We definitely should not shut down this blog just because some people disagree. It is impossible to please everyone.
Both Belinda and AB made excellent points. When I first started Medical Patient Modesty, I did not realize how common sexual abuse in medical settings was. I knew that sexual abuse in medical settings happened, but I did not realize how common it was. A number of women have contacted Medical Patient Modesty who were sexually abused. One young lady was sexually abused by a male gynecologist recently and I gave her some information about how to report the sexual abuse to the medical board. I got a very heartbreaking case from a lady who went to an all-female ob/gyn practice that had 3 female doctors for many years who was sexually abused by a new male doctor they hired. Her female OB/GYN was out on a particular day and she was asked if she would be okay with seeing another doctor and she said yes because she assumed that one of the other female doctors would treat her. She was so shocked when a male doctor came in. Everything happened so quickly. He sexually abused her. The nurse / medical assistant reported it, but she could not prevent the sexual abuse because everything happened so quickly.
Because of this lady’s experience, I wrote an article cautioning women about all-female ob/gyn practices. All-female ob/gyn practices could stop being all-female in a matter of months if they hire a male doctor. In fact, I know of some all-female ob/gyn practices that became mixed practices.
I really appreciate this statement Ray Barrow made a few weeks ago: 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. If more steps are taken by health care providers to protect patient modesty, we will see a decrease in sexual abuse by medical professionals.
I encourage everyone to check out this great article on another web site about sexual abuse under guise of health care presents barriers.
AB: I encourage you to look at Non-Consensual Pelvic and Genital Exams. Make sure you check out the links to different articles at the bottom of that article. Some of those articles discuss how non-consensual exams can be amounted to sexual battery.
I agree with you that medical students doing pelvic exams on women under anesthesia without their consent is sexual misconduct. You can contact me through Medical Patient Modesty’s web site.
Misty
Ray, to explain:
in response to what you wrote "The pertinent question is: “Does treating physician-patients differently from lay patients by ensuring that physicians are not exposed to the unnecessary humiliations described in this blog lead to unnecessary hazards“?, I wrote
I am not a naturist and I have physical modesty like others but when I am in a medical situation as a patient effective diagnosis and effective therapy, to me, are more important than my modesty. So, therefore, "safe and effective treatment" to me is my primary concern and will trump my modesty. It is known that VIP treatment toward physicians or others provides hazards to such safe and effective treatment.
I don't look at acts which involve patient modesty when part of established patient therapy as "unnecessary humiliations" but a side-effect of the therapy. What I am saying about "hazards" of VIP treatment deal with inadequate physical examination because of the provider's concern not to embarrass the physician-patient or avoiding diagnostic procedures or treatments only because the provider's concern about patient's discomfort or again embarrassment... protection against "necessary" discomfort or "necessary" involvement of the physician-patient;s own modesty issues. These are the practical dangers of VIP treatment I was writing about... not protection against "unnecessary humiliations" as part of being a patient.
Humiliation is part of the response of a specific patient to an action taken upon him or her. Sometimes humiliation need not be felt if the value of the goal of diagnosis or treatment trumps that sort of emotional reaction. ..Maurice.
Maurice, You are absolutely right. I can personally tell you that I never felt humiliated for any exam including gynecology even when I was still using male doctors because I recognized why I was there and trusted my provider.
The environment is a sensitive one though and something like having someone walk in on you, unexpected observers, or an inappropriate remark can change that feeling of comfort into humiliation very quickly. Once something happens, if it's bad enough, you will never feel the way that you do and the way that I used to feel ever again.
It's not about being undressed. It's about feeling degraded; it's intolerable if you've never experienced it.
This is why I blog, to try to explain what happens and why. I must admit that I feel like I'm talking to a brick wall most of the time and until one is
in that position, one will never understand.
belinda
It would sure be nice if patients in need of more intimate exams/procedures were given the choice of a male or female provider.
There are more female health care providers now than ever before. It is not about being unprofessional but having to be exposed and touched by opposite gender providers. This is personal, even if the provider is professional about it. Is asking for a male/female provider that big of a deal?
BK
In response to the original prompt, I think that if every patient was given the option of only same-gender care there would be a significant loss of efficiency, and a "significant loss of efficiency" is a lot worse than it sounds. It means that either more personnel have to be hired (adding expenses to already bloated medical costs) or patients get care that is so inferior that it could seriously harm their health or well-being.
I think one part of the solution could be that people who want same gender care have to pay some extra expense. The expense could be money or it could mean that they just have to wait in the lobby for an extra hour. The added costs of providing same gender care should come at the expense of the patient demanding same gender care and not the more cooperative patients.
The other reason that I think this should be part of the solution is that a lot of the people who demand same gender care do not really care about modesty that much. While working as a male CNA in a facility I found that many patients withdrew their request for same-gender care when it meant they had to be slightly inconvenienced.
Other requests for same-gender care are rooted more in sexism than in modesty. I do private duty care right now, and after accepting the first job offer I got the company called me back to say the patient's daughter wanted a female. I doubt this came from any modesty issues because the patient himself was a male. I've seen two ads on craigslist for people wanting a female CNA to take care of a male relative. Some women prefer female CNAs the same way some men prefer male mechanics.
My point is that if a patient can request same-gender care with no cost to himself/herself, we are going to see a LOT of patients making that request and we're going to see a lot of costs being incurred as a result, even though many if not most of these patients don't really care that much about modesty.
Additionally, I think part of what bugs people about the modesty issue is the lack of power and choice. If people are offered a choice for same-gender care that is so unattractive (e.g. it costs too much money) that they decide against it, I think they would feel better about being exposed in front of the opposite gender, knowing that at least they had some say in the matter and were not totally powerless.
--RDW
I think the issue of inappropriate sexual behavior is another aspect that I feel is more prevalent than outright abuse. This I feel the medical community has way to much tolerance for, joking about patients whether they know it or not is inappropriate but defended by many providers as harmless or therapeutic. Those incidents I believe are more common than we want to admit, I would venture to say most of us have witnessed this in one form or another while abuse or assault has been experienced by far less. Still there is a difference between inappropriate behavior and modesty violations but in my opinion are close enough to be on this thread together.
Dr. Bernstein, my problem with your view is providers always approach this as if it is an either or proposition. Why shouldn't we approach it as if both quality care and accommodation for modesty can be achieved? When the approach is they are automatically exclusive of each other there is no attempt to address them and the envelope gets expanded. There are colonoscopy shorts to provide an extra layer of comfort, why are they not a standard issue? As often posed before and never really answered, why does a patient have to be naked except for the stupid ICU gowns for wrist or cataract surgery? There are no doubt going to be occasions where we will have to sacrifice our modesty due to the nature of the procedure, but it doesn't address those occasions where the modesty concerns are discarded, ignored, or not acknowledged simply because it is easier for the provider. SOP says do it this way so lets not question. They make disposable surgery shorts, are they offered? Perhaps if providers made any effort to address the unneeded violations when it was needed patients would have an easier time accepting nothing could be done. It doesn't always have to be a choice between modesty or care.
We touched on the Lucifer Effect and Mob mentality for providers, but what causes patients to accept things that they find uncomfortable ,traumatic, and later may haunt them for a long time? Ray, is there anything like the Stockholm Syndrome that may explain any of this? Could it be that we are under stress so we attempt to convince ourselves this is OK, this is natural, we rationalize to get through it and later when the stress is gone we reconsider? I can tell you from my personal experience I would suck it up and I am reasonably sure the provider could tell I was uncomfortable, embarrassed but not to the extent I was feeling. I had a scrotal ultra sound by a female tech, we talked through the whole thing and I was almost completely overwhelmed and remember only bits and pieces of it as my mind was in such a state of... for a lack of better word panic that I wasn't even processing the whole experience, it was like I was partially shutting down but still talking. The kicker, I thanked her for what I found was so humiliating I left the facility, hit the nearest C-store and bought a pack of cigs and lit up for the first time in nearly 20 years. I vowed never to return until I discovered this blog and discovered I wasn't a freak and had the right to ask for accommodation, for the next visit and got a male. So, what makes patients "grin and bear it" rather than speaking up, we even try to hide it. Is this a self defense mechanism where we try to reconcile vs address? Are we just to afraid to challenge what we see as authority? Is there something else that makes us try to justify in our minds what we find so wrong?. Are we the abuse victim that blames ourselves rather than the abuser......don
I wanted to throw in a few thoughts on the psychological origins of modesty, since Dr. B said he’d like to see more of this. I’ve read a few psychologists commenting about modesty and I’ve found that their psychobabble abstractions fall pathetically short of providing a satisfactory explanation. What follows are just my hypotheses, derived from introspection. I don’t have any kind of evidence to support them.
Modesty serves a function. Part of its function is to protect the genitals from mutilation (more of a male function) and rape (more of a female function). When I (as a male) imagine walking naked into a dark shed filled with sharp objects, I get a certain feeling that I also have when I’m naked in front of other people. Additionally, when I’m naked in front of others, I have a certain impulse to bend forward, as if to protect the genitals. If you look at the body language for different animals (including humans), you can tell a lot about their confidence by the degree to which they leave their genitals open to attack. Dogs put their tail between their legs for a reason.
Modesty serves another function: it protects us from gossip. This plays a far, far, more powerful role then you might think. Take a moment to imagine how you’d feel if you were seen naked by a person of the opposite gender who cannot form long-term memories. Everything they saw, everything that happened is going to be instantly forgotten once they leave the room. To me this is hardly distressing at all and I think the reason is that they cannot tell others what they saw. Similarly, if you’re visiting a foreign country you’ll never return to, being seen naked probably won’t be as distressing because any gossip is almost certainly going to be inconsequential – no one you know is going to hear about it. On the other hand, if I get seen naked by a female who knows girls that I’m attracted to, that can be extremely embarrassing. She now has a power (she’s liable to exercise) to tell secrets about my body. She can spread rumors that aren’t even true because others haven’t seen it. It’s more embarrassing if she’s the type of woman who’s likely to do a lot of talking (e.g. young, blonde, and bubbly). Rumors about what people look like naked are rumors that spread very easily and can significantly impact their romantic and sexual prospects. I have a related theory that a lot of homophobia originates out of a need to enforce boundaries, especially those related to nakedness, which could explain why homophobia runs most rampant in places like sports and the military where men have to shower in front of each other – men don’t share details about their peers’ anatomy in large part because of a fear of being labeled the ‘f’ word, and in order for this boundary enforcement to work men have to perceive gayness as something that is bad.
A related issue with modesty is one of power. If you’re a naked male athlete in front of a clothed female reporter, she may not gossip, she may not judge, she may not even look, but she has the power to do so. Furthermore, you don’t have any reciprocal, balancing power because she is fully clothed. You’re liable to feel like you shouldn’t rub her the wrong way lest she use her power against you. You’re liable to feel a lot of resentment for being put in this unequal position.
[My post ran over the char limit and is continued below]
[continued from above]
This brings me to another issue concerning modesty – there is a certain modesty about admitting that one does not want to be seen naked in front of the opposite gender. If I have to drop my drawers for a nurse, I know I’ll feel embarrassed, but I also know, intellectually and from my experience as a CNA, that my genitals won’t be mutilated, that in all likelihood she will not gossip about it, and I know that if I don’t show any embarrassment, if I act like I’m proud and I don’t care what she thinks or says, then there won’t be so much of a power differential. On the other hand, if I do request a male nurse, that’s news that HAS to be spread to at least one other person in the office (and will likely be shared with others). Furthermore, it’s information that healthcare workers feel a little more carte blanche to talk openly about – I think most nurses wouldn’t see anything wrong with saying “the patient in 501 doesn’t want a female” in front of a group of staff, patients, visitors. And therein lies the rub – because my fear is that when all those people hear about my request they will assume I have something to hide (i.e. a small penis). Add to that the fact that I know this request is likely to be unfulfilled and you have a situation where my request will probably cause damage to my public image while preventing none. This is a concern for both women and men, but it’s a greater concern for men because a certain amount of modesty is both expected and virtuous for women.
Men, particularly of my generation, are extremely self-conscious about our penis size. I think our modesty about our genitals being seen is an order of magnitude higher than women’s modesty about their genitals being seen, the same way women have a modesty about their breasts that is an order of magnitude higher than men’s. I think a large part of the reason for this is that we did not grow up with the open showers or naked swimming that was customary in earlier generations. Today, we don’t see each other’s penises, which leaves us free to lie about its size and wonder if the other guys are lying as much as we are. That puts us in a very vulnerable position when it comes to showing it to anyone, but especially to women, because they’re not in-sync with guy code on this issue and we’ve all had one too many experiences with women emasculating us or ruining guys’ reputations behind their backs. For some men who haven’t gotten a firm handle on these largely subconscious, automatic thoughts, I imagine the only credible way to protect that one neurotic aspect of their dignity is to avoid the doctor’s office entirely.
I want to thank all those who are making an effort to make the communication on this blog thread a true discussion by presenting argument responses with analysis. In other words, not just repeatedly arguing a point (like hitting the reader over the head with that point) but helping the reader through an intellectual structure understand the logical basis for that point. And also I am very happy to read about approaches to solutions. After all, to argue against a potentially reversible situation without suggesting approaches to perform that reverse, is not truly fulfilling. Again, thanks. This is what the title of this whole blog "discussion" is all about. ..Maurice.
R Williams
Your thought process is flawed and here is
why. You don't give an equivalent analogy if
the patient is female and refuses to allow you,
a cna to provide an ekg. Would it be on the
basis that the patient has small breasts and
would feel self conscious or perhaps has the
perception that all males are perverts.
After reading your posts I have doubts about
your claim as a cna. You said " add to the fact
that I know this request is likely to be unfulfilled
and you have a situation where my request will
likely cause damage to my public image while
preventing none."
Are you suggesting that a patients care will
diminish after such a request. Care cannot be
forced upon a patient. A patients request on
gender choice for an intimate procedure should
never result in ridicule wether it be in front of
the patient or at the nurses station.
