Patient Modesty: Volume 64
In this and the following Volumes, there is no need to go
into more detail (and I will not allow that to be published here!) about
"unprofessional behavior" if it amounts to describing prurient sexual
interest and acts or frank sexual crimes by professionals. This behavior is
clearly wrong for a physician or nurse behavior and requires notification of
state professional boards in the United States and law enforcement as
necessary. That is the solution for that behavior. To educate the patient to
ask their provider "are you planning to manipulate my breast or genitals
for your own pleasure or do you intend to rape me?" are ridiculous
questions to ask at each medical exam or procedure. The way to feel confident in
the behavior of the doctor you plan to visit is by getting recommendations from
friends and neighbors and by visiting the state board website to see if there
are any "bad marks" for that doctor. Also, if the patient can have
the opportunity and afford (it certainly may be worth the expense) an
introductory visit to talk with the doctor about his or her experiences and
views (including religious) and at the start tell the doctor how you want to be
treated in terms of your modesty issues but also in other regards. I am sure
most patients will be able to size up this doctor and the doctor's environment
and enter for an examination at another time with more confidence that the
doctor has been "made aware".
What I want is this and the next Volumes to be directed to is listing specific issues to educate and attempt to change the behaviors of the medical system to make the system aware of the need to incorporate programs of attention, mitigation or resolution of issues of patient modesty beyond current concerns about medical mistakes, preventable risks, patients' medical record privacy, ways to pay for patients' medical care and so on.
How do we do this beyond the one on one conversation with a doctor, nurse or medical tech? It is all this that we have to discuss. And where do we start? I believe I have previously mentioned for the United States: the Joint Commission that sets standards for patient care in hospitals and a hospital not passing the regular detailed surveys: no governmental Medicare or Medicaid payments.
In the next Volumes, instead of tearing down the medical system with accusations (and many may well be valid), let's go ahead and progress to "doing something" to meet the requirements for meeting the ethical principles of "justice", "beneficence", "autonomy" and finally "non-malificence" for all patients of either gender and their own degrees of physical modesty. ..Maurice.
Graphic: From Google Images and modified by me with ArtRage and Picasa3
What I want is this and the next Volumes to be directed to is listing specific issues to educate and attempt to change the behaviors of the medical system to make the system aware of the need to incorporate programs of attention, mitigation or resolution of issues of patient modesty beyond current concerns about medical mistakes, preventable risks, patients' medical record privacy, ways to pay for patients' medical care and so on.
How do we do this beyond the one on one conversation with a doctor, nurse or medical tech? It is all this that we have to discuss. And where do we start? I believe I have previously mentioned for the United States: the Joint Commission that sets standards for patient care in hospitals and a hospital not passing the regular detailed surveys: no governmental Medicare or Medicaid payments.
In the next Volumes, instead of tearing down the medical system with accusations (and many may well be valid), let's go ahead and progress to "doing something" to meet the requirements for meeting the ethical principles of "justice", "beneficence", "autonomy" and finally "non-malificence" for all patients of either gender and their own degrees of physical modesty. ..Maurice.
Graphic: From Google Images and modified by me with ArtRage and Picasa3
NOTICE: AS OF TODAY APRIL 15 2014 "PATIENT MODESTY:
VOLUME 64 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING
COMMENTS ON VOLUME 65.
posted by Maurice Bernstein, M.D. @ 9:30:00 PM
176 comments
176 Comments:
Maurice
Actually, in my case the physicians have
nothing to do with my level of dissatisfaction
nor their lack of trust. It's the nursing staff who
I am concerned about.
PT
PT, I think the goal of this Volume and the ones in the future is to attend to patient modesty and gender selection issues related to all in the healthcare profession and that means, of either gender, doctors and techs and as well as nurses and importantly also the administrators who run the system. ..Maurice.
I would like to put a challenge out there. There are a core group of posters here. I would challenge each of us within the next 30 days to something, anything that involves interaction with a provider that generates benefit or a point of discussion. I could be as simple as sending an email asking if they have both genders of nurses, if they have the ability to provide both genders for imaging, write a letter to the editor etc. Do one thing to create a ripple in the provider community and report it here....don.
I encourage you all to check out this article about how some nurses helped to scrap the “no underwear” policy for surgeries at
http://www.kellogg.northwestern.edu/course/opns430/modules/operations_strategy/nurses.pdf. I have done some research and I have found out that some hospitals allow patients to wear underwear as long as they are 100% cotton. This is encouraging because there is no reason for a patient to be required to remove her/his underwear for many surgeries that do not involve the genitals.
I was particularly encouraged by this paragraph in this article:
SOME PATIENTS were especially bothered to spend half the day without underwear -- for shoulder surgery, say. Ms. Lelis
was convinced this longstanding practice was meaningless as a guard against infection, persisting only as the legacy of a
culture that deprived patients of control. "If you're practically naked on a stretcher on your back," she says, "you're pretty
subservient." The nurses persuaded an infection-control committee to scrap the no-underwear policy unless the data
exposed a problem; they have not.
It’s encouraging there are some nurses who are sensitive to patient modesty. There are still many hospitals that have this ridiculous policy that underwear should be removed for all surgeries. I think we all should consider encouraging local hospitals if they have this policy to change their policy.
Misty
Don, I agree with your proposal. However, our visitors should not include the name or identification of the provider for that report to be published. Thanks. ..Maurice.
Reading the description of this volume - that's not it at all.
Women are taught to see their bodies as objects. They are there for other people's viewing pleasure and sexual pleasure. Women who "don't mind" pelvic exams tend to say that they detach themselves from their bodies during the exam as a coping strategy. They are objectifying their bodies: Seeing as an object, not as themselves.
Ideas from the video I posted: If sex sold, we'd see naked men in advertising. Instead, men are sold sexualized, objectified women. Women are also sold on sexualized, objectified women reinforcing the idea that they should see their bodies as objects that others consume.
Having someone put fingers in your vagina is a sexual experience. Putting my fingers in someone else's vagina is a sexual experience. It's a coping strategy to avoid that: This is not a person. This is just an object. This is a mechanic working on a car doing an oil change. It's not sexual.
Male patients haven't been socially conditioned to view their bodies as objects. That's why so many men avoid medical care. They just can't separate their body from themselves. And they shouldn't! Your body is a part of who you are.