Furthermore, I have suspicions that you are
not a cna as you claim for if you were you would
be particularly sensitive to male patients request
considering the nursing gender imbalance coupled
with the fact that you are probably turned away
with female requests for female only care.
Your reasoning is particularly flawed in that it
does not take into consideration males such as
myself whereby modesty is really not the issue,
rather the double standard, the inequity imbalance.
Your ideas perpetuate the notion that males
are perverts and all females in the healthcare
arena are gender neutral. It's my opinion that you
see this issue more as a fetish.
PT
Don: You write, “I think drawing similarities from Prison Guards, Abu Griefm [sic] and the medical community has a bit of a difference.”
What occurred in the Stanford prison experiment, at Abu Ghraib, in health care settings when actions such as the one you mention are committed, and even at My Lai during the Vietnam War can all be explained using the same theory or set of theories. In short, these and many other events are linked theoretically. The theories and research findings of both Phillip Zimbardo and Joan Emerson, among others, help explain them all.
Zimbardo, in particular, explains why good people sometimes do evil things (the Lucifer effect). He uses the metaphor of an apple barrel. He tells us that at Stanford, My Lai, Abu Ghraib, and other places good apples were put in rotten apple barrels. It was not something about the individuals (e.g., their level of emotional stability) but something rotten about the situation in which they found themselves that resulted in their evil behavior; it was the rotten apple barrel that resulted in the good apple turning rotten. He calls this phenomenon the power of the situation.
Zimbardo then proceeds to tell us what it was about the situation (the rotten barrel) that resulted in the reproved behaviors. By the time you finish reading The Lucifer Effect or watching the video, you should be able to theoretically explain why good people sometimes do evil things in any number of settings, including hospitals and other bureaucracies. Once we understand the theory, we can try to find the rot in the barrel that causes the behaviors we don’t care for. Given that theory is meant to be tested, the best way to find what is causing the barrel to rot is to conduct research that tests the theory. Once our ignorance is so informed, we will have the knowledge regarding how to change the barrel to reduce the likelihood that the good apple placed in it will turn rotten.
Consider the research conducted by Peter Ubel and his colleagues. They found that 70% of medical students who began their OB/GYN clerkships believed that it was unethical for students to perform gratuitous pelvic exams on anesthetized patients without their consent. By the end of their clerkship, only 50% believed it was unethical (Endnote 1). What do you suppose may have occurred to the 20% between the time they began and ended their OBGY clerkships?
I’ll address the first part of your post later.
1. Actually, they did not conduct a longitudinal study whereby they measured students’ beliefs before and after their clerkships. They simply compared the responses of those who had not begun yet to those who had completed their clerkships.
Ray Barrow
PT
Your post makes absolutely no sense to me. I don't mean that as an insult, I'm just saying I don't know how to respond. I don't think you understood the points I was trying to make.
To answer a specific question (maybe this will help clear things up), what I meant when I said this:
" add to the fact that I know this request is likely to be unfulfilled and you have a situation where my request will likely cause damage to my public image while preventing none."
I meant that if I, as a male patient, ask for male caregivers, then it will get around that I want a male caregiver, but I probably won't get one. This means many people will know I have this special demand and will likely presume I have a small penis or something.
I think that maybe where you got confused was when I started using the first person to refer to me, the male patient, where you think I'm referring to me, the male CNA.
The idea that one would be at a disadvantage due to paying extra or waiting longer for same gender care is unconstitutional the same as making women pay more for healthcare because they have the babies (they didn't there by themselves).
Titlle VII (the law institututed for equal pay and non discrimination as a privacy clause. A bona fide job qualificiation, as it is referred to in the law (regarding gneder) means that the job cannot be performed by the opposite gender), i.e., bathroom attendant. So, if a bathroom attendant must be of the same gender as the patrons of that facility, then why did the healthcare system choose to go gender neutral. If this issue went to court, they would lose on the legality that each person has a right to privacy.
belinda
To RDW:
Are you the same person as R. Williams? If so, your posts seem to contradict each other. I can't really agree with your notion that if patients had to pay extra they would drop their requests for same gender care. I for one would be willing to pay a little extra for same gender care when it involves something intimate. In most cases that would be a request for support personnel (nurses, techs, etc.) since I do have the option of choosing a doctor of my gender choice. I would also be willing to wait longer for that convenience. There probably are those who would drop their request if they had to pay more but I don't necessarily think that's because they have no modesty issues; it just may be that they cannot afford to pay the difference. I'm not so sure sexism is the reason most people would request this. I don't necessarily think patients requesting same gender care, especially if it were ONLY for intimate care related things, would cost the system more. If more facilities staffed with mixed gender there would probably be someone available for the patient requesting same gender care. Not all patients would request this so I don't necessarily see it causing that much of an added expense. Also, as I stated before, this would only be for intimate care and not for general care. If you are also R. Williams, your second post seems to be more sympathetic to the issue, especially for males. Which is it?
And, Don, as usual I agree with you completely. I also don't understand why the medical industry doesn't make any attempt on respecting patients' dignity when there are obvious solutions (as your example of colonoscopy shorts, disposable surgery shorts, remaining clothed for hand surgery, etc.). No one has ever seemed to answer that question. I feel very sympathetic about your experience with the female ultra sound tech. You are right on when you relayed your feelings (about hiding your angst and reacting afterwards with the smokes!). Having one humiliating experience such as this is on the same par as Belinda's experience. It only takes one thing to impact your feelings about health care and color your future experiences.
And for the record I agree with Dr. B that this blog is more interesting when people try to figure out reasons for these issues and, better yet, come up with solutions that will help us ALL, male and female. Jean
I want to again display my appreciation for what I observe as discussion of theories and explanations of the matter of patient modesty, the direction of this thread. In fact, you may not believe it but I, myself, am learning from the discussions. This kind of discussion of theories and explanations is the way to lead to hopeful resolution of the conflicts between patients and the medical system regarding patient modesty but possibly including other areas.
Productive and ethical discussion, however, must always exclude ad hominem statements where in place of arguing the theories and explanations of the commentator, it becomes that person or personality which comes under attack for what was written.
But I again say, I am very pleased as moderator what is currently being written. ..Maurice.
R Williams
No I did not get confused from your post. What
they might think is your perception of what they
might think. Personally, I would NEVER care what
they think. When I am the patient, it's all about me.
I want the same respect, same considerations
for privacy that they get. They get the same gender
when it's time for their mammogram. That is what I
expect and I will recieve that when I need health
care.
I want a private room to change just as female
patients expect. I expect those in healthcare to
treat me respectfully and if any of those expectations
are not met I will let them know immediately. I will
ask for the charge nurse or the house supervisor
and will let them know that if you cannot rectify this
I will report those along with you to the Bon. It is
now your responsibility, you are the charge nurse,
house supervisor, resolve it.
My permission for nursing students or residents
must be sought first. I do not allow packs of people
to enter my room, ie residents, nursing students
etc. My classic line for patients who suddenly have
some attending whom you don't know along with
half a dozen residents enter your room, which I
think is rude by the way is to say, " you had to
go find all these other people to help you figure
out what is wrong with me, you can't be very
bright." with my right hand I motion them to shoo,
go away.
Charging people extra for same gender care,that
is the most ridiculous thing I have ever heard of. I'll
bet that wouldn't last long. Go back and charge all
the female patients who automatically recieved that
service for years and then present your idea of what
you could do with that money on your next post. We
will decide if it's approved or not.
PT
Don: You write: “Ray I intend to review your links when I get a chance.” Please do, and if you’re so inclined, please give me feedback.
You also write: “[D]o we have a common agreement on what is a modesty violation, sexual inappropriate, abuse, and assault. I am guessing there is a lot of distance in our definitions of each.”
I am guessing our level of agreement is much closer than you think, although I may use some terms more precisely than you do. For example, you may use the word “assault” to label the actions of Dr. Twana Sparks and the actions of nurses to whom you refer in your post, while I think they may be more correctly labeled acts of battery. Also, although sexual assault and sexual battery are, legally speaking, mutually exclusive categories, the concepts modesty violation, sexually inappropriate behavior, sexual abuse, and sexual assault are not. For example, I conceive of sexual abuse as including sexual assault (and sexual battery) and sexually inappropriate behavior as including them all. But these are technical issues of conceptualization rather than substance.
You follow through with: “To me [sexually inappropriate behavior] would include things like nurses joking about a patients anatomy . . . yet many in the medical community have justified this as just stress relief. There was a post on allnurses that was quoted here where nurses were taking a peak at a young man's abnormally large penis while he was out. Abuse, inappropriate, assault, or no big deal, the opinions ran the gambit. So in the eye of the beholder appears to be in play. That means we don't have a common definition of these to debate from.”
Ray Barrow
Continued from Last Post
Don: I visualize what you have written through the lens of a theorist. I agree that what the nurses did may be construed as being sexually inappropriate behavior. The theorist might be interested in explaining sexually inappropriate behavior which would include behaviors of the sort in which the nurses participated. Joking about patients’ anatomy and justifying sexually inappropriate behavior can be theoretically conceived in a manner that is independent of sexually inappropriate behavior.
Let’s take a peek at what David Matza calls neutralization theory. It has been used to explain delinquency, crime, cheating at school, white collar crime, corporate crime, etc. Let’s use part of it to explain sexually inappropriate behavior in healthcare settings.
Bear with me for a moment. According to Matza, before people engage in reproved behavior (let’s call this behavior deviant behavior and the person who commits it a deviant), they will tend to first neutralize two things including 1) the internal effects of conscience and 2) the external threat of formal and informal punishment. The neutralization of internal and external controls is achieved by learning neutralization techniques. Our future deviant learns these neutralization techniques during the process of interacting with others in groups and organizations. Among the neutralization techniques learned is normalization. Our budding deviant, who has not yet committed the deviant act (e.g., sexually inappropriate behavior), comes to believe that some types of sexually inappropriate behavior in healthcare settings is normal under the circumstances. They learn to justify that behavior in advance of its commission as a way to relieve stress and that anyone in the same circumstance would do the same or similar thing. They may also normalize the behavior by arguing that it is human nature for people to behave this way under stress, if given the opportunity to do so. By defending the action as due to human nature, they are attributing their behavior to biogenetic factors, which cannot be altered, rather than to social forces which can.
The successful neutralization of internal and external controls via the learning of neutralization techniques opens the way for the initiate to deviance to break his or her bonds to dominant social norms and “drift” into deviance.
Among the many things which may occur in some healthcare organizations that help foster neutralization and the subsequent commission of sexually reproved action against patients is the adoption of slang and the communication of irreverent and gallows humor that dehumanize patients. Melvin Konner and Robert Conrad in separate publications write extensively about this phenomenon.
By way of conclusion, I have conceived of sexually inappropriate behavior as something to be explained, the learning of neutralization techniques as one explanation of the behavior, and the prevalence of language and humor that denigrate patients as a factor that helps foster neutralization.
The social scientist prefers not to end with the application of theory to help understand aspects of the social world. The next step is to test the theory or some of its propositions. In our case, this requires, among other things, a theorist to precisely define what is meant by sexually inappropriate behavior, create an instrument to measure it, and provide evidence that the instrument is acceptably valid and reliable. This process, which tends to be difficult and time consuming, helps reduce the ambiguity to which you allude in your last sentence.
I should add, neutralization theory has been confirmed by research on delinquency and cheating. However, as far as I know, it has not been put to the test to see if it helps explain sexually inappropriate behavior in healthcare settings.
Ray Barrow
While I appreciate the current discussion, I think it's a little insulting to imply there hasn't been value in previous discussions. I certainly found a lot of value in reading previous incarnations of this thread.
Don -
We have survival mechanisms that in times of great stress allow us to survive (Fight, Flight, Freeze). You're survival mechanism kicked in and it allowed you to survive the event. It did it's job: you survived. It's not necessarily "threat of death" but the amount of stress a person is under that triggers survival mechanisms (but if you were worried about the diagnosis, that may count as threat of death).
http://www.stressstop.com/stress-tips/articles/fight-flight-or-freeze-response-to-stress.php
Someone previously linked me to an article about Trauma Informed Care and I really appreciated it. I'd like to attend this conference in the future. This is their definition of "Trauma Informed Care" - something that is needed by many of us here.
Trauma-informed care requires that the healthcare provider is informed about and sensitive to the impact of trauma and adjusts how care is delivered in order to accommodate trauma survivors’ unique vulnerabilities. Trauma-informed care includes ensuring that the trauma survivor feels safe, that the provider and healthcare setting are experienced as trustworthy, and that the survivor is given as much choice and control as possible. Treatment by uninformed healthcare practitioners can be re-traumatizing and result in survivors avoiding further treatment even if it means putting their health at risk. For instance, when the healthcare professional is not knowledgeable about the effects of trauma and does not provide trauma-informed care, the care provided can trigger memories of trauma leading to an inability to comply with treatment recommendations or to return for further treatment.
http://www.traumatalks.ca/what-is-trauma-informed-care.html
I feel that this ties directly into patient modesty because many "irrational patient demands" aren't irrational at all - they can be easily understood with a good knowledge of human behavior.
-RJ
R Williams
Based on your opinion if I request a male nurse
for any intimate procedure the gossip at the nurses
station will be that I have a small penis. If I order
small portions of food the gossip at the nurses
station will be that I have a small stomach. If I
request only a certain phelbotimist the gossip at
the nurses station will be that I am a wuss.
If I have a large penis there will still be gossip at
the nurses station. If I order large portions of food
the gossip at the nurses station will be that I am a
slob. If I tell the phelobitimist don't bother with the
ac, go for the carotid,I'll show you how. The gossip
at the nurses station will be for me to get a psych
eval.
In these competitive times for healthcare dollars
it's just amazing that nurses have time to gossip
about their patients rather than advocate for them,
rest assured this same gossip dosen't happen to
them when their scheduled visit to their mammo,
L&D or post-op gyn.
Would I expect them to send the small penis
committee to my room after the male nurse performs
an intimate procedure, would they ask him if that
were the case and if so how would my continual
care after that diminish. What happens if I have a
large penis? Would my food be restricted for having
a large stomach.
Please enlighten us so that we can better prepare
for this.
PT
I want to contrast what we know about humans and fight, flight, and freeze vs. what we used to think.
We used to believe that "freezing" behaviors were confined to prey animals. The thought was that humans are hunters, therefore they shouldn't freeze.
We know now that isn't true. For example, a common reaction to childhood sexual abuse is for the child to pretend to be asleep.
We also used to believe that babies did not feel pain, because some babies when seriously injured will simply go to sleep. We think that a baby in a peaceful sleep is not in pain, when they are actually "freezing". (How many parents have said their baby's circumcision didn't hurt because the baby slept through it?)
Here is blog post by Professor Emeritus at West Virginia University Medical School about surgery on babies with no pain relief:
http://ltinnin.com/2010/12/30/infant-surgery-without-anesthesia/
In case you think that children being traumatized about surgery as infants is impossible, consider this case study. I remember reading a case story of a woman having constant nightmares about drowning. She finally opened up to her mother about it, and found out as a baby she had fallen into a pool and almost drowned. After that acknowledgement, she was able to work through her fears in therapy and the nightmares stopped.
-RJ
Belinda: In fact, there are a number of law suits brought by male nurses against hospitals that discriminated against them in OB/GYN units and the decisions have been mixed. I’ve already mentioned two on this blog: Backus v. Baptist Medical Center and EEOC v. Mercy Health Center. Both decisions were in favor of the hospitals but more recent suits favored the plaintiff male nurses. Both Backus and Mercy used the bona fide occupational qualification (BFOQ) principle as the basis for the decision, but I believe the 1991 Civil Rights Act (an addendum to the 1964 Civil Rights Act), which addresses BFOQ rather than Title VI, was the basis of the two decisions, although my memory may be incorrect.
I was quite surprised when I found out about the decisions because I thought they’d go the other way. Out of curiosity, I read the cases and recognized the soundness of the logic behind the decisions. To prevail, the hospital defendants had to prove to the satisfaction of the courts that, among other things, there were pregnant women who would object to intimate touching by male nurses and to replace a male nurse with a female nurse for those who requested it would cause logistical problems of the sort that could jeopardize the continuity of care given to patients. The hospitals were able to muster support for heir arguments sufficient to convince the courts to conclude that in the case of labor and delivery employment, “all or substantially all men would be inappropriate for the task.” Given that Mercy Health provided services to a large number of high-risk women, it added to Baptist Medical’s arguments that the birthing process is itself stressful, especially for high risk births. To allow male nurses who have not been chosen by the patient to engage in intimate treatment required during the birthing process could add to that stress. Thus, the court concluded that Mercy Health “provided a factual basis for determining that the employment of male nurses in the labor and delivery area would cause medically undesirable tension.” The Baptist Medical decision was appealed but was deemed moot when the hospital decided to change its policy.
I wrote something up about the other decisions and posted them either on Dr. B’s blog or Dr. Sherman’s blog years ago. What I wrote is packed away somewhere. At any rate, the decisions in the most recent cases favored male nurses because the hospitals failed to adequately address one or more of the criteria necessary to justify a BFOQ decision. The defendant hospitals in those cases were not allowed to rely only on the evidence of gender preference from Mercy and Baptist but would have had to spend the time and money to conduct independent research that showed that patients in OB/GYN at their hospitals would object to male nurses.
I believe both Mercy and Baptist had policies that were nondiscriminatory on their faces – male patients would be assigned male nurses and female nurses would be assigned female nurses unless patients asked otherwise. This put the hospitals in a dilemma because the natural consequence of what on the surface appeared to be a nondiscriminatory policy could end up discriminating against male nurses in the sense that OB/GYN units would basically end up with only female nurses caring for pregnant patients while the few male nurses employed, if any, would have little to do.
I conducted a content analysis, both quantitative and qualitative, using dozens of articles in nursing journals on the reactions of nurses to the two decisions and, more generally, on hospitals which employed only female nurses in OB/GYN. The outcome of the research was interesting because it provided insight to why nurses sometimes respond with umbrage when patients request same-sex nurses when intimate care is involved. Anyone interested?
Ray Barrow
We have batted around the legalistic definitions of abuse, battery, assault etc. before. For the benefit of this thread and discussion perhaps it would be best if someone were to define and use relevant examples of each. Inappropriate behavior is... examples include, nurses taking a peek for entertainment vs therapeutic, joking or discussing a patients anatomy for amusement, Assault is...modesty violation is...so at least we could all be talking the about the same thing when we use the terms.
I have seen the movie on the Lucifer Effect, I read Dr. Zimbardo article and watched the clip. I found the clip fascinating including his presentation. I want to watch it a couple more times and try to glean a little more understanding but there were a lot of aha moments. When he was talking about "The power of the institution to influence behavior" and referred to it the concept of medical focus on the individual to one of public medicine that looks at the disease. I realize these were metaphors for not looking at the individual for insight into why people became aggressive and abusive in the situation but look at the larger group, the institution for why individuals became someone other than who they were in the beginning. I also thought the discussion of "Situations have the power to do 3 things inflame evil, render one to become a passive bystander, or inspire heroic behavior was interesting. They all have a place in this discussion. Dr. Bernstein earlier commented on how early on students are mainly concerned with hurting or embarrassing patients/medical volunteers. I asked the question, how do they move from that position to one of claiming to be oblivious to the situation. We tended to look at the individual providers a single group instead of one of the three options presented. Perhaps this is where some of the disparity in our opinions of providers comes from. Perhaps I have experienced passive bystanders and others the inflamed evil. Consider the situation where a teacher/instructor/institution hammers over and over you are not to be mainly concerned with hurting or embarrassing the patient, you are to be mainly concerned with treating them, and the mantra that you know best, you just need to make them see it our way as we know best does create the three, those inflamed by evil, the passive participants and in some cases the hero. Perhaps I have only been aware of the passive participants and others the inflamed evil. Now condiser this, what if the inspired hero's are treated like the med student who was chastised and essentially ousted when she resisted. If in Zimbardo's prison the guards who were the good guys were fired or failed because they were the good guys? What would that say to the others? If a nurse or tech refused to participate in a colonoscopy unless a patient were provided colonoscopy shorts, how would that be received and what effect would it have on their career? Would the institution see that as good, would the passive bystanders join them or stand passively by wishing the hero wasn't making waves? So perhaps rather than concentrating only on the provider in this discussion perhaps we should focus more on the institution that fosters this behavior. I found it interesting that Zimbardo himself did not realize he had crossed over until confronted by the woman who would eventually become his wife. There were several incidents, in this case Zimbardo and in others "prisoners" whom had to be reminded this is not who they really were. I am going to end this one and jump to the prisoner/patient side....this is awesome...don
Now from the patient/prisoner side. I found it interesting how the prisoners not only fell in line, but actually joined in by chanting and labeling the prisoner as a bad prisoner. The "prisoner" was ready to go back into the situation which had reduced him to tears rather than be a bad prisoner. He had to be reminded, he wasn't really a prisoner, he was a student. If we substituted provider and patient for guard and prisoner...how many parallels would we recognize? When you are told you are a patient, and this is how a patient behaves and this is what happens to a patient, how many accept that and become the patient and not themselves even though the power to reject it lies within them. We accept treatment we feel degraded by from people in uniforms (another interesting thought that uniforms increased the proclivity for violence) even though these people really do not have the power to force us to take it. I found it interesting that in the Stanford Prison & reality at Abu stripping the prisoner was universally seen as a way to punish, degrade, or control but in a medical setting it is assumed to be accepted by the patient with no real ill affect. There is an added aspect of the medical situation, we need help, we are there for a reason, we may even be there for life and death, so what additional pressure is there with that said, or is it another similarity to the prisoner whom may see this as life or death, his survival as well ....this is a lot to digest so I think I need to go have a glass of wine and watch this again. I love where this is thread is going...don
Don: You write, among other things: “So perhaps rather than concentrating only on the provider in this discussion perhaps we should focus more on the institution that fosters this behavior.” Bravo!
Let me expand what you’ve written a little bit. If we really want to understand human behavior and social conditions, the first place to start is to develop an imagination that covers four levels of understanding, from micro to macro. The most micro-level disciplines used to understand human behavior are the biological/chemical/ physiological/genetic sciences which focus on the internal workings of humans (e.g., Cesare Lombroso’s explanation of criminal behavior). The next level is the psychological level which focuses on personality and the mental and emotional workings of human beings (e.g., Adorno, et al’s explanation of prejudice). Unlike the citizens of other high income nations, U.S. citizens’ imaginations tend to go no further than this. These two levels of understanding encourage people to believe that “nasty” behavior is a product of something evil in individuals, a product of, so called, “bad apples.”
The next level of explanation is the social-psychological level which includes disciplines that focus on the effects of people’s social and physical environments on human behavior and social conditions (e.g., Edwin Sutherland’s differential association theory of white collar crime). At this level, adherents study how, using Zimbardo’s words, “rotten apple barrels” produce “evil” behavior.
If you read about Zimbardo’s Stanford prison experiment, you’ll see that he screened out volunteers who had emotional/psychological issues in order to rule out psychological/personality anomalies as determinants of the outcome of the experiment. He then randomly assigned the remaining volunteers to be prisoners and guards. Random assignment, probabilistically speaking, was done to basically equalize the two groups. If guards and prisoners were statistically the same, then had the random assignment procedure resulted in guards becoming prisoners and prisoners guards, the results, probabilistic speaking, would have been the same. The effect of the experiment on guards and prisoners was so damaging that Zimbardo was compelled to call off the experiment prematurely. He concluded that it was the power of the prison situation (“rotten apple barrel”) rather than psychological factors (“rotten apples”) that determined the disturbing outcome.
The final level of explanation, and the level which is given the least attention, is the sociological level which focuses on how macro-level institutional and historical forces determine human behavior and social conditions (e.g., C. Wright Mills’ explanation for social problems). For years, Zimbardo seems to have been stuck at the social-psychological level of explanation. Somewhere along the line, his view of the causes of “evil” behavior became more sophisticated and he added a sociological imagination to his understanding of the world symbolized by his observation that there are macro-level institutional and historical forces that create and help maintain “rotten apple barrels.” So historical/institutional forces create and maintain “rotten apple barrels” which are, in turn, empirically responsible for creating “rotten apples” and making “rotten apples” more “rotten.” By way of illustration, Jeffrey Reiman, David Simon, and E. Stanley Eitzen in separate publications tell us how the legal, prison, economic, and political institutions in this country are organized to ensure high rates of “crimes in the streets” as well as “crimes in the suites.”
The extent to which we reject any one of these levels as providing explanations for human behavior and social conditions is the extent to which we will fail to fully understand these phenomena.
Ray Barrow
But Ray, is there enough understanding through sociologic controlled studies to fully understand the modesty and gender needs and limits of patients along with the equivalent understanding of all the institutional related issues with their limits and therefore as a conclusion to be able to suggest whether both parties can come to a resolution? In other words, can we tell if we are dealing with an impossible resolution or one which has the potential for success? What is the prognosis? ..Maurice.
Ray I would be interested in a little background on you if you feel like sharing. I graduated in 1977 with a degree in sociology originally because I was told it had the easiest professors and would allow me to pursue my true passion..beer drinking. As I got into it I feel in love with the study of man and added some psych classes because I found it fascinating. I briefly dabbled in social work but went into and stayed in the business arena for the next 35 and counting years. Some of your references seem vaguely familiar. I also have a daughter completing her masters in Psych and we discuss these things whenever I can command her presence.
I agree 100% this is not an either or individual/institution but a combination. The institution may be the same but the individual will react or perhaps interact differently so the question is how and perhaps how much. I drive my daughter crazy by constantly asking her if she has figured out the nature vs nurture question. She has moved to eye rolls and ignoring.
To Dr. Bernstein's question I think the question is how far can we move the mark on the continuum? If I were to sit down and share the discussions from the last week with a group of providers and a group of patients, what it means to each group would likely be different. However I would hope it would move both to question and move toward the center. Now if the two were to sit down and discuss it together, would it move them even closer to the center. I think it would. Then there is the agenda to factor in. I think we will have additional discussions on understanding this issue from our new approach, but even if we make headway, the discoveries would have to be shared and applied but that is for another day....interesting turn of events isn't it Dr. Bernstein...don
Don, yes..most interesting and to me valuable at this point. Yes, those "moaning and groaning" responses from my visitors were important in the first dozen Volumes to get a feeling of the concerns and perhaps also the degree of concerns about their experiences regarding modesty. But after a while, though it still may have been therapeutic for the individual visitor to "ventilate" it is not a helpful function if we are thinking about how to change the system to be more accommodating and particularly more, shall we say, "humanistic" in this system-patient relationship. That requires some formal consideration of all the pertinent issues involved and, indeed, some of the issues or relationships may not as yet been fully informally or particularly formally dissected. The current discourse on this blog thread, if continued and expanded may provide better understanding to all of us and lead the way to patient-system change. Isn't that goal what we all want from what we already know from the 61 volumes?
I hope making this thread a bit more academic instead of considering only what the news sources or the website "allnurses" write will be understood by all my visitors as something beneficial for our final goal. ..Maurice.
Don,
A few blog numbers back (59-60), we all experienced Dr. Bernstein very carefully justifying to all of us that he and his students “needs” trumpeted the needs of the patient. We haven’t moved him one iota in over 5 years of this blog. We are a bunch of outlier winning troublesome patients to “understand” and deal with in order to mainstream us.
Academic discussion is all that Bernstein wants to have. We even have learned that his ethics committee he sits on has no power to effect change.