That is one reason why medical personnel can be so careless during an exam. They have to switch to "mechanic" mode. Mechanics don't need to talk to a car, or ask it permission to touch it, or explain what they are going to do. They just do it. And many doctors and techs act that way toward PEOPLE. When I've suggested that patients should get an EXPLANATION and then be verbally ASKED PERMISSION before being touched, I'm told that if a women goes to a gynecologist she should expect to be examined and the gynecologist shouldn't have to ask the patients permission for anything. This from a doctor.
This isn't about questioning INTENT. It's about EFFECT. It's about respecting reality and not denying it.
-RJ
RJ, if what you write is a major factor in the patient physical modesty issue, then what can be done to educate patients and to educate the medical system so that patients will still be able to attain the best diagnostic workup for their symptoms and the best treatment. Will not so simply changing to system to provide male providers to all male patients and female providers to all female patients be the basis for resolution of the modesty issues? ..Maurice.
I'm not a fan of the medical community in general. I don't trust them.
Going to school for years, and doing it day in day out for years doesn't give some random stranger the right to see me naked or touch me in a place that would be sexual assault in any other setting on earth... I don't care how much they try to convince me. They're still some random stranger to me.
ANYHOO, that being said, last week I had a doctors appointment for the first time since they relocated to a newly built building.
I got led to the exam room, and the first thing I notice in the room...
a frigging CAMERA built into the ceiling.
One of those black domed cameras you see in stores.
It wasn't hidden, but I know a lot of people don't look around that much. (especially if they're worried about a medical issue)
I asked the nurse why there was a camera, and she said for patient and doctor safety...
I looked at the door of the exam room and the reception / registration area on the way out and there was no notice that you'd be putting on a strip tease for whatever rent-a-cop happened to be working that day. ( I can only assume they're being watched in live time, otherwise if I snapped and attacked the doctor / nurse, the cameras wouldn't be much good for their safety...
and yes... the patient table thing had the gyno stirrups, so I can only imagine the minimum wage security guards personal collection of "local girl amateur porn" he has at home now.
I was only going for some booster shots / basic interview kind of exam for a form I needed to travel, but I guarantee I'll never so much as take off my shoes in a room with a camera filming me.
Jason K
Jason, very interesting. Did you challenge the doctor as to its true purpose since it obviously wasn't being monitored second after second. I have a feeling it was really there as a chaperon, to be reviewed later to protect the doctor in case the patient made claims of unprofessional behavior about them.
This is clearly an "door left open" to the exam room and this is addition to the environment should be one of the important issues to discuss with the medical system as the patients are attempting to educate the system about the need to attend to patient modesty issues. ..Maurice.
I am no lawyer, but I have to believe that the use of a camera in an examination room, such as Jason describes, would be illegal, unless the patient was informed of its presence and the terms of its use. I would think that the office would require the patient's consent in writing, before recording an examination.
But then, technically illegal or not, I do have to question how often this is happening. I've noticed that many doctors and nurses are using tablet computers these days, and most carry smart phones. All of these devices have one, or even two, cameras on them, as well as microphones. I've often wondered what assurance a patient has that these devices are not recording the examination.
The younger generation of medical personnel have grown up with such devices, so I doubt they would even question if their use was legal, or ethical. Besides, it's easier to ask for forgiveness, than to ask for permission.
If such recordings are illegal, they still might provide exculpatory evidence in the event that a patient makes a false claim against a doctor. The doctor still might get into trouble for the recording, but probably a lot less trouble than he/she would face due to the charges made against them. It's a bit like having an unregistered hand gun, and then using it to shoot an assailant. You would be happy to plead ignorance, and pay a fine, rather than not have a weapon when you needed one.
I mentioned once before that the urologist's office, where I had my vasectomy, had a standard form that they wanted me to sign. One item on that form indicated that video cameras would be present and recordings made. When I challenged this, I was assured that I could cross that portion out, and that no cameras would be present. But, were there? I certainly will never know for sure. Clearly, at least some of their rooms have recording equipment, or else that line would not appear on their form.
Medical personnel already have an incentive to make such recordings, even surreptitiously. A new generation, used to being monitored and recorded, may have fewer ethical misgivings about using such devices.
God help us all when Google Glass finally arrives. I've already seen articles discussing its use in Emergency Departments. How long before your doctor enters your examination room, while wearing a pair?
"Jason, very interesting. Did you challenge the doctor as to its true purpose since it obviously wasn't being monitored second after second. I have a feeling it was really there as a chaperon"
I didn't, since I was just there for a couple needles in the arm, and a questionnaire.
If I needed to undress in the least (which is a huge reason I don't go to doctors as a general rule... my shirt is my limit) I would have pushed the issue, and either the camera would be covered (bucket taped to ceiling over it...) I'd be in a room without a camera, or I'd simply walk out.
Jason K
The question is whether a video camera in an examination room does represent a chaperone for the physician. A chaperone in the exam room and the value or harm was discussed by Dr. Joel Sherman on Kevin MD website back in December 2010
My thoughts about the value of the human chaperone's presence in the exam room is as a witness presumably to protect. The question become which party is the chaperone protecting, the physician or the patient.
If the chaperone is selected by the patient (possibly a family member) then the chaperone's presence would appear to make any unprofessional behavior by the physician unlikely though the physician might feel that the chaperone might be biased toward the patient's later claims. In addition, if a family member, this may inhibit necessary communication or examination by the doctor with the patient.
If the chaperone is selected by the physician then it would be for the physician to have a witness present to counter any claim by the patient of unprofessional behavior. However, the patient could argue that such a chaperone selected by the physician would be biased to protect the doctor in claims by the patient.
So here might be the medical system's argument regarding the value of a video camera in the exam room. This was not discussed in Dr. Sherman's article. It would provide protection to the patient by its presence to deter unprofessional behavior by the physician and provide protection to the physician for claims by the patient of unprofessional behavior. Of course, what is essential is that at no time anyone has access to the video unless and until a claim is made by the patient of unprofessional conduct. In addition, the value of the video must be explained and accepted by the patient. If unaccepted, the patient should be provided evidence that the camera is turned off or the exam performed in a room without a camera.
In view of what I wrote above, what is your view of the presence of a video system in the examining room in terms of being an absolutely fair "observer chaperone" and as such a recorder of the true facts but also a deterrent to unprofessional behavior? ..Maurice.
I personally believe that using a video camera as a chaperone in an examination room is a bad idea. Some doctors could abuse it to store pictures of patients’ private parts. It is also an invasion of a patient’s privacy especially if she/ he is not asked for consent. Also, think about how the video camera could videotape private parts of a patient that could be shown to several people. Think about how a male patient would feel if he had an urological examination and he is determined that he does not want any females to see his private parts. The male urologist might show the video camera to some female nurses in the practice. How can we trust that the doctor will not show the video camera to any of his female nurses?
I believe that the only patients should be allowed to bring video cameras to their appointments. Doctors should not have access to video cameras for patients especially if intimate examinations will take place period.
I think it is a good idea for a patient to bring a personal advocate to certain appointments especially if intimate examinations will take place. For example, I would strongly recommend that all married men seriously consider bringing their wives to their appointments if intimate male procedures will take place. The wife could sit against the door to make sure that no female nurses can come in during her husband has an intimate examination. I feel that when a patient has her/his own personal advocate that the doctor will be less likely to do anything wrong because he/she knows that he / she is being watched.
As for physicians choosing their own chaperones, it is simply to protect themselves rather than patients in most cases. The chaperone is the doctor's employee so she looks out for him and she will often defend him even when he does something wrong. Keep in mind that the nurse or assistant is there to "protect" the doctor and is rarely on the patient's side. There are times a nurse or assistant may know that the doctor is doing something wrong, but she may be afraid to expose his criminal activities for fear of being fired or facing discrimination in the workplace. The truth is a nurse / assistant employed by the doctor rarely will advocate for your wishes.
Misty
I get the whole "The camera is an unbiased witness" aspect...
But from my modest personal point of view, I take into account 2 things...
1) google "leaked tsa naked scans", and you'll see that thousands of scans were stored off site, and eventually found their way out into the world... even though the TSA was adamant that the scans did not save any images. That is just one example of how nothing "kept in secret" is guaranteed to never be released (legally or not).
One decent hacker or disgruntled employee trying to cause problems before they leave, and everything in their data base could go online.
2) Ever been to a clothing store, and there's a sign that says the room is "monitored for loss prevention"? I worked with a guy who used to be a security guard at the mall here in the town where I live, and he said there is someone watching the cameras 100% of the time the store is open ( a wall of cameras).
I wouldn't trust this guy to the point I logged of my computer before I'd go to the washroom, and he was always probing networks to try and gain access... he thought it was hilarious to download files from other peoples machines.
He never admitted to making copies of tapes, but he bragged to "the guys" about how during his stint at the mall he saw most of women in town naked at one point or another.
CNN has a story from a former TSA agent admitting they did nothing but make fun of people as they went through the scanners.
I can only assume that the same type of person who watched those cameras is the same type watching the ones at my doctors office. (if they're being watched live... if they're not watched live, refer back to point #1)
Either way, as a guy who would ONLY take my shirt off for a doc, I'm not ok with a camera being in the room at all.
Would you be 100 percent guaranteed that nobody would be watching it live or that the video would never be viewed unless legally necessary? Even then if something happened would it be shown in a court setting for everyone to see? That may be humiliating depending on the exam. I think we all know that everything is kept on hard drives and look at how many peoples personal info is hacked or data bases stolen. In the wrong hands people could black mail you for money or simply put it on the internet for everyone to see. That would probably be more humiliating than just having a chaperone present. Unlikely event but people buy lottery tickets knowing they are unlikely to win. I don't like being filmed or having my picture taken in the first place. Don't think I would like it while having an intimate medical exam performed on me.
Ref: "At Saturday, March 22, 2014 8:53:00 PM, Blogger Maurice Bernstein, M.D. said... "
It's trust. I wouldn't believe anything the medical community told me about the purpose of the camera in the exam room. They will tell you wantever is expedient for their purpose. My thought would be that the staff, their friends, and even the rent-a-cop would enjoy their favorite recordings.
BJTNT
Shouldn't there be the ethical principle of justice present in the medical examination room? What I mean is, if only a patient selected chaperone is present (such as a family member) don't you think that the chaperone will more likely support any accusations of unprofessional behavior by the doctor as made by the patient? Is that potential support for the patient providing equal justice to both parties of the examination? I would think the answer is "no" and that would be the same potential injustice if only the physician's selected chaperone was present. Rather than have 2 chaperones present and observing, wouldn't a sealed video system, opened only after accusation, be the best solution to this potential dilemma. Comparison with the TSA is not the same since, scanning the images by an individual is required for passenger safety. Obviously, normal images must be destroyed. ..Maurice.
For those of us who value our privacy, a known video camera would be another deterrent from getting medical care if you feel another reason to mistrust the medical system.
Years ago, at a mammogram facility, the consent form said (am I'm paraphrasing), that you consent to being video taped including your face for medical education.
I crossed out that part of the form and was told there were no cameras at that facility. I did have my procedure but never went back.
It seems that many hospitals use cameras in the OR. Who would want that if you are the patient?
Chaperones in general are just more people watching you get examined.
Sexual impropriety such as assault is so rare that I'd rather be one on one with the doctor.
The above scenario probably wouldn't be a factor as I don't see male doctors for intimate exams.
belinda
With no chaperones and with no video to document activity in the exam room, how can a physician defend against the patient's accusation of professional misbehavior. In such a situation would you support the physician or the patient's description of what occurred or did not occur? And why? If a patient enters the room with concerns about potential misbehavior (after reading all the blog talk and advice) wouldn't there be any reasonable chance that the patient may be likely to misinterpret and possibly exaggerate the physician's behavior and actions? Shouldn't, to be fair to the doctor (and, of course to the patient), there be present some "referee" (either human or video) to document what is occurring at the time? ..Maurice.
Dr. Bernstein,
I also would not consent to allow a video camera in an exam room, OR, patient room or any other area where there may be a chance of intimate exposure. This includes both recording and live observation.
In the case of a specific procedure for which video is a component, i.e. endoscopy, my consent would be conditional that the video is to be used only for treatment purposes and is not to be shared or used for any other purposes without my specific written authorization.
As to using video as a chaperone, there is no way that anyone could guarantee such a recording could be kept secure. It just isn't possible, and there is no equipment that could provide that level of guaranteed security, especially at what the typical office could afford.