Sorry. If we can’t influence Bernstein, this blog now has run its course. I think the focus should now be: How to “fix” the outlier patients so that we learn how wrongheaded we our about our bodies. Bernstein will only consider something valid if and only if he has experienced it himself AND it fits with his world view. A very typical “close-your-eyes” method of dealing with inconvenient facts.
I’m basing my conclusions on the statements made on this blog. If Bernstein feels I have been wrongheaded about this, I invite him to use his own words on this blog to show us how I have wrongly interpreted his position.
The point here is that Bernstein is the quintessential archetype of the professional view of medicine today. That leaves us with a generational fix to this. Meaning that the future generations of doctors must be sensitized to this issue. But that remains a problem, because Bernstein is teaching his students the hidden curriculum from the moment they enter med school.
So, how do we change the teaching methods for future docs?
-- amr
Amr, you don't understand the term "hidden curriculum" as it applies to medical education and as I have written about it here.(Google it, too) We don't teach our first and second year medical students a "hidden" view of the necessity to be aware of patient modesty issues both in terms of history taking and physical examination. It is the "teaching" that goes on in the 3rd and 4th years of medical school and internship/residency that is the "hidden curriculum" which does not fit with our own teaching and over which we have very little control. It is there in those later years where the forces of completing tasks of education and active treatment in brief periods of time supervised by attending staff who are not of the same mind-set as we first year instructors run the show. What happens in those later years, to some students or graduates is some degree of degradation of some humanistic behaviors that we cherish and teach.
Amr, I have never written or practiced that patient modesty does not exist..even before starting this thread. What I didn't know and what I learned by reading the comments here was the severity of the symptoms and the extent of the experiences of patients writing here. The only reason I have inferred that those writing about their concerns here were possibly statistical outliers was because in my internal medicine practice, I have never had patients talk to me either before or after examination about modesty issues. I practiced attention to patient modesty as I had been taught and apparently, in view of no patient comments, that was sufficient. Perhaps, if I was in another specialty, that would be different. But I was describing only my experience.
To "change the teaching methods for future docs", I think we have to dilute the "hidden curriculum" with better educators rather than some of the attending physicians we have now, more medical educators present, provide more support for students and intern/residents to "speak up", without punishment, to their superiors when they see unethical or improper non-humanistic behavior, provide more time for students and physicians to spend with their patients and not feel rushed to get to the next patient and even more. I hope I have answered amr's request. ..Maurice.
Amr
I couldn't agree with you more. This blog
should have ended long ago, it is diseased with
non-constructive agenda disorder. It's somewhat
contiagous in that many posters have left. Nothing
more to say.
PT
Couple of posters and suggested this blog should be closed.
Obviously some have touched a reality nerve, unable to cope!!!
Turn blind eye to happenings in the real world, listen/write about things they want to hear, unable think outside the box IMHO!!!
Pailrider...
Don and Dr. B – I’m afraid I won’t be able to give your posts the attention they deserve since I am preparing to head to CO tomorrow morning (given clement weather) and thence to sunny (I hope) AZ where I and my wife hope to thaw out. However, I look forward to doing a better job attending to your posts after I return on Jan. 11, unless to do so deviates too much from the discussion going on at that time. I’ll post something this evening.
Also, Dr. B, I began to type a response to your last post which was precipitated by my reference to A Taste of My Own Medicine but decided to first speak to a friend of mine who teaches about holistic medicine at an osteopathic school so I would have a sound basis for my response. I have spoken to him and have some ideas that I won’t be able to articulate until I return.
Ray Barrow
Ray, as you can see, this thread is in constant deviation..so I doubt you will notice any change! p.s.- you will find the weather most comfortable here in the West. ..Maurice.
Dr. B – You ask: “[I]s there enough understanding through sociologic controlled studies to fully understand the modesty and gender needs and limits of patients . . .?” The answer is “no.” There are at least two reasons for this. First, the question can best be answered by psychologists and social psychologists rather than by sociologists. Second, I’ve never read a research report in which the statistical analyses demonstrated that the aggregate variance in independent variables fully explained the variance in the dependent variable (e.g., need for modesty). Indeed, there has always been some, usually considerable variation that remains unexplained, and I would be suspicious if this were not the case.
You then ask if sociologists have the “equivalent understanding of all the institutional related issues with their limits . . .” The answer, again is “no,” for the same (second) reason given above. However, there is some understanding that comes from at least two sources.
First, there are publications on the structure and/or culture of healthcare bureaucracies and how they affect patients. For example, Gretchen Fleming studied the effect of hospitals’ social structure on patients’ satisfaction with their treatment. She found that, contrary to expectations, patients rated teaching hospitals more poorly than private hospitals. She then used some correlates of satisfaction to hypothesize as to the causes of this finding. She doesn’t directly comment on whether or not the level of depersonalization had anything to do with the findings. However, we can consult George Annas’ Judging Medicine, in which he reports on his socio-structural analysis of hospitals, to further our understanding of how the social structure of hospitals may affect
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1072211/pdf/hsresearch00530-0042.pdf
patients’ satisfaction. He writes, “In teaching hospitals, the main mission is often viewed as education rather than patient care.” If Annas is correct, and if patients pick up the social cues that send the impression that they are not providers’ first concern (often as advertised in he media), then it is no wonder that patients who get health care in teaching hospitals are less satisfied with the care they get than patients who receive care in private hospitals.
The second source includes publications on studies of organizations other than healthcare organizations. For example, sociologist Diane Vaughan’s The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA informs us of how the culture and organizational structure of NASA and Morton Thiokol influenced decisions that resulted in near tragedies and, ultimately, in the Space Shuttle Challenger disaster. Sandra Howe, in her review of Vaughan’s book (see link that follows) quotes a statement made by Vaughan that is a chilling reminder of one of the points made by Zimbardo: “The decision to launch Challenger was, incredibly and sadly, a mistake embedded in the banality of organizational life. . . No fundamental decision was made at NASS to do evil; rather, a series of seemingly harmless decisions were made that incrementally moved the space agency toward a catastrophic outcome.” In effect, “good apples” did an “evil” thing because they operated in “rotten apple barrels.” Publications such as Vaughan’s can inform our understanding of what it is about the culture and structure of
http://www.bc.edu/bc_org/rvp/pubaf/chronicle/v4/F01/VAUGHAN/VAUGHAN.html
hospitals and other healthcare organizations that may help explain the unfortunate experiences that so many contributors to this blog have had.
Ray Barrow
You continue: “. . . and therefore as a conclusion to be able to suggest whether both parties can come to a resolution?” I’m not sure to what two parties you are referring. I’m guessing a physician and a patient. Thinking that only two parties are involved places you at the social-psychological level of imagination. There’s nothing wrong with that on its face; social-psychologists have contributed immensely to the understanding of how and why human beings interact the way they do in their social environments. They have also identified phenomena which many of us don’t recognize as we make casual observations in our everyday lives (including “hidden curricula” and “group think”). But, if one wishes to find out how to foster significant change – really, truly wants to find out how to foster change that ameliorates an undesirable phenomenon – then it would behoove him to allow his imagination to broaden and subsume in it just about all categories of people who work in hospitals including, and maybe especially, administrators. Ones imagination would also include in the equation politicians, professional organizations including physician organizations (AMA, IOM, etc.), lobbyists, patient rights organizations, the popular media, legal organizations, and more.
Your final questions are: “[C]an we tell if we are dealing with an impossible resolution or one which has the potential for success? What is the prognosis?” The resolution to which you are referring, I’m guessing, has to do with the feasibility of fostering change in a way that reduces the likelihood of those undesirable things on which people have reported in this blog occurring. One thing I do know is that significant institutional change can only come about via organized collective action. To leave it up to individual patients to, for example, ask or demand that their privacy rights not be challenged whenever they visit hospitals won’t do the trick. I also know what the essential elements are for fostering social change be it at the group level, organizational level, institutional level, or societal level.
Continued
Ray Barrow
What’s the prognosis? When I think of prognosis in medicine I tend also to think of the old ditty, “Doctor, doctor will I die? Yes, my child, and so will I.” When it comes to the individual patient, my own opinion is that physicians, as an aggregate, are pretty good (or at least best) at diagnosis and treatment, in part because of the technology and medicines that are made available to them for prescription. Prognosis in medicine generally requires predicting from aggregate-level research to the individual patient, so prognosticating tends to be tenuous at best. It’s at least equally if not more tenuous to prognosticate about social change, so I’ll have to plead ignorance but I’ll venture a guess anyway; once the causes for the violation of patients’ privacy rights are known and steps are taken to influence the powers that be to take action, the chance that significant change will occur is “fair-to-midlin’.
Truth be known, though, I can’t make a better prognosis without sufficient data and I don’t have those data yet. However, just as I suppose one finds in medicine, as we successfully clear each hurdle in an effort to reach some goal, we become more likely to offer favorable prognoses. When it comes to patients’ rights, some hurdles have already been cleared, at least in policy if not as much in practice. I know how we got over some of those hurdles in the past but not others. So I plan to inform my ignorance. That seems to be the first step in effecting significant institutional change: Inform ones ignorance by gathering the data or, more specifically, reviewing the literature. So one of the first things I plan to do after the holidays is to see what is published, if anything, on the history behind the passage of HIPAA, its administration, and its effects, if any. What does a review of the history behind HIPAA have to do with “the price of rice”? I hope the reader considers this to be a rhetorical question.
Relevant to what I’ve written here is an article that comes from a recent piece in The New York Times (12/13/13, p. A25) about the failure of prosecutors to successfully prosecute New Orleans’ police officers thought to be culpable of gunning down innocent unarmed civilians on the Danziger Bridge in the aftermath of Hurricane Katrina. Criminologist Peter Scharf of Tulane University, addressing the prosecutorial bungling that occurred, is credited with saying: “You can’t solve what you don’t understand.”
Ray Barrow
amr I have not forgotten Dr. Bernstein's comments that follow the mantra that patients forfieting their right to modesty for the betterment of society is justified (my words not his), nor have I forgotten his argument that med students should not have to compromise their modesty to partcipate in thier own education and yet justifies the practice of allowing students to "watch" for the benefit of the med students education. I agree with none of this. I also take issue with Dr. Bernstein when he makes the issue about what I see as a fringe group who completely avoid medical care at the expense of their health. I counter that with the fact that providers could easily provide additional accomodation for patients in the form of colonoscopy shorts, surgery shorts, etc. BUT I also take exception with those who think providers are this group of eviel people who delight in inflicting pain on patients, or that patients should have only same gender for intimate care.
While there is a lot I disagree with Dr. Bernstein on, I do agree we have spent enough time establishing that there is a problem. While we may not agree what that problem is or what to do about it, to spend another 5-7 years pointing it out does nothing toward understanding and addressing it. That isn't to say we will not need to bring personal expericences and history to put context on things, but the turn this thread is taking toward trying to understand what is allowing this behavior to continue is a logical next step. I would counter Dr. Berstein's classifying some of this as moaning and groaning with classifying some of his positions as self serving justification by towing the industry's line.
But I also understand this is just my opinion, which is the product of my upbringing and life experiences and my poiint of perspective so it is just that, my view point. If I am expect Dr. Bernstein to understand and perhaps accept my view point I need to try understand his. The answer is not on one end or the other of the continuim it is somewhere in between.
the fact that this thread has turned to attempting to disect and understand is a positive. If you want to focus on the condemnation of providers and the system feel free to do so.
PT, Palerider, and all those who feel the thread should be shut down...wouldn't the logical answer for you be just stop coming here? You do have control of that....don
Don..and I agree with your last statement. In fact, I have almost 900 other topics on my blog that could receive some energetic input by the group here.
I also am encouraged to read Ray's conclusion "One thing I do know is that significant institutional change can only come about via organized collective action. To leave it up to individual patients to, for example, ask or demand that their privacy rights not be challenged whenever they visit hospitals won’t do the trick. I also know what the essential elements are for fostering social change be it at the group level, organizational level, institutional level, or societal level." That's exactly what I have been previously writing about the need for developing some formal advocacy group. I would look to Misty to move beyond writings on the internet with her website and move to actually directly, with the support of hundreds or hopefully thousands of followers to enter direct communication with hospitals, medical organizations, state medical boards and politicians to create the changes in the system that everyone here is waiting for. I will continue to do my part by seeing that the results of my participation the medical student education system, though limited in scope, is kept consistent with the patient issues described on this thread. So again, let's follow Ray's recommendation for "organized collective action" and the sooner that is started, the better. ..Maurice.
Don, specifically responding what you wrote " I have not forgotten Dr. Bernstein's comments that follow the mantra that patients forfieting their right to modesty for the betterment of society is justified (my words not his), nor have I forgotten his argument that med students should not have to compromise their modesty to partcipate in thier own education and yet justifies the practice of allowing students to "watch" for the benefit of the med students education."
I am not requiring that patients give up their modesty issues for medical student education. I believe and teach that patient modesty issues be considered by all students and the patient should be understanding about what parts of the physical examination is to be performed by the student and to have the patient's permission and attention be given to attend to their concerns. My opinion is that medical students simply watching a procedure performed by physicians on a partially undressed patient and with the patient's understanding (which in situations of which I have no control, I must assume was obtained) is acceptable. As I have previously written, students examining each other, partially undressed, also requires specific permission by the examined student. However,the modesty issue is more sensitive in these situations where students personally know each other and work together. In the prior situation the student is unknown to the patient. It is the policy not to compel students to be examined by a colleague if not desired. And, again, I repeat, it is the policy not to have a patient examined by a student without the patient's informed consent. I hope this clarifies the issue. ..Maurice.
amr – You write: “A few blog numbers back (59-60), we all experienced Dr. Bernstein very carefully justifying to all of us that he and his students “needs” trumpeted the needs of the patient. We haven’t moved him one iota in over 5 years of this blog. We are a bunch of outlier winning troublesome patients to “understand” and deal with in order to mainstream us. . . I’m basing my conclusions on the statements made on this blog. If Bernstein feels I have been wrongheaded about this, I invite him to use his own words on this blog to show us how I have wrongly interpreted his position. The point here is that Bernstein is the quintessential archetype of the professional view of medicine today. That leaves us with a generational fix to this. Meaning that the future generations of doctors must be sensitized to this issue. But that remains a problem, because Bernstein is teaching his students the hidden curriculum from the moment they enter med school.”
You may have a point there, amr. Regarding the “hidden curriculum,” let’s assume that Dr. B instructs his students sending the same formal messages to them as he does to us, such as his oft repeated instruction for us to “speak up” if we don’t want our sense of modesty unnecessarily compromised; that it is the patient’s responsibility to “speak up.” And let’s assume that the “we” he frequently uses when writing about what or how he teaches students refers to him and his colleagues who also teach. And, let’s assume that he and his colleagues communicate the same formal messages at the same rate to students, and thereby collectively and equally contribute to the hidden curriculum of the sort that you believe exists. These last two things must be assumed if one conceptualizes the hidden curriculum as referring to the aggregate of informally transmitted messages in schools as distinct from formal messages. It would sure impress me if, after I arrive back in town and have access to a computer, I saw a post from you that dispassionately uncovers what you believe is Dr. B’s contribution to a hidden curriculum. For example, does he contribute to a hidden curriculum if he tells students at the same rate that he tells us that it is the patient’s responsibility to “speak up”? If so, what is that hidden curriculum? And you might address which of his posts sends the message that, “We are a bunch of outlier winning [sic] troublesome patients to ‘understand’ and deal with in order to mainstream us.”
You suggest that Dr. Bernstein prove he is not contributing to a hidden curriculum. However, generally the burden of proof is on the affirmative given that one cannot “prove a negative.” It would be a challenge for anyone to provide evidence of a hidden curriculum. Personally, I find analyses designed to do this, to discover the gaps between formal and informal messages in organizations, makes for very interesting reading.
Ray Barrow
Dr. B – You write: “And, again, I repeat, it is the policy not to have a patient examined by a student without the patient's informed consent. I hope this clarifies the issue.” Informed consent at hospitals where I’ve recently been entails going before a clerical worker who has been instructed to hand patients a “Condition of Admission” form and to tell the patient that by signing the form they are giving permission to the physician to treat them. Hidden in a mass of verbiage on the back page is a statement to the effect, “I understand that medical, nursing, or allied health students may participate in my care.” This approach may satisfy legal requirements and the JCAHO but it certainly does not conform to ethical requirement of informed consent. I’d be laughed out of my profession were I to defend the ethics of doing such a thing before an internal review board. I don’t have time to argue the merit of my assertion, but I would like to know how consent is approached at the hospital or hospitals at which you have privileges.
Ray Barrow
I would like to say that "the hidden curriculum" to us teachers of first and second year students is that which is taught them in subsequent years and is not in conformity with what we are teaching and where we have no immediate awareness of what is being taught (particularly in terms of humanistic behavior) and have not direct control of any misbehavior. To us, that is the "hidden curriculum". Now, if one is concerned that all curriculum in medical education beginning from the first day of medical school is hidden from the public..all I can say is I hope not. Over a number of posts here and on my many other blog topics dealing with medical education, I have tried to describe what is being taught relative to the topic. So I am not trying to keep anything hidden including my description of our recent children's hospital surgical observation experience by my students and my attempts to find and understand how and whether family members were informed for permission.
For those who are interested in reading more about the "hidden curriculum" as is known to the medical profession, as I already said, just Google the expression. ..Maurice.
Ray, I am not aware that the hospitals which we use have any further written consent other than what you suggested. As for oral informed consent, when we participate we make sure that is occurring.
I can tell you that in no way does simply medical education trump attempt at effective patient care and patient comfort. For example, in one hospital we attend that has a cystic fibrosis ward, students are not allowed to interview patients until 9:30am since the patients in that ward "tend to awaken late." We should be starting at 8am but obviously attention is provided, in this case, more to patient comfort than routine student education. Students presence on a ward in no way delays scheduled tests,procedures, treatments, physician examinations and communication or nursing procedures. ..Maurice.
Dr. Berstein I evidently misunderstood your position. I took your comments to mean that students watching was acceptable and specific permission was not required, my apology. I do not think the medical industry as a whole follows that policy as evidenced by experiences such as those documented by Art Stump in My Angels Art Come. Likewise the manner in which the profession obtains permission is often part of that hidden cirriculum. From waiting until a patient is in a vulnerable position to ask or making consent part of the registration paperwork which can not be modifed, thereby making consent a condition of treatment,
To Ray's comments, if Dr. Bernstein teaches respecting patient modesty, but those that follow teach it is dispensible and an annoyance, my guess is the later lesson will be the one that sticks most often...don
Don, you wrote: " if Dr. Bernstein teaches respecting patient modesty, but those that follow teach it is dispensible and an annoyance, my guess is the later lesson will be the one that sticks most often"
I am not sure that students then interns/residents are taught that patient modesty is "dispensable" or "annoyance" as two concepts to always remember and follow. What happens, most likely, is that in the rush (and there is a "rush" in managing patients both in an office and on the hospital wards), the concern about patient modesty becomes a lesser issue to attend to when there are so many more issues and patients to diagnose and treat. A possible analogy (correct me if it is not): when firemen enter a burning building, I am sure the primary goal is first to find and get people out of the building. The expensive and important artwork on the walls at that moment is of lesser interest.
It is not that the firemen are ignoring the great artwork but in the conditions and time allowed, getting people out first is the most important action. ..Maurice.
Don
Maritime legend has an old saying, "rats
leaving a sinking ship." A well known phrase with
allegorical associations, often applied to human
situations,for example where people are abandoning
something before it's gets too bad. Apparently you
haven't noticed but the ship has already gone down.
Condemnation of providers and the entire
medical system, absolutely. Take a cue from the
black community, they didn't sit quietly to effect
change. I'm glad to hear Maurice and his medical
students allowed these hospitalized children to get
a little more sleep before rounding on them. Do
you think all hospitalized patients are given the
opportunity to get ample rest.
Most hospitalized patients suffer from
sleep deprivation. Excessive noise from the nursing
station coupled from this age old rules for patients
to get tests all night long only for the convenience
of the attending physicians when they make rounds
at 7 am. Sad truth is they don't even get to the
hospital till late morning,what's the point?
Sleep deprivation, strip naked for needless
tests by opposite gender which parallels experiments
by Dr Zimbardo and techniques later applied to our
own military and prisoners at Abu Ghraib. They even
made a movie about Dr. Zimbardo Stanford experiment that you could rent.
Ray Barrow mentioned an old lawsuit
brought against baptist medical center by the EEOC
regarding a male nurse who sought a nursing
position in the L&D department. Greg Backus was
denied this position by the courts and most notably
although this was never mentioned in court briefs,
his goal never was to work in L&D. The real goal
of the lawsuit was to increase awareness of the
inequities in gender care, appreciate the fact this
was over 30 years ago. It's well known that gender
bias is present as part of the hidden curriculum.
PT
Maurice,
The fire analogy is flawed. Patients who have serious modesty violations do not come out unscathed. They end up having serious medical and mental health issues (ptsd) as a result often.
That means you are putting medical issues before mental health issues. "To Do No Harm" must be part of the medical protocol. Right now it isn't.
Those patients you call "outliers" will one day trump patients who are compliant. I wouldn't want to work in a medical system that has to deal with that. So unless the medical community fixes their problem, they are setting themselves up for failure in the future to the benefit of no one and to the detriment of many.
belinda
Dr. Bernstein
I can understand how in the chaotic rush to get things done there will be times when a choice has to be made at that instance. What it does not explain is how then need at those times becomes the norm and how that turns into ignoring those things that could provide a little more comfort but not impede the provider. We have discussed and to a degree have some agreement that the modesty concerns in a ER may be different than on an office visit for a routine physical. I get that, but then what about things like the afore mentioned colonoscopy shorts? How does that impede the provider from meeting a crowded schedule? Is it the 1 second it would take to hand it over, the 15-20 seconds it would say "here are some shorts, if you want to use them the opening goes to the back. How much time would providing disposable shorts take for a patient having wrist surgery take. I think if modesty was being taught as a concern from a patients perspective and not for what fits a providers agenda these things would be common place or at least recognized. But they aren't so whether it be active or passive there has to be some sort of learning process that makes is acceptable to compromise the patients comfort. If the teaching was modesty is important, you need to attend to it unless you are forced to chose between taking care of the physical and modesty. Compromising should be on an as needed basis not a standard. Unfortunately it is in many cases the standard, it isn't compromised because we have to, it is compromised because we can.
PT I don't see the ship as sunk, I am here for my benefit and personally I am still learning and benefiting. I do believe Dr. Bernstein sees things differently than when this conversation started. Exactly what that means I can't tell you. I know I see things differently and it has changed how I deal with it which benefits me. If we can change the system that would be awesome, but at a min. it changed me and that helps me and that matters to me. Of if you feel the ship is sinking or down, by all means abandon ship, it is your choice to click the link that brings you here....don
Don, in current days, in most medical practice there is no slow normal as there existed in the pre-HMO, pre-Medicaid or Medicare eras. There are always more patients to see, interview, examine and perform procedures awaiting the doctor. This is not the 1930s, 1940s and 1950s of one hour office visits as examples.
I am not arguing that attention to patient modesty should be ignored in modern times but one can see that any diminution of accepted attention can be explained by attention to other aspects of medical practice.
I can't argue at all about the use or non-use of shorts for colonoscopy since I never have performed that procedure though, of course, I have performed many, many simple digital rectal exams on both genders, lasting a few seconds with uncovered buttocks.
As for PT, I hope he stays around since he appears well versed in the technicalities of medical practice within the hospital medical systems.
And to Belinda, after reading the comments on this thread, I certainly agree that patients who have "serious modesty violations" appear to definitely "not come out unscathed". However, what are "serious modesty violations" is really in the eye of the beholder.
And if the primary goal is to save the patient's life like a fireman going into that burning building to rescue an inhabitants, perhaps many more than one, other issues may be diminished in those firemen's eyes such that some inhabitants would want their properties within the building also saved. ..Maurice.
Maurice,
We have to disagree on this one.
It can be safely said that modesty violations happen quite regularly in healthcare due to a variety of reasons.
It can be safely said that those violations change the mindset of those people who use the medical system.
It can also be said that some of those people effected end up with a mental health disorder when there was none before.
You are right, though, that the severity of the violation is in the eye of the beholder. However, it could also be safely said that a violation that removes all dignity, privacy, perhaps involves the public (janitors, visitors, etc) does harm to the patient, sometimes irreparable harm, then that "fireman" needs to be trained to implement procedures to keep the public safe.
The mental health and preservation of dignity, privacy, the elimination of unnecessary humiliation needs to be taught and implemented in healthcare. As of today, it is not. There is no program going over "standard of care" practices that could be improved upon greatly without medical detriment to the patient. A little common sense, a little humanity.
What good is it to put out the fire and fix the body, when you have damaged the mind?
belinda
Dr. Bernstein with all due respect, I have never stuck my hand in a meat grinder but I can imagine I wouldn't like it. I fail to see how anyone can say simply providing a patient a pair of colonoscopy shorts, which are designed for that purpose, could possibly be a major issue for time or effort. Have you in your life had a colonoscopy, if so imagine being handed a pair of shorts and told you could use them, and how much time that would waste for a busy professional.
Now, another point, you walk into a busy McDonalds, the cashier says what do you want? Goes back and grabs your order, shoves it accross the counter and says please step aside..NEXT Their job is selling Big Mac's and they are busy would we excuse these minimum wage folks for not taking the time to take care of us how we deem properly, the burgers good, the fries were good, but the way it was presented was awful..would we be expected to just accept that because they are busy?....don
PT: Yes, I still keep up with most of this blog. I’ve been busy lately. I have been out of town some over the past few days. Feel free to email me anytime. I agree with you R Williams’ solution that patients who prefer same gender intimate care be required to pay extra is ridiculous. I think patients who want same gender care should simply leave a medical facility if they cannot honor their request and go to another facility. A local hospital in my community hardly has any male nurses. But a hospital about 20-25 minutes away has many more male nurses.
R Williams’ statement:
My point is that if a patient can request same-gender care with no cost to himself/herself, we are going to see a LOT of patients making that request and we're going to see a lot of costs being incurred as a result, even though many if not most of these patients don't really care that much about modesty. was very disturbing. This reminds me of the male urologist who came to this blog once and said he could not hire male nurses. I suspect that some urologists choose to not hire male nurses to save money which is a terrible excuse.
I did not like how R Williams thought the reason men did not want female nurses was because they were self-conscious about their genitals. There are so many other reasons why men simply do not want female intimate care. In fact, I have heard from a number of men who do not want female intimate care because they believe that their wife should be the only woman in the world to access and touch their private parts. Many men value their modesty.
Don: I agree with you about colonoscopy shorts. In fact, one man contacted me earlier this year after finding the article I wrote about modesty during colonoscopy. He was very concerned because he wanted an all-male team and colonoscopy shorts. I encouraged him to talk to the doctor and head nurse. They were very receptive to his wishes and worked out for him to have an all-male team and colonoscopy shorts. He said that the receptionist did not know anything about colonoscopy shorts. He also requested to not be sedated. He said he had a positive experience. I encourage you to check out this web page that shared that patients could wear boxer shorts backwards for colonoscopy.
Misty
R William I am 6' 175 and fit, I should not have to pay for the over wieght persons extra expenses, and my daughter should not have to pay for the old persons additional expenses, and those dang smokers, drinkers, motorcyle riders, sports people who get hurt, or how about those women who choose to get pregnant why should I have to help pay for the maternity wing I won't ever have a baby, my wife did. Changing a few things like encouraging more male nurses won't add that much cost.