Hex
Hex, I know a way in which the recording could remain secure. Just give the recording directly to the patient to hold or destroy. If the patient has a complaint about the doctor's professional behavior during the exam, the patient would be required to present the held video to the appropriate authorities evaluation the accusation. As I said, if there was no problem, for the patient's own privacy, the recording can be physically destroyed. I am sure there is no way for the patient to alter the recording to prove a point without the alteration found by experts.
How is that for a way to calm the patient's modesty concerns? ..Maurice.
I have had numerous bathrooms in my business vandalized, should I be able to film them to protect myself, slip and falls are the largest claims for insurance companies so filming locker rooms, public restrooms, etc. would seem reasonable. where would it end? While you may claim viewing patients in as state of undress is required as part of the treatment, providers have no more right to violate a persons privacy than anyone else to avoid a lawsuit. Why would providers deserve anymore protection in the form of violating a persons privacy than anyone else, this is about liability not treatment? Unless providers are claiming they have a higher right to protection than the rest of us...seems a little bit of the we are something special creeping back in...don
"Just give the recording directly to the patient .... I am sure there is no way for the patient to alter the recording to prove a point without the alteration found by experts. "
So instead of a witness telling what they saw happen, you get to play the tape in court...
That'd just make more of us modest folks not speak up.
And if the doctor KNOWS he's going to do something wrong, just "forget" to turn on the camera, give the patient a blank disc, then claim they did give the tape to the patient, so the patient MUST be lying since they can't provide the tape.
Jason K
With video recording, I was simply attempting to provide a way for both parties (patient and physician) to be treated justly if there is a conflict of what happened in the exam room when only the two parties were present. It would appear to both, that a human chaperone attending the exam might be biased to one or the other if the patient expressed a complaint of unprofessional behavior. A video is the most obvious method to provide information to substantiate or negate a patient's claim. I am sure there is a way to prevent the camera from "turning off" except when the room has no light.
I hope nobody thinks that the only person in the exam room with personal concerns is the patient. There is always present the not outwardly expressed concern by the physician of being accused of unprofessional behavior by the patient. Don't think that personal concerns are just one-sided. Whether it is out of a overly sensitive patient concern about personal modesty issues and fears of doctor misbehavior or a patient with some other agenda, doctors have such a underlying concern. Accusations and suits against doctors are certainly not rare and I am sure that all physicians bear that in mind. In fact, these concerns in their mind can adversely affect their standard and systematic observation and manipulations such as speeding up a procedure or avoiding some manipulation which might be wrongly interpreted by the patient. Of course, better communication with the patient regarding these activities might relieve the patient's concern or maybe not.
Yes, I am all in favor of the patient to feel comfortable and at ease during an examination but also I am in favor that the physician should also have comfort too. ..Maurice,
I appreciate Don’s excellent points. I find it strange that the medical profession finds that it is okay for them to violate patient’s privacy and modesty, but that it is not okay in other settings.
How about high schools requiring video cameras in their locker rooms and bathrooms to check on fights between students and falls?
Using a video camera as a chaperone only benefits the doctor.
Misty
Misty, I am confused what you mean by " I find it strange that the medical profession finds that it is okay for them to violate patient’s privacy and modesty". If it is about medical/surgical procedures, various degrees of loss of patient privacy is involved in history taking, physical examination and procedures if the goal of diagnosis and relief of symptoms and disease is the goal.
If you are writing about the use of video cameras as an objective "chaperone", this was only a suggestion for discussion and in no way is this a standard of practice in medical offices or hospital rooms. I also disagree that a video camera as a chaperone "only benefits the doctor" since it might clearly document any unprofessional behavior by the doctor in the exam room and fully support the patient's claim. And further that camera might deter the doctor from such behavior.
Again, my proposition of a camera was only a idea regarding a logical solution to the matter of unbiased chaperones. ..Maurice.
The cost of cameras and recording devices at many
medical facilities are passed on to the patients. At
many intensive care units nurses are required to
wear dog collars (electronic monitoring devices). A
number of patients complain the nurses never round
on their patients. These dog collars track when and
for how long the nurse enters the patients room.
Again, there is a trend to place high resolution
cameras inside the rooms of intensive care units
with a nurse watching some distance away in
addition to the bedside nurse the patient has.
Would it be easier if people did their job? Why
are cameras used in the operating room. Why are
cameras recording every level one trauma at
most level one facilities and without patient
consent. Are those cameras there to protect the
physician, the patient or both?
PT
The medical profession isn't the only industry that's using technology to monitor you. Your being monitored in your own home by the electric company. https://www.youtube.com/embed/8JNFr_j6kdI . There are people trying to stop that. Maybe we should take a page from their book. AL
So now let's come to a conclusion as to what to instruct the medical system regarding patient modesty and concerns issues in an examination room or similar procedural environment. Should there be human chaperones (selected by whom?) or should there be some sort of a system of recording which can only be accessed at the time of a professional or criminal investigation. ..Maurice.
Policy: The MD himself [herself] should ask the patient if he [she] wants a same gender chaperone - then compliance.
Why does the MD need a chaperone and don't give me the insurance excuse? If insurance is a reason for an individual MD, revoke his license. If insurance is a reason for the medical community, then we should have same gender medical care.
BJTNT
The doctor-patient relationship is a unique relationship. This is not a relationship where someone (doctor) serves and the other (patient) receives like in a restaurant or grocery store or gas station. The input provided by the patient is just as important or even more at times to allow the physician to complete his or her responsibilities to the patient. What I am getting at is the doctor-patient relationship should be looked upon as a team, working together to accomplish a goal.
Not only are they working together for a unified goal, they are both subjected to risks involved in this relationship. And how these risks are handled should follow ethical principles. As I have previously noted, one ethical principle applied to both the patient and the doctor is justice. Each must be treated fairly and ethically and that includes safety and fairness with respect to the potential harms we have been writing about both to the patient but also to the physician.
As we decide the way to promote change in the medical system, it should be based on fairness for both parties in the doctor-patient relationship and the doctor is one of the parties. If you don't agree, please clearly explain why all doctors should be ignored in terms of what is ethical. ..Maurice.
Once again we start from the point that is not medical care. While you can claim it affects care, it could in reality create a postitive for fear of getting sued just as easily as a negative. Dr. Bernstien, if this truely was a about a team, it truely was about both the patient and the provider why would it not be discussed with the patient and their thoughts, concerns, and preference included. Only if the patient protest are they heard. I was given the form only after I was gowned, and right before the Anestesiologist was ready to come in, it was an intimate procedure and the nurse had to see the stunned or perhaps panic on my face because she said oh they rarely film it, it is just a SOP. Today I would not sign it, then I did so against my better judgement. When we do our history why is there not a box to check off for consent instead of it often being buried. If the difference between this and the gas station is the team, then both parties in the team should be considered, informed, and given a choice. This is not about protecting the patient, this is about protecting the provider and I think we all know that. It is to me but another example of providers doing something for their benefit that they do not want to admit, even to themselves perhaps that they are doing at the expense of the patient. How many patients are truely comfortable with this? I would say very few. How many women do you honestly think are comfortable with the thought of being filmed with their feet in stirups? How many men would feel comfortable being filmed bent over a table with a MD doing a prostate exam. On the other hand, do you think it would make a MD uncomfortable knowing the same procedures were being filmed. Sorry Dr. Bernstein this is about protecting the provider not the patient....other wise, ask the patient don't tell or conceal by omission...don
Don, I would think that a sealed video (not looked or investigated unless there was a complaint by the patient) would be of value to both the patient and the doctor, whereas the recollections by a chaperone would be open to dispute by the opposing party. I refuse to consider simply protecting one party, since both, to their own needs, need protection.
And certainly, I would fully agree that if the doctor is aware the presence of a camera in any clinical situation, the patient should be made fully aware before undressing and have the opportunity to refuse its presence.
I also agree that in many medical situations, patient modesty is not at the very top of the concern list within the medical practitioners mind. And certainly one of the changes to the medical system would be to put modesty at the top of the list with protocols provided to attend to the patient's modesty issues and at the same time attend to the patient's illness. ..Maurice.
There are hundreds of level 1 trauma centers in this
country and they are teaching centers as well. Most
level 1 trauma centers will average well over a
thousand trauma patients a year. Most of these
trauma centers film all their trauma patients.
These patients do not get the opportunity to consent
to these videos of them being nude on a backboard
for the duration of the trauma. I have always wondered where and what happens to the videos. These patients are never told they were ever video taped. I could see this being a hugh hipaa violation
as well as a legal fiasco if these tapes were ever
allowed to fall in the wrong hands for any facility.
PT
" A video is the most obvious method to provide information to substantiate or negate a patient's claim. I am sure there is a way to prevent the camera from "turning off" except when the room has no light. "
In order to assure a patient that they are getting the only copy of the video, it would effectively have to be a camcorder that records to dvd on a tripod in the corner of the room, and the disc is taken out of the camera and handed to the patient at the end of the exam.
Having a camera mounted in the ceiling, hooked up to a light switch implies that it's still run through a central server and we the patients would have no guarantees that it's still not being kept on their system.
as for a sealed video system that's only reviewed if a legal thing comes up... that's still a HUGE leap of faith expected on our part to trust that the policy will be followed.
I'm sure you have heard hundreds if not thousands of violations of patent modesty that the medical staff involved didn't grasp that there was a problem.... those same people would be the ones who wouldn't think twice to open up a tape.
As far as I'm concerned, it boils down to.... I'm expected to trust random strangers with my most personal and intimate secrets, and just cross my fingers and hope these random strangers feel like "keeping my secrets".
It's not far off from walking down the street and handing some random passer by your ATM card and telling them your PIN number, and just sit back and hope they don't steal from you.
I know that might seem like a bit of an over exaggeration to most of you, but that's about how much I trust the medical profession.
Jason K
Yes, it is all about trust. But think about this enigma that would be presented to a physician who read the postings to this blog thread. Here one reads about the high degrees of mistrust of physicians with regard to their assumed sexual misbehavior by intent or action and yet patients still go to physicians trusting their physical health with the practice and risks involved in diagnosis and treatment. Wouldn't the physician expect patient trust should be all or none from what is written here. Again, I pose the following: If a patient is regularly expecting the possibility of being denied adequate attention to issues of modesty or even extending to frank sexual misbehavior by any doctor but particularly one of the opposite sex, how can the patient be trustful regarding diagnosis and treatment by that very same doctor? Or does it all boil down to gender availability of the treating physician: opposite gender--no trust, period; same gender--trust?
To attempt to educate and make changes in the medical system, we should first discuss how to look at the essential connection between the patient and the doctor: trust. ..Maurice.
Doesn't the use of a video camera just perpetuate the violation of privacy? If Maurice is right and the incidence of sexual assault is so rare, why in the world would you need a camera. Same with a chaperone, just another pair of eyes.
If I give me full trust in a physician with my well being and health and they can't trust me, what good is that?
The entire idea of video cameras and a complete loss of privacy is outrageous and if I'm ever hospitalized, I will get in writing either that there is no camera or the location of it. A little tape goes a long way!
belinda
Belinda you wrote: "If I give me full trust in a physician with my well being and health and they can't trust me, what good is that?" If you gave full trust, that would be sufficient and no "chaperone" of any type would be necessary.
Again, I am not encouraging use of cameras in medical practice for observing the environment for misbehavior or misinterpretation. I just suggested that a video documentation would be more unbiased if a conflict of what had occurred. ..Maurice.
Maurice,
That's exactly what I'm saying. I would never want a chaperone and have many male physicians. They are just not the ones I go to for intimate exams and that's for my comfort and no negative reflection on them.
I'm willing to trust them with my medical outcomes. I'm a big girl and if anyone thinks I would allow anything inappropriate I have a mouth. It's not something I ever worry about.
belinda
Video cameras should never be used as chaperones. In fact, doctors who want to do something inappropriate could install those video cameras so they can do inappropriate things to patients and then alter the videos in case the patient takes them to the doctor. It is so easy to alter videos to destroy evidence.
I believe that if patients found out that doctors had video cameras, they will avoid medical care which can be a serious problem.
I wanted to share this information from someone in the “How Husbands Feel About Male Gynecologists” Group shared about chaperones.
It seems there was even an instance of a medical board acknowledging that the dr/chaperone relationship disqualified her testimony against the patients claims of misconduct.
"A New York physician lost his license when a patient contradicted the testimony of a chaperone that nothing improper happened in the examining room. The State Board claimed that the chaperone was biased because she had been retained by the physician. The reliance by physicians, including many members of our organization, on chaperones to defend against allegations is now in doubt."
http://www.peerreview.org/seattle/Unfair%20Disciplinary%20Proceedings%20by%20Boards.pdf
Misty
I just realized I made a typo in this sentence:
In fact, doctors who want to do something inappropriate could install those video cameras so they can do inappropriate things to patients and then alter the videos in case the patient takes them to the doctor.