A funny little coincidence, about 15 years ago I found myself on my knees in my front yard with a daugher in each arm, my wife standing behind me watching our house burn. I remember a lot about that night, but one of the most clear moments was watching a volunteer fireman I know emerge from a first floor window arms laden with the family pictures off the wall. While everyone once and awhile I question if there is some bs in some of these posts I assure you this is 100% true. Now if it were an absolute choice no doubt my family over what we felt were priceless pictures, hands down my family. But, the firemen were there to save lives, fight the fire, but they still cared enough to take the time to save the "art". It doesn't have to be either or and to often it becomes just an excuse not to when it could be done.
It appears to me that there is what I would term widespread medical arrogancy. I do not intend that to be mean spirited. But it seems our medical providers have given themselves liscence to suspend the rules that the rest of the world lives by. We are medical providers so your modesty disappears in our presence, if you don't agree there is something wrong with you or you just don't understand. This isn't about making the patient happy or comfortable, this is about us being healthcare providers and we just don't have time for this modesty nonesense. What other industry feels they can ignore a customers comfort because it gets in their way. Granted this is an extreme version but isn't that to a degree what is being said here? We are to busy saving lives to take time to attend to your modesty? I think that is engrained from the past where we felt in awe of the profession but I think we have an opportunity to start getting at least personal change if not systemetic. I live in a small town with a small town hospital, the competition for pateint is ramping up, there are two billboards in my little town advertising other hospitals. As Belinda stated, the solution is express your displeasure with your feel, it you won't accomodate let me find someone who will, and I will make sure to let the admin know why I went elsewhere...don
Misty
I looked at your website and I see you have
a site on facebook, that's great. Once the holidays
are over I have some ideas I would like to present
to you and others. Perhaps we can jump start the
process and additionally I have ideas on donations,
advertising as well as recruiting some free legal
help. I will stay focused on this and see what we
can accomplish.
PT
PT, go to it! This is exactly what I have been writing for years: form advocacy groups that extend beyond simply writing to a few individual blogs but eventually interacting directly with the important elements in the medical system that need change.
Unless I am greatly mistaken (and there really medical professionals reading here), I think writing to this blog thread is only "preaching to the chorus". Right?
..Maurice.
If, without stirring up too much anger in our patient modesty visitors here, might I refer to my blog thread from June 2012 titled "Munchausen by Internet: Should We Believe Everything Our Visitors Tell Us Here?" ..Maurice.
PT,
I look forward to hearing your ideas. I hope you can play a role in encouraging medical facilities to hire more male nurses, CNAs, and technicians to work with male patients. I have gotten a lot of sad emails from male patients who had bad experiences with female nurses.
I am sure you probably have seen some of the male modesty violation cases listed at http://patientmodesty.org/Case.aspx?GID=2.
Misty
What are the options? Should we trust the patient, the provider, the plumber? I think you take everything with a certain degree of doubt but either choose to go forward with a degree of trust or go forward with doubt in everything put forth, including the providers....I think you accept both sides at face value but with a critical eye. If we say we can;t trust posters here when there is no money on the table why would we trust providers when there is big money on the table> Don
The question was asked about providing same-sex intimate care, and some suggested that to do so would be too cumbersome and costly.
Well there's a township in New Jersey which thinks it is perfectly fine to restrict massage therapists to performing therapy on clients of the same sex.
But if the massage clinic is overseen by a physician, chiropractor, or physical therapist, the restriction does not apply. Hmmmm.......
Here's the link:
http://www.nj.com/ocean/index.ssf/2013/12/lacy_spa_illegally_allowed_massages_to_be_given_by_members_of_opposite_sex_authorities_say.html
Doctor Watchdog
Doctor Watchdog further evidence!
The link below out lines the unethical procedure carried out on women in vulnerable stressful medical setting.
“No doctor can opine in report whether rape took place not. Opinion must be evidence-based,” reads the documents.
The guidelines say procedure of medical examination is not only degrading but medically irrelevant. From now on the two finger test has been prohibited. It would be considered a breach of her privacy.
http://www.dnaindia.com/india/report-now-a-rape-victim-can-approach-doctor-for-a-medical-test-without-filing-fir-1940641
Pailrider...
Dr. Bernstein proposed an interesting an appropriate question when he asked if we could believe everything written here. After some additional thought on it I think the simple answer is no, not everything. Now what and how much becomes a little more complex. Now let me ask you this. Should you fully trust your provider? I would say the answer is no you should not. That goes not only for the physical care but I would add more to the point, to be honest with us about this topic of modesty. If we asked a group of providers, do you ever notice a patients genitalia and think "wow he has a big one or a small one" or "whoa look at the set on her" (sorry for the crudeness) how many would be honest and say yes I have if it were true? How many would own it and admit that is only natural, I am human? How many would say not really they are just like other body parts to me, it is clinical so it isn't like that, I have seen so many I don't even think about it. Now before we pull out the torches and pitch forks, would we really want to know if they did? Perhaps providers need to hide the truth for our own benefit. If we knew with any degree of certainty that they did think this way, or that they did absolutely talk about patients anatomy between themselves, would we ever feel any degree of comfort entering into a medical setting requiring exposure? While we have varying degrees of discomfort now, if providers admitted this would we be able to cope? I don't know where that leaves us, I personally do not believe they do not have different feelings and thoughts treating opposite gender and even different people of that gender. Does anyone here believe that a group of female nurses treating a nude Brad Pitt would have the same thoughts as treating a nude Danny Divitto? I don't believe it, I have read and heard to much with my own ears to believe it. Now I am going to admit, I don't know which causes me the most concern, knowing I am being "lied" to or being told point blank the truth, could we cope? Maybe we need to be lied to. Is this part of the self defense that allows providers to justify breeching our modesty but defending not doing so when it is their modesty as in the case of student nurses etc. not participating in their own education but expecting patients to? I believe using the excuse it is different because they work together is merely justification not a valid reason. But is it knowingly justifying or is it convincing ones self for their own benefit.
So I would ask again, should we trust our providers? If not, how then can we trust they are really concerned about our modesty for us and not for their benefit?
And to bring this to point, if so what do you do about it, is there any benefit to challenging providers to come clean if not with us, but with themselves so they can at a minimum acknowledge our concerns are legit if not understand them? To admit they are not above all these things means they must admit maybe they should do something different....don
Don, does it matter what the professional is thinking (about "sex" or getting home in time for a family meal) as long as the duties and professional behavior is in no way affected? If either the two classes of thoughts wrongly affects the attention and care of the patient, then it should be condemned. ..Maurice
If gender choice was offered, it would eliminate most modesty issues IMO.
Honestly how is modesty possible when the hunter sex chooses to treat female genitalia 24/7.
Pailrider
Oh I think it does Dr, Bernstein. One of the justifications for compromising the modesty of patients, especially in opposite gender is when one dons scrubs and holds a degree they are not the same as the person on the street. They are not sexualizing the patients so the patient should shed not only their clothes but their inhibitions that they hold so tightly to in every other segment of our society. I have never heard a provider own up to it and say yeah I am going to compare your penis or breast to other patients, yeah I am going to have lustful thoughts while I am examining you but hey it's medicine so you will just have to grin and bear/bare it. No they say they have somehow magically attained a different level of thinking-feeling that puts them above these things...so while the distraction may be similar, my naked anatomy is a whole lot more personal than the rump roast on your table...side note, interesting topic on Trisha Torrey about students and how they should or should not identify themselves in hospitals and Dr's offices....don
Don, you wrote "when one dons scrubs and holds a degree they are not the same as the person on the street" Perhaps doctors should follow the words of the Chinese philosopher Lao-Tau who wrote "to lead people, walk beside them". If the doctor is walking too far ahead, the doctor may miss what the patient is experiencing behind that doctor. ..Maurice.
Don,
I would say that while working as a CNA I have attained a different level of thinking and feeling when it comes to certain things. When I have to clean up a patient's BM, (which is often diarrhea and sometimes an especially noxious kind such as C Diff), I don't have the same disgusted reaction as I would have had before I got into healthcare. When I first started I was so focused on doing everything correctly and getting the job done that I didn't have time to think about it being gross. By the time I got into the swing of it I had become desensitized.
Likewise, when a trauma surgeon sees a patient who's intestines are falling out of his stomach, where a lot of people would faint at this site, the surgeon can deal with this without wincing.
We still have human reactions to these things, but they're very, very muffled.
It's been said on this blog many times that there is a certain amount of projection among healthcare providers: since we've become desensitized to these things we assume the patient has as well. The reverse is just as true: people here who've only been on the patient side often feel that since they are not desensitized in this situation that the healthcare provider must not be either, but to a limited extent, we are.
For what it's worth, I have an average amount of modesty, but my time working in healthcare has made me much less sensitive about it when I myself have to go to the doctor.
“does it matter what the professional is thinking (about "sex" or getting home in time for a family meal) as long as the duties and professional behavior is in no way affected? If either the two classes of thoughts wrongly affects the attention and care of the patient, then it should be condemned.”
This certainly matters for a committed Christian male doctor. The bible makes it clear that it is wrong for a man to have lustful thoughts toward a woman who he is not his wife. In fact, if he has lustful thoughts toward a woman, he has committed adultery. Jesus makes it clear that it is wrong for men to lust after women even if they don’t act on their thoughts. Jesus makes this bold statement: “But I tell you that anyone who looks at a woman lustfully has already committed adultery with her in his heart.” (Matthew 5:28) . Many medical professionals do not act on their thoughts. But it is wrong to have lustful thoughts. There is just no way that a medical professional especially male doctor can stay pure in thoughts when doing intimate examinations. It is very normal for a man to be aroused by a beautiful lady’s nude body.
Dr. Bernstein, I think the writings of Lao-Tau do have application here, I do think a certain amount of the issue is providers walk ahead. They seem to have a tendency to project a I know what's best, follow me and my advice and rules as we know what is best. There is little asking and mainly telling. I do agree that is part of problem but i have come to also agree patients are part of this by not speaking up and demanding. Providers have expanded the we know what is best for you physical being to knowing what is best for your physical and you just need to follow us (our instructions), there is little listening in that other than gathering medical history.
R. Williams, I can easily believe your comment, but desensitized and dead to or oblivious are two different things. From your earlier posts I think there is also a degree of "self rightousness" in the process. How dare you inconvience us, how dare you do require something that would cost us precious time. That perhaps is a little harsh but at the very least there is a tendency to justify actions that support the agenda of providers. Dr. Bernstein has stated in the past that context makes a difference in how we should view exposure, yet context doesn't seem to apply when it comes to students leaning on each other. I understand there is a degree of being desenstized over time, but I don;t think that is all of the story and it completely ignores the patient. i also understand and agree that part of it may be because it is no big deal to a provider the assume it is no big deal to patients. But there are many cases that have been discussed here where when the provider becomes the patient they have a different feeling. I don't disagree with your comments. Now i am going to ask you to be 100% honest, you have two patients that you are going to help shower, opposite gender, one is morbidly obese and unattractive, the other one of the best looking man/woman (i don't know your gender) you have seen. Can you honestly tell me that you have no difference in how you view their naked body?. And please be honest. 2nd question from your days of being a CNA have you ever heard nurses discussing patients anatomy in anything other than clinical terms or purpose. Again, I ask you to please be 100% honest... don
Now i am going to ask you to be 100% honest, you have two patients that you are going to help shower, opposite gender, one is morbidly obese and unattractive, the other one of the best looking man/woman (i don't know your gender) you have seen. Can you honestly tell me that you have no difference in how you view their naked body?. And please be honest.
I've only showered elderly patients so I can't speak from experience, but if I were to have to shower an attractive woman the main difference is that it would make me extremely nervous/anxious because the situation is more sexualized and I would be extremely self-conscious about not doing anything inappropriate. I cannot honestly say it makes no difference in how I view their naked body, but I can say that I would make extra effort to be respectful, focus on the work, and to not stare. These situations are a little nerve-wracking, partly because I'm a male and we're under greater suspicion, but also because I really am sensitive about these issues.
2nd question from your days of being a CNA have you ever heard nurses discussing patients anatomy in anything other than clinical terms or purpose. Again, I ask you to please be 100% honest
Yes, three times. There was one CNA I worked with who spoke about a male patient's anatomy in non-medical terms -- one because he was huge and once because he was small. She was unprofessional in general and was the most disliked CNA on the floor.
The third time, I myself kind of broached the subject. I had a patient who wanted to use a urinal (essentially he wanted to pee in a bottle). He was lying in bed. He couldn't move without a lot of pain. He insisted he could pee into a urinal, but I couldn't see how it could be done because of his anatomy -- his penis was completely recessed and for all practical purposes he just had a hole in his skin. With him lying on his back, I couldn't figure out any way to do this without the urine coming right back onto him, but he said he had done it before. I was a floater and this was a new patient to me, so I asked some co-workers who were more familiar with him about how this could be done. I didn't specifically bring up his size, but they knew what I was talking about and yes there was some giggling about it. I worked with one other male patient who had the same complete lack of "endowment" and I never heard anyone discuss it, even though he was a fairly obnoxious patient who had was there multiple times.
I've never heard anyone talk about a female patient's anatomy in non-medical terms.
A couple things to keep in mind: I worked predominantly on the rehab ward of a long-term care facility, and long-term care is not generally known to have the greatest level of professionalism when it comes to staff. The other thing is that during the two years I was at a rehab facility I worked with over a hundred nursing professionals and several times that number of patients. I would say the odds that any given male patient will have his anatomy talked about unprofessionally is less than one percent. I know this is probably hard to believe, but I've worked with people who had a complete lack of professionalism and respectfulness, but aside from the exceptions mentioned above, they never talked about patient anatomy in non-medical terms.