I meant to say court instead of the doctor in this sentence.
Misty
From Misty's link to a speech by a lawyer for American Association for Physicians and Surgeons:
Physicians feel threatened because they have fewer rights than almost anyone else in a judicial
proceeding. Physicians can lose their license based on very little proof, and inadequate due
process. Physicians are vulnerable to manipulation of the process for economic reasons, rather
than true concern for patient health.
And so you see that physicians also feel threatened and even more likely than any of their patients. And as you read in Misty's excerpt even an attempt by physicians to have the exam observed by a chaperone is open to rejection. That is why we must come up with a fair and neutral observer if we are to have any observer (and even having an observer present when human or electronic is worrisome and embarrassing to some.)So what's left?? ..Maurice.
" If a patient is regularly expecting the possibility of being denied adequate attention to issues of modesty or even extending to frank sexual misbehavior by any doctor but particularly one of the opposite sex, how can the patient be trustful regarding diagnosis and treatment by that very same doctor? Or does it all boil down to gender availability of the treating physician: opposite gender--no trust, period; same gender--trust?"
I've never been worried about sexual misconduct from medical staff (rape wise)... I'm a big guy and people tend to get out of my way, so if someone did something I didn't like, they'd be glad it happened in a hospital.
As for trusting their medical advice, but not their conduct...
I take what doctors say with a grain of salt... my dad died years ago... he was having "attacks" where without drinking he was acting drunk, and it was happening more and more frequently... he was taken to the doctors and they ran a battery of tests, and the doctor looked my mom in the eye and said they weren't sure what was going on, but they ruled out this, this, this and stroke.
2 weeks later he died of a stroke, and apparently he had been having mini strokes.
So when a doctor can't tell if you're stroking out, that doesn't inspire a whole lot of confidence.
And as for me seeing a doctor, and the whole male vs female thing... it really doesn't matter if the doctor is male or female... I'm not taking my pants off for either one. I'm a hugely modest person, and that's simply not going to happen.
I've had a sharp pain in my hip for over a year now (I think I chipped a bone or something after a bit of a fall)... but I know that dealing with it would involve getting nekkid for at least a doctor, and likely an x-ray tech or mri team.... possibly end up with an entire surgical team, and anyone who felt like walking in, teams of med students, and any plain old person who walked past the operating suit if they leave the curtains open...
I'd rather live with the pain. Thanks anyways.
Jason K
And incase anyone hadn't read it...
http://www.mirror.co.uk/news/uk-news/epsom-hospital-hospital-visitors-saw-3027723
they left the blinds to the operating room left open for the world to see a naked patient, and the biggest issue in the story to me is "She also said she informed a nurse on Buckley ward, who said "that happens all the time" and did not take any action to raise the alarm with operating staff."
Dr. Bernstein I could make the same arguments, me filming the bathrooms could just as well protect and benefit customers since my team would be more aware and diligent about keeping the floor clean and if a customer slipped on a wet floor their rights would be better protected. I would lay money that I have defended more slip and fall cases than most MD's so should this not justify my filming? Further talk to my loss prevention agent and you will find there are a high percent of slip and falls that are serial and purely financially motivated, does this justify me filming?
Again if this is a team effort, the patient should be fully informed and given the choice but providers do not do that. They make the decision and at times hide issue or "trick" the with small print or ambush them when it is to late to turn back. If they were as you indicated made aware and given a fair opportunity to accept or object we would have a team, that that isn't usually the case.
And trust, so you question how a physician would feel it they didn't feel the patient trusted them...does not the mere presence of a chaperone or camera indicate to the patient the MD doesn't trust them the patient, that they need someone there because they have to be protected against unfair malicous intent from patients? I doubt patients were asked, do you think it would be a good idea for us to put a camera in the exam room.
While in an ideal world providers and patients could have this discussion and agree on what to do. However that is not the case, this is still a one sided decision in the vast majority of cases so it is still about the provider in most cases....don
Dr. Bernstein,
I'd like to suggest that maybe we need to look at the issue from an engineering approach called root cause failure analysis.
As I see it, what lies at the base of many of these issues is a fundamental breakdown in the nature of the doctor-patient relationship that has eroded the trust that is necessary for this kind of relationship to work well.
The big question is how do we fix it? Treating symptoms, i.e the chaperone issue, doesn't address the underlying problem.
Once the underlying problem or root cause has been identified, the next step is to figure out why it happened. Only when you know the "what" and the "why", can you formulate an approach as to how to address it.
So the two questions I have for everyone here are:
1. Do you agree that the true underlying issue is the breakdown in the doctor-patient relationship and the resulting loss of trust?
2. What do you see as the top one or two causes (not the symptoms) that caused this to happen.
Once we have a consensus on the "what" and the "why", maybe we can start to address the issue of "how" to fix it.
Hex I don't feel lack of trust is THE issue, I think it is a issue. What causes feelings of modesty goes beyond trust in some cases. If you walked out of a shower and infront of a member of the opposite gender unexpectedly, and jumped back in the room, is trust an issue? I don't think it is though it may be more so in the medical institution. I do think the lack of trust does affect to a large degree how we accept exposure and the related vunerability we feel. Trust from the point of view the provider is not judging our bodies, perhaps for some it is trust providers are not getting some sort of enjoyment from our situation..etc...Causes (1) contradiction to what we are told over and over about exposure "exposing yourself to the other gender is wrong, perverted, or embarressing (2) hearing, seeing, and experiencing things that are contradictory to what we are told for example gender nuetral, not seeing the difference between body parts, we are professional, all of the thing put forth on this blog....when one experiences a contradiction to what they are told, maybe what they believe...trust is a casualty...don
Not sure why everyone is so bent out of shape
with the placement of video recording equipment
in health care areas where patients have always
thought their privacy is protected. If we are going
to go down that road then we should place video
recording equipment in every other area.
Let's start with the restroom and dressing rooms
of all medical and nursing students. Then proceed
with further placement in all hospital staff restrooms
and from there we will proceed to colleges and
universities. After all, I want everyone to be safe
and feel safe. No one will know where the video
feeds to and after all it's none of their business
anyway.