In prospecting there is an old saying " Gold is
where you find it.". That is also true about
unprofessionalism. I do not believe rehab and
long term care (LTC) facilities harbor a higher
incidence of unprofessionalism than any other
facility.
There will always be unprofessional comments
at every medical facility made about patients, I
do believe most of the unprofessional comments
made about patient genitals tend to be mentioned
and kept within same gender crowds.
State boards of nursing consider such talk
grounds for misconduct and license revocation
and it is for this reason such talk is kept among
those who trust other coworkers whereby such
shop talk is common.
PT
Thanks R Williams. I appreciate your honesty and am comfortable you were honest and am not surprised by your answer. Where I was going with this was the issue of trust. I have heard so many providers try to convince readers/patients there is nothing sexual about these encounters since it is clinical and we are all professionals so we never discuss these things. Others have taken the stance well we are only human so it is normal to talk like that but the patient doesn't know we are talking about them so no harm no foul. Then there is the it is just releasing stress which we need to do to handle our difficult job so again no harm no foul.
What I see is a failure to be honest about it, your answer as to what you feel would be your response for bathing an attractive woman is about as honest of an answer as I have heard. I just do not think you can de-sexualize the human mind. I think your term desensitize is more accurate over time but to claim a penis or vagina is no different to me than an arm when I am working is hard for most to believe so it creates a certain degree of "you are lying to me" in a patients mind. Same with talking about patients, there is no way it is ever right in that context. You cannot claim "professional priviledge" on one hand then claim we are only normal when it fits your need. These things make me feel you are being less than honest....BUT, and I hate to admit this, I question whether a certain degree of dishonesty in the current environment does not in someway serve the patient in the short term, but add to the problem long term. Does KNOWING providers talk about patients and there is a sexual element in the interaction help or hurt the patient. Does being able to lie to ourselves, even if deep down we feel differently enable us to get care we might avoid. Long term this lying facilitates the problem for us. By lying that it doesn't happen or exist providers can justify opposite gender, not making the maximum effort to accommodate modesty, etc so it is at the root of the problem...but at this juncture would we want to walk into a hospital knowing without a doubt, this happens. I don't know, I struggle to be honest with myself about that.....don
I thought my visitors here would be interested in what I have been doing recently.
I have been "spreading the word" to those around the world who are educators of medical students.
A listserv whose subscribers are those medical educators have been recently posting comments from them dealing with the tendency of professionals to examine patients through clothing or even less "laying on of hands" on physical exams. I, then, wrote the following posting:
"Anyone want to discuss physical examination in terms of physical modesty
issues of the patient and the concern and unease about that subject by the
medical students and later the physicians with regard to the current incomplete,
inadequate and perhaps hesitant performance of parts of the physical
examination? What has been discussed here with regard to various aspects of the
physical examination can be, in part, related to issues of patient physical
modesty both on the part of the patient but also with the concern of the examiner."
The very first response to my posting came as follows:
"I wish my teachers had helped me talk about and think about that. My patients
and I would have been the better for it."
Later, I wrote to the listserv the following:
"Beyond teaching 'knowledge and sensitivity' to patient modesty issues, there exists one action by the physician, which based on my own many years experience in practice, I have never performed nor do I think most doctors don't either. That action is to specifically ask a patient prior to any examination or procedure but after informing the patient was is going to occur: 'Do you have any personal modesty concerns about what is going to be done?' or something similar to that question. We always, hopefully, ourselves and expect from the students that we and they will fully inform the patient specifically about what is to be done and then await permission to proceed, but what I and we don't usually do is to specifically ask about the patient's modesty concerns. In fact, I have never asked that specific question but also I have never received instructions about modesty by the patient before the exam nor have I ever received comments by the patient after the exam, I have always felt my simple informed consent was sufficient and patients seem to be relatively free of significant modesty issues when faced with the need for medical evaluation of symptoms. Yet, despite absence of patients 'speaking up' about their modesty, this has always been in the back of my mind. Do you think my experience and actions are that of a statistical outlier in the practice of medicine? The question I pose here is: should I teach my first and second year medical students to ask their patients that specific question before an exam: 'Do you have any personal modesty concerns about what is going to be done?' and then if concerns are expressed to actively attempt to mitigate them? "
I now await a response.
And now, what are you doing to change the system? ..Maurice.
On a side note, I have to agree with PT, from my experience while the staff at "nursing homes" may be less professional in terms of degrees and titles which translates into training, I have heard first hand enough from "professionals" especially nurses to feel it still exists and has been defended by "professionals". The other side of that, I think the sexualized part of viewing a patient would be much more prevalent in the hospital setting where a larger portion are not elderly. Society has deemed older people to be for the most part "unattractive" so we don't look at them as sexual beings in normal life. Two females, 5' 6", 120lbs, well kept, both considered attractive for their age, one is 85 the other 25 how many would consider the 85 year old as a sexual being much less equal to the 25 year old. So have to agree the staff might be less professional, but the element of sexualizing them is also much less. Speaking for myself I was also taught to have more compassion and patience for older people, so not sure we have an apples for apples comparison so we have to do a little extrapolation here but I tend to see PT's point. And I have to agree with him that we tend to keep our inappropriate comments within our own gender. Wow PT, I had to agree with you twice in one post....don
Don, I think I might have an answer for that... I was hospitalized several times on a short lapse of time (something I now regret). To cut it short, when I checked in, (last time, I couldn´t take it any longer), as soon as the nurses laid eyes on me (I was surgical patient) they congratulated me on a quite dark tan I had and wanted me to tell them all about how I got it. was it a sunbed? Fake tans? Did I sunbathe). Three more came, and soon I was surrounded by a crowd of five! Actually it was kind of embarrassing and it added to my uneasiness to the whole situation.
I just can't believe they are so professional they don't even notice anything. Otherwise, why were they so focused on that one thing, to the exclusion of the rest, including pertinent medical questions that should¨ve been asked? An icebreaker? Give me a break!
For Dr. Bernstein, the nosy questions were completely unrelated to the reasons for my surgery and hospitalization. It was gossip, not medical information. I can swear that truly happened to me. What conclusions can be drawn from those experiences, I don0t know.
That is outstanding Dr. Bernstein. I am guessing you will get an answer that follows the current protocol that asking patients on the front end is not needed. I think the best way to gather information would be a simple ask on the intake, but it would have to be done in a manner that wasn't asked to get a predetermined response, a simple Do you have any paticular modesty requests or is there anything we can do to make your care more comfortable might get a more honest response than asking while you are sitting there on a table. An exit questionaire might provide another alternative if they could fill out and return. As I indicated before I know I did covered my extreme discomfort well. I applaud you for asking
I also think the vast majority of the issue isn't with our chosen provider. If we choose a provider we are likely more comfortable with them on the front end. I am guessing the majority of the issue comes from the support team or in situations where the provider is chosen by someone esle or assigned without the patient's choice. So the discomfort with you personally might not have been as much a concern as in other cases.
I don't know your area of practice. Were patients assigned to you or do/did they choose you?..It would be interesting to have people on the thread guess the answers you will recieve and compare to what you recieve..don
Maria
Sorry that happened to you, inappropriate
line of questiioning should have been reserved
for relevant questioning regarding your current
health status. You were some what ambushed
in that regards in what was meant to be routine
Pre-op questions turned out to be attention
being drawn to your body unrelated to why
you were there.
PT
Maurice, Thanks for putting yourself "out there". It's exactly what's needed.
Do not make the mistake that the only motivation for invading someone's privacy has to do with the attractiveness of the patient.
There are those out there who are interested in other motivations like instilling fear of humiliation in the elderly to gain cooperation and compliance, deviance, etc.
Elder abuse and other institutional abuse has already been researched and there are government agencies designed to protect those who can't protect themselves.
Does it matter what the practitioner is thinking if they show no response? Depends. If the patient fears being ridiculed for whatever reason, it would only instill less confidence in the provider if they are wearing a mask because then you don't know.
Patient consent forms should address what state of dress is required for a specific procedure, who will be in the room and what to expect of everything else. Anything short of that is deceptive.
Once this has changed, patients will at least be on an equal level understanding whats going to happen. Then, it's up to the patient to consent or not.
The idea that focuses on the patient being the problem because they may have modesty concerns is ridiculous. Everyone except for a very few have modesty concerns. It's in our psycho social cultural expectations and is everywhere from our fitting rooms, restrooms, gym locker rooms. The focus needs to be on the healthcare system and why they find this gender neutral mindset acceptable.
Let's see how fast the employees of such hospital would have no modesty issues if treatment needed.
belinda
To Belinda's point and to one you have addressed several times Dr. Berstein, there is a focus on informed consent. Years ago before I even knew this thread existed I needed some elective surgery. The particular procedure required exposure and is embarrassing. I met with a specialist who said I needed the surgery and scheduled it. I got to thinking about it and emailed the specialist office and told them I wanted to know what to expect, could they send me information. I got a sheet that looked like something they did on a memograph machine like we got in 4th grade that everyone smelled...it was a drawing of the anatomy with a description of the ailment and surgery options. I thought they misunderstood so I emailed back and told them no I wanted to know what was going to happen to me, what the process was that I could expect, and what the day of surgery would be like. I got a response back saying you were provided with preparation instructions which should answer your questions but we are resending. Of course it was the usual no food or drink after midnight, no medication, no body lotion or perfumes, etc. I emailed again saying no I want to know what I can expect to be done or required to be done. I got a 3rd response saying report through door 3, report to this desk, go to blah blah blah, nothing about what they were going to do to me, nothing about the anesthia, who, what, anything specific about the procedure. On the day of I was sitting there in my little open backed mini skirt and the nurse comes in, I need you to sign these consent forms, this is this, that, privacy notice (that's a ironic twist isn't it, they are more concerned about our records privacy than ours), and then the "and this one gives permission to film it"...I was stunned and it must have shown as I froze for a minute and she said oh it's nothing to worry about they rarely do it and it's just for review if there is a problem even if they did film it no one would probably look at it unless there is a problem. I remember numbly signing it still in shock. So I really don't feel I had informed consent, just consent. To Belinda's point had I received this earlier I could have been on a more level playing field to make informed consent. Really, given the procedures are often standard, would it not be reasonable to be provided a copy that says this is what to expect, you will be escorted back to an pre-op room, the nurse will ask you to sign the enclosed forms, you will be asked to change into a hospital gown, you the have the following things done in preparation for your surgery, at some point you will be visited by the circulating nurse and meet your anestheologist etc. In today's world creating this one time and updating it would be so helpful and would go a long way to achieving INFORMED consent. I have to question how much of it is lack of effort and how much of it is intentionally keeping the patient in the dark ...don
My wife had infertillity issues and the journey to get state funded IVF treatment was shocking. It was like she had to earn her right to IVF by exposing herself to many male doctors, repeated investigations and humilliating sexual remarks. She had multiple similar investigations by different doctors who didn't communicate with each other with regards to their findings. All I can say about the whole journey is sexually shocking!
rega
Rega,
I am so sorry to hear about your wife's bad experiences. I encourage you to contact us at Medical Patient Modesty. We receive a lot of modesty violation cases.
Misty
Can someone explain how this could happen after medical training and years penetrating female genitalia, they say arousal isn't possible after doing this job daily. Anyone care to explain this to the modest people of the planet.
A COFFS Harbour gynaecologist who had sex with vulnerable patients has been banned from practising medicine for at least three years.
The NSW Medical Tribunal heard a "lack of foresight" and problems at home led Dr Michael McKay to make friends with and romance two of the women he was treating and counselling.
He admitted to the health watchdog that in January 2002, he had struck up a relationship with a female patient, accepted "emotional support" in regard to his marriage problems and told her he was having "intimate feelings" towards her.
http://www.coffscoastadvocate.com.au/news/doctor-banned-after-having-sex-with-patients/2127459/
Pailrider
Pallrider, It can be explained very easily. The medical community is just a cross section of the rest of the population. We are all "colored" by our experience, and also by other emotional experiences along the way both positive and negative.
The real question is...Is this person mentally ill? Is any sexual predator mentally ill? Probably not because most know they are doing something wrong. Just because someone is a doctor doesn't mean they aren't part of the human race with all the other "sickies" on the planet. They come in all backgrounds, and yes, genders too.
The medical community needs to do a better job as I've said many times regarding background checks, keeping detailed records of misconduct and of course, prosecuting those who abuse patients to the fullest extent of the law, including losing their license.
Someone who can't control their impulses won't be stopped no matter what because they have an addiction. The best we can do is get them out of the medical system.
belinda
The question Belinda is,do you feel sexual preditors or sexual offenders what ever you want to call them are the norm or the exeception. I Personally believe they are rare and the exception. I do not think they are a significant number. If we seperate the ones whom we feel violate or modesty either intentionally or in ignorance...what percent of providers do you think are molestors, preditors, what ever,,,,,,,,,,,don
Don,
At first glance, I would agree with you. I do feel that actual sexual predators are in a vast minority.
The problem is that the opportunity for sexual impropriety is great and is not rare at all. It is often disguised. Many years ago I was subjected to extremely cruel, degrading treatment that involved both male and female employees, doctors and a system who defended the behavior.
There was also sexual abuse involved.
Since that time, I have used myself as my own guinea pig watching the behaviors and stopping them when needed. Sometimes, it is almost comical to watch how a routine ultra sound on a ten week pregnancy turned into an experience with a male technician who instructed me to get completely undressed and put a gown on open in the front. No blanket was offered. When confronted by the male technician when I didn't cooperate and removed my clothing, yelled at me. What did I do? I yelled back and said, "When you can tell me that my bra has to be off for you to do an ultrasound on a ten week pregnancy, I'll think about it". He was absolutely furious. There have been other instances.
I wouldn't consider this abuse, but sexual impropriety that is all too convenient, common, under-reported.
I could give dozens more examples that happened to me, however, I think I made my point.
One of the remedies as mentioned in the article entitled "Naked" (that has been discussed on this blog before), would be to have written protocols on what state of undress is expected for routine testing. It takes away the opportunity and patients know what to look for.