PT
My suggestion of a camera documentation of the events in an examination or procedural medical/surgical environment was only to provide documentation that would allow justice to both the patient and the doctor. However, if a camera will only provoke further anxiety related to the patient's modesty and provoke suspicion and worsen the trust between patient and doctor it therefore should not be an option.
So now, as applied to all physicians, nurses and techs regardless of gender, what changes should be advocated to promote trust and promote both the patient and provider to strive for the goal of diagnosis, treatment and attempt to resolve the illness and its symptoms? ..Maurice.
Let's start with modification of consent forms and brochures on what to expect when you are having an operation or procedure.
This includes who will be in the room, patient state of undress and a full disclosure that the team will be of mixed gender.
Additionally, in the case of a patient who medically or psychologically requires a same gender team, gets it.
If this issue is not important to most people, then it shouldn't tax the medical profession and prevents psyhcological trauma because everyone will know what to expect.
belinda
"So now, as applied to all physicians, nurses and techs regardless of gender, what changes should be advocated to promote trust and promote both the patient and provider to strive for the goal of diagnosis, treatment and attempt to resolve the illness and its symptoms? "
It may sound like I'm being sarcastic, or a smart***, but have the medical staff undress to the extent the patient does during the exams / procedures.
I'm sure they'd be far less inclined to try to tell a patient to completely undress to examine a shoulder injury if it meant they also had to strip down.
I also guarantee they'd pay a lot more attention to doors left unlocked, curtains not drawn and all the other accidental "oh well, it's nothing we haven't seen before, so you should just accept it" unnecessary exposures.
And if Doctor so-and-so isn't ok with being naked infront of me, why should they expect me to be ok being naked infront of them?
(pretty sure the cameras wouldn't even be considered then...)
Jason K
Jason, you said it so well. That's exactly where my focus was when I posted the new consent form.
Trust needs the be earned. Patients feel violated when they feel that information is being withheld. I think that's a great place to start.
belinda
Jason, there is no need for a patient to be "naked" except on the operating table (while under anesthesia) for a few minutes in preparation for major abdominal or chest surgery. And even then, the genitals are covered. During medical examinations, there is no need to have the patient naked and as I have written numerous times, not only is the patient's modesty challenged but also the patient's chilling can interfere with the proper examination besides being physically uncomfortable. Sequential undraping is the appropriate exposure method and this is what my students are taught. Finally, though some dermatologists look at the naked patient's skin, most also follow sequential undraping for obvious modesty issues but also more accurate inspection and detection of lesions.
No need for physician's to be exposed stark naked since they are all fully aware of the concept of modesty. What, I am sure most are unaware, is that some patients will have modesty trump any medical/surgical benefit to their bodies by not allowing certain parts of the body to be exposed for examination or procedures. It is this lack of understanding about the choices by some patients for which physicians have to be educated. It isn't that medical professionals would say "I've seen this all before" with regard to body parts but they would certainly say "I've never seen or heard from a patient that their modesty trumps their heath". It is exactly that which must be taught the medical professionals. ..Maurice.
Dr. Bernstein I find this so interesting. I struggle to understand some of your responses, are you intentionally evading the real intent or does your position as a MD just cause you to think differently to this degree. When many of us say naked, it is obvious to me we mean exposed. If you were asked to walk around in clothes with no crotch or rear end but everything else, would you be OK with that? You would be far from naked, shoes, socks, legs covered, shirt, hat, gloves...not naked but exposed. When the poster uses naked it is often just in the context of being embarrassed from exposure. They don't care if their feet are exposed. You have responded like this several times about there is no reason to be naked and how providers use slective exposure. (and in the day of the internet and posting teaching videos, I would say genitals are not always covered) I struggle to understand if you really don't understand what the poster means or if it is avoidance. You can cover 90% of someone's body and expose their genitals and they are likely to be embarrassed. You focus on the term naked and miss the intent. Either way it is telling, if you intentionally avoid to justify, even subconciously it indicates one thing. If you don't realize or more accurately recognize it says another.
Another observation, you have often brought up the concept that providers don't need to be exposed, students don't need to partcipate, they are aware of the concept of modesty but not that it is so deep that patients avoid care. If they are aware of the concept of modesty, they have to be aware of the role gender plays. They also have to understand violation or compromising ones modesty is atleast uncomfortable for most people. And yet they consistently compromise these aspects of modesty under the guise of gee we didn't know, we are professionals, and all the excuses. If providers are aware of the concept of modesty and do not require experiences to reinforce that, why is the simple fact their practices compromise modesty not enough to cause them to be concerned. Concerned to the point where they actually attempt to at a min. to involve the patient in choices. While I do not agree with Jason's suggestion I fully agree with his contentions. Providers would not accept the lack of concern for modesty they inflict. If they really understand, they either practice an US AND THEM mentality or they choose to ignore what they understand. They can't understand modesty and do what they do unless they just don't care...and the double standard when applied to them seems to back that....don
Don, "naked" as I have used it throughout the Volumes and as I have understood the word as written by others is "unclothed" or "nude". If it is just the breast or genitals that are exposed then those anatomic parts should be expressed by the word "exposed" and that should be sufficient to indicate what is intended to be described. We use "exposed" all the time in medicine ad surgery to represent the part of the body in "uncovered". As I have written, there is no rationale (except by some dermatologists) to exam the patient's body nude or naked. There is, of course, importance to examine breasts (both male and female) and genitalia and rectum in an uncovered, exposed state in order to carry out the exam and procedure necessary. However, in a woman, doctors may expose one breast at a time for examination but if some abnormality is detected on inspection or palpation of one breast, the other breast may be exposed for simultaneous comparison.
I hope these definitions of the acts of exposure will help explain what I am writing. Again, naked or nude examination of a patient is usually unnecessary and can only lead to embarrassment and the physical effects of chilling. ..Maurice.
Don, with regard to your question about how medical students are treated and how they react, think of this: THEY ARE NOT PATIENTS at the time of a learning examination by their colleagues. This means that any degree of undress or exposure which can, in some, be embarrassing because of general personal physical modesty or specific modesty in front of their colleagues. And such exposure is not to diagnose or treat an illness but to be an "object" for a learning experience. As instructors, we agree that there is a difference in requiring exposure of the student's body as a learning experience for others compared with the need for patient exposure in a purely clinical setting, if they were a patient. Therefore, we allow students to decide how to participate in these situations. Most of the time, sufficient exposure is attained by both genders. Other times, the female student may wish to be examined by another female student though with male students also in the room. Only once in my career, did two female students want to examine each other in a separate room away from the male students.