If I had not known what to look for, I might not have realized that impropriety was happening.
For those of us who have been ill, see it, recognize it, know how to stop it. Because, I'm nobody special, can this only be happening to me? Absolutely not.
The health psychologist I work with sees these kinds of behaviors all the time. So do patients like me.
We are human beings. Human beings love to see naked people I'm not sure why but it must be in our nature. It's not always sexual, but rather a curiosity of the forbidden or something. The people who work in medicine are just like the rest of us, human beings. I do believe they take advantage of a situation and because they are dealing with patients who are ill, those that participate in this behavior should be fired.
If being fired was the known outcome of such behaviors, it wouldn't happen as often.
Talk to friends and relatives who work in healthcare. Bring up this subject. You will be surprised and hear dozens of stories. So...I hope I answered your question Don.
This is more than an opinion, it's been more than a thirty year experience with the healthcare system.
The behaviors erode trust, exploit the vulnerable. The behavior is unprofessional and for those who support the employees who inflict embarrassment on sick patients are causing psychological harm to those patients, invalidating their experiences.
Worker who are inappropriate should be singled out and put on a medical registry; just like a sexual predator; never to work in healthcare again.
belinda
While editing my last post, it appears that I did remove my clothing. Just to clarify, I did not and that's when I got yelled at.
I thought his head was going to explode when I yelled back. Red faced and silent, he completed my test.
belinda
I have a question for everyone here (this might have been brought up on this blog before and if so, forgive me):
If your care team were made up entirely of homosexuals, would still prefer same-gender care?
I am a male and I personally would prefer a gay man to a lesbian, but I'm curious to see what others here have to say.
R Williams,
My wife and I actually recently discussed the fact of a homosexual provider.
She wanted to know if I would be willing to let her see a male provider if he was gay.
My personal thoughts are that I would still prefer her to see a female, even if she was a lesbian.
Belinda, I do understand. I brought up the issue before that if we do not share a common definition we have a hard time conversing. If you consider violation of modesty abuse, but I consider abuse a physical touching for gratuitous reasons or intentionally inflicting emsotional or physical pain, the discussion gets difficult. I think the motivation for intentionally ignoring providing modesty accomodation comes from many sources. I do agee that i still feel some do enjoy seeing naked people for various reasons, some for control or power, some are voyeristic and sexual, some don't care, some may not truly realize the depth of the concern, and some may really enjoy inflicting discomfort.
R Williams, personally i would choose a gay male anytime. i have said before, I am not under the allusion that some female nurse is going to look at my 58 year old body and go wooo hooo look at that,I'd like to get some of that....the discomfort is mine as it goes back to my upbringing that I have been told from a very young age it is wrong to expose yourself to women, you should be ashamed of yourself for doing so. We are segregated from early on not by sexual orientation but by gender. To propose that all that integrated training disappears when we walk into a medical facility, that we don;t see the female who put on her make up, sometimes jewelry, and all the things women do as opposite gender nust because she wears scrubs is ridicoulous. I have seen more than one provider say things like "I love being able to put my make up on and feel like a pretty woman and a nurse. Gender is one of the very first and basic things we use to identifyo ourselves. So yes I would feel more comfortable with a gay male than a female.
I find providers like to fluctuate between gender nuetral and male/female depending on their need at the time. How many have heard, I am not a male or a female nurse, I am a nurse, yet they don;t see themselves that way. ....don
For those interested in the subject recently brought up on this thread, I have a number of interesting responses to a thread I created in August 2010 titled "Would You Accept a Gay or Lesbian Physician as Your Doctor". ..Maurice.
Maurice,
I posted something late last night that I'm hoping will show up this a.m.
And...I just read the articles on "Would you accept a Gay or Lesbian Physician". i think the question posed is different from your question.
I would not care about the sexual orientation of a provider even if I requested same gender are and found out everyone was gay.
i would still refuse the male caregiver for intimate care because just it's not about the provider, it's about me and what makes me feel comfortable.
Just like those days long ago when I accepted male care for everything and never gave it a thought, i would accept care from someone of my gender who is gay (though sometimes it's hard to tell what someone's orientation is).
Al those gay females have the same parts I do, they make me feel less likely to feel humiliated by bodily exposure and definitely wouldn't make me feel degraded unless there was something wrong with the conduct. Male caregivers make me feel like I'm giving up my right to privacy and dignity regardless of their orientation.
So, for me, gay has nothing to do with anything and I accept everyone's right to be who they are, but I still want my privacy and dignity and won't feel I have it with male providers in intimate situations.
belinda
With regards to the "gay/lesbian" I believe that same gender intimate examinations is the safest option. I would mind a lesbian woman examining my wife in an intimate way, however I could not feel ok about a male intimately examining my wife, even if he were homosexual. Men are visually sexually stimulated, I believe that even a homosexual male would be excited if confronted with the naked genitalia of an attractive woman.
OK, so... do you think that male porn stars get bored of vagina? After all, they are exposed to female genitalia regularly just like the Male Gynecologist. If male porn stars do get bored, then how do they reach orgasm? I'm sure men can't fake that part!
The truth is actually the opposite... visual sexual stimulation is actually addictive to male human beings, like 'drugs', the more they see, the more they want to see. That's 1000's of years of mother nature's evolution that's seen to that rule.
I think we all need to do a little research on human sexual psychology. Arousal is an issue within Med-Schools here in the UK, male doctors are trained to "hide it" rather than try to "repress it", as that's known to be almost impossible for a male to do.
And... if ladies 'loose their sexual appeal' then how does the Male OB/GYN doctor create a family with his Wife?
A woman is more emotionally sexually aroused (by love etc) whereas a man is easily visually aroused.
Women make better gynecologists, women have always took care of each other in that way up until the last decade or so. It was a male gynecologist who invented the vibrator which was actually used to 'treat' women within the doctor's office, bringing them to orgasm. I can't imaging any female gynecologist inventing such a 'tool' to 'treat' men during visits to their female doctor.
Men can be extremely manipulative and very clever at taking advantage of the 'power imbalance' within the doctor/patient relationship.'Good' doctors also become VERY good at concealing sexual arousal.
Even if some Male gynecologists are professional... no one, YOU or ME, can really know, for sure, a male doctor's thought processes when a completely healthy, fit, perfect body, gorgeous woman walks into his office, in a pretty dress for a pelvic/breast examination... then exposes her inner thighs, her sexy butt cheeks, her (sometimes) wet vagina and her beautifully formed breasts tipped with perfect nipples to his command. I personally (even if I were a completely trained professional), can't help but think I would be VERY aware of the 'sexual beauty' before my eyes.
PART 1...
I know people who actually know male gynecologists personally as friends or family members. Male gynecologists sometimes confess things to people close to them, in social situations, or when drunk.
They sometimes says things like, "it's a real buzz examining young teenage women" and things like, "You should have seen the breasts on the one I saw to today!" and things like, "I couldn't believe how wet and excited she was!" and things like, "wow, I couldn't believe the swelling of her clitoris!" and things like, "her cute little 'box' was perfect, just like a mouse's ear passage", need I go on?
This IS how male gynecologists sometimes talk to people that they completely trust (fact). How does this make you feel ladies?
How does this make you feel after they've fooled you by acting completely 'professional' in front of you?
Don't you feel a little deceived? Some of you may like this kind of 'banter', but that makes you no better than the Husband who secretly visits a prostitute.
You can 'Google search' and read for yourself the long list of dishonorable male doctors who have been rightly exposed! I feel that women have been brainwashed into thinking that male gynecologists are 'too professional' to get sexual pleasure from intimate examinations!?
Any man knows that the body of an attractive woman is going to turn a man on sexually, doctor or no doctor.
People don't usually just do things for other people... People are naturally selfish. The main reason that people actually choose go into a certain profession is often subconsciously related.
"A woman who was once bullied by her brother became a pediatric nurse. Why? What do nurses give to children all day? Shots! (injections). She gets to see young boys cry all day!"
Besides all the 'spoof' that people often 'splurt' out in order to make themselves look good in front of other people, they often do things only for 'self-serving' reasons.
Why would a male take OB/GYN? Of course they average $200,000 annual income, but you can't remove the fact that despite all those 'honourable' reasons, a male gynecologist may well have picked OB/GYN for the fact that he gets to do intimate things to many women without out all the dating rigmarole and expense.
It's easy to overlook that fact that Gynecologists are 'biological beings'. It's easy to overlook the fact that their choice to become an OB/GYN could be sexually motivated. To overlook these definite possibilities, is voluntary blindness!
However, career choice reasons set aside... those who practice OB/GYN successfully, are often VERY professional in their mannerism (good at hiding their true feelings and motives). Doctors are taught and instructed to keep these natural feelings to themselves through med-school.
It's complete nonsense when male doctors say that they don't find any sexual gratification from seeing an attractive woman naked! This goes completely against the nature of man!
PART 2...
Many women will not believe not hear anything negative said about male gynecologists no matter how 'logical' argument, this is because most women's reasoning is 'primarily emotional'. Only a logical thinking woman will understand my case here and they already tend to keep well away from male doctors!
Go ahead and research the 'female clitoris'... you will soon discover that stimulation of the clitoris is virtually guaranteed during a gynelogical exam. As a result, vaginal lubrication begins to flow, this is the start of sexual arousal! Some women even say that they've had orgasms during such an examination and that they couldn't help it!
As for the male OB/GYN... his male genetic make-up is naturally programmed to respond to female pheromones (natural hormonal scent given off by the vagina) and he is getting a faceful of this during an intimate examination no matter how 'detached' or 'desensitized' he is.
The programming deep within his genes does not automatically shut off during an intimate examination! And if he were somehow 'desensitized', then he'll probably have a VERY unhappy wife or girlfriend at home!
Of the 2 basic instincts, men have - survival and reproduction - the female patient's reaction, as well as the male OB/GYN's reaction, are naturally governed to this basic reproduction level no matter what the veneers of present-day society, past society, attempts to explain, rationalizations and justifications are used to wrap the realities an intimate examination situation.
In my opinion, women who choose male gynecologists are as much to blame, especially if they are in a 'committed' relationship, or even worse... if they are Married!
I find it extremely repellent how male doctors tend to manipulate women into having these intrusive examinations, however that doesn't excuse the fact that many women deliberately go to these male doctors knowing full-well how much it hurts their Husbands!
I think about 90% of the blame rests on the medical industry. Women were raised to believe that male doctors can do anything, since they are 'experts' of the human body. This is a HUGE cultural blind spot! My Mother went to a male gynecologist for many years, I started questioning her when I was about 8 - 10 years. It made no sense to me how it was okay for a grown woman to disrobe in front of a male doctor to whom she wasn't married. My Mother used to ignore my concerns. But when I grew up, she listened to me. She has not gone to a male gynecologist for over 13 years now. She told me she no longer believes that any man (including male gynecologists) can stay 'pure in thought' when they're confronted with naked women.
The medical industry uses scare tactics to encourage women into intimidating examinations. Most women who go to a male gynecologist hold their breath and go 'in the name of medicine'. They don't even think about how it could affect their relationships and Marriages. Most women assume that male gynecologists are professionals who can turn off their sexual feelings within a medical settings, which is just not true.
I find the whole thing mentally and emotionally tormenting.
I have read and heard with my own ears enough to know this is not an issue limited to the male gender. While historically we pin the visual stimulation and preoccupation with sex on males, more recent studies indicate the gap is very narrow and more from feeling free to be honest about the subject than a material difference. The issue then becomes providers are damned it they do, and damned if they don't admit this. If they own up patients may avoid them, if they deny patients might not believe them and damage trust anyway. The bigger issue I have is denying it facilitates the failure to address it, and that truly is gender neutral, both genders are guilty of it, and both genders suffer because of it....don
Anonymous at 3:04 AM today made good points that men are visually stimulated. A homosexual man does not take “man” out of him. In fact, I believe that one of my sister’s friends who is gay enjoys seeing pictures of naked women. I personally think that there is no difference between a homosexual and a heterosexual male gynecologist. Both are men. I am sure that many men who are uncomfortable with female intimate care would not feel any different about lesbian female urologists or nurses. You just cannot change the gender of a homosexual person.
Anonymous at 5:18 PM: I really cannot see your point about a woman becoming a pediatric nurse because she was bullied by her brother. I see no connection between this to a male gynecologist or patient modesty.
You made some good points about male gynecologists. Male gynecologists do make a lot of money, but why would they choose OB/GYN where they get to examine and see private parts of women instead of other specialties. There are plenty of other specialties that men can choose from if they want to become a doctor. You are right that it is normal for a man to be visually stimulated when he sees attractive naked women.
Medical Patient Modesty has received a number of cases from women (especially young) who were abused by male doctors during intimate examinations. This is exactly why we advise women to avoid male doctors for intimate examinations.
I personally disagree with you that many women have become sexually aroused during exams. The truth is many women find those gynecological examinations uncomfortable or painful. I am sure that some women have indeed become aroused. Many women go to the gynecologist because they are worried about their health.
It looks like you quoted exactly what I said on another forum somewhere a few years ago:
Women were raised to believe that male doctors can do anything, since they are 'experts' of the human body. This is a HUGE cultural blind spot! My Mother went to a male gynecologist for many years, I started questioning her when I was about 8 - 10 years. It made no sense to me how it was okay for a grown woman to disrobe in front of a male doctor to whom she wasn't married. My Mother used to ignore my concerns. But when I grew up, she listened to me. She has not gone to a male gynecologist for over 13 years now. She told me she no longer believes that any man (including male gynecologists) can stay 'pure in thought' when they're confronted with naked women.
In the future, you should share that you found this paragraph from another person and source rather than claiming that it is from you.
Misty
NOTICE: AS OF TODAY JANUARY 3, 2014 "PATIENT MODESTY: VOLUME 61" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 62
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