It is in this regard that our view of "uncovering the body" is different between students and patients. But, as you see, this is all related to the student's own decision and agreement.
When the students are examining their patients in the hospital, any bodily exposure is only with the specific permission of the patient (just as the students are likewise being treated with specific permission by them examining themselves). I hope this explains the issue. ..Maurice.
Dr. Bernstein I agree and understood your definitions, I also understood when some used 'naked' for exposure so the physcology of it was interesting. Did you focus on the technical aspect of the term naked vs the emotion-intent of the post. It does sort of align with the technical/medical aspect of exposure vs emotion.
But if you review your post you will see that the decision of what is and is not embarassing is determined soley by the provider. Providers have recognized that "any degree of undress or exposure can in some be embarassing because of general personal modesty or specific modesty in front of their collauges". It was medical people recognizing and honoring this for other medical people. Yet these same people have a history of not recognizing the same for patients. It is medical people who have determined the fact that people are patients causes these same aspects of modesty to disappear, be suspended, or perhaps not important enough to accomodate in the same fashion they give eachother. They recognize the concept of modesty but somehow claim ignorance that some patients may have general or specific degrees of modesty that would likewise deserve the same consideration. Patients are forced to one degree or another to endure compromising their modesty for their health, the problem is providers have expanded the compromise to what I would consider unreasonable lenghts not for the benefit of the patient, but for themselves. Obviously the role gender plays in this is recognized and accomodated for students...but it is largely ignored or discounted for patients. And specific permission is a stretch. When a teaching facility requires submitting to students as terms of admittance, does that constitute specific permission. Does one give specific permission for a MD to allow staff partcipate and chaperone when the patient isn't asked, or even informed of what is going to happen? Is the effort to obtain specific permission from students the same as patients or is that permission more deliberate and informed. It is providers who have decided that exposure of students and exposure of patients are so different that they are to be not only treated completely different but the patient's mental state and view BECOMES different. That view is self serving and I would say void of true patient consent or input. If you walk into one of my establishments and I have loud vulgar music blarring, did you consent to that by coming in to buy something or are you merely enduring it because you need something?...do professional athletes give specific consent for reporters to view them undressed in the locker room or do they endure it because they have no choice if they want to make a living. We all view things from our side of the table and justify from that point of perspective. The difference may make sense to providers, but the majority of non providers have expressed the opposite opinion...but then some are just now starting to understand they don't have to just accept it...don
Don, a medical student who is sick and becomes a patient and is examined in a clinical setting or a physician who is sick and becomes a patient are both treated with regard to necessary exposure of segments of the body as is determined by medical standards for diagnosis and treatment. Sure, the med student or the doctor as patients can refuse examination or treatment for their own reasons but nevertheless the need for exposure is unchanged regardless of their titles. And sure, while the standards of examination and procedures have been based on anatomy and physiology and even physics, some may be partially modified if challenged by patient modesty, though I can't see how a rectal exam nor a pelvic exam be carried out through modesty protecting coverings when part of a rectal and pelvic properly performed requires actual inspection of the tissues.
Let's get back to patient modesty as understood by medical practitioners. We doctors and nurses are all aware but what we are not aware sufficiently is the intensity of the modesty which can appear in some patients and as fully described within these Volumes. We all think that for a sick patient with symptoms and suffering from a yet undefined disease that physical modesty would take a back seat to doing whatever is necessary to relieve the symptoms and cure the patient. Obviously we are ignorant in this regard and need to be educated Patients should directly communicate to us their balance of modesty vs diagnosis/therapy and if modesty, itself, becomes a factor in the illness then modesty should, continuing my analogy, take a front seat too and be recognized in that front seat. ..Maurice.
The comments that Dr. Bernstein made to Jason:
Jason, there is no need for a patient to be "naked" except on the operating table (while under anesthesia) for a few minutes in preparation for major abdominal or chest surgery. And even then, the genitals are covered.
confirms the truth about how vulnerable surgery patients are. Many patients are not told the truth that their genitals will be exposed for a brief time. Many people do not want their private parts to be exposed for even a few seconds. Many patients who must have their private parts exposed want same gender intimate care. Many surgery patients who value their modesty have their wishes violated once they are under anesthesia.
Misty
I wanted to share an interesting article that was on CNN about how many women do not like to have their private parts examined. I found this sentence: Gender - Female gynecologists are usually the choice of most women. very interesting. It is true that many women do prefer a female gynecologist.
Misty
While it is embarrassing to have an intimate part of the anatomy exposed, it is much worse when you are left completely unclothed. I can tell you from having had the experience of both (all authorized except the nude one) that there's a big difference in how you feel as vulnerable and victimized especially if you are pregnant (and your body doesn't represent who you normally are) or overweight. Then being naked is more humiliating; not less.
Maurice, they do not wait in the operating room for you to be "out" to uncover your body if you are going to be awake for surgery or you need a surgical prep. Then you are exposed shaved and whatever else in the presence of all the staff, wide awake, door sometimes opened, janitors and extraneous people about and that is the problem--a complete lack of regard for the emotional well being of the patient and a complete disregard for preserving the dignity of that patient. You can deny that these practices in the course of normal activities in a hospital don't exist, yet I don't know anyone who hasn't either experienced some of this or witness to it.
belinda
"your question about how medical students are treated and how they react, think of this: THEY ARE NOT PATIENTS at the time of a learning examination by their colleagues. This means that any degree of undress or exposure which can, in some, be embarrassing because of general personal physical modesty or specific modesty in front of their colleagues."
But they're supposed to be professionals who have "seen it all before" (a quote I heard from a nurse, not a quote from you)... why would they be embarrassed from other "professionals" seeing something they have also seen before? everyone in med school or beyond should know what the human anatomy looks like, and everyone knows what their co-workers should have under their clothes, anatomy wise, so what's the "big deal"?
(yes, that was tongue in cheek, since I find it to be a bit funny, and a HUGE double standard that patients are supposed to be ok being "sequentially undraped" to medical staff & students, but suggest they do the exact same thing, and it'd apparently be the end of the world if someone they knew saw them naked... sorry... "sequentially undraped")
"Only once in my career, did two female students want to examine each other in a separate room away from the male students."
That should tell you that there was at least 2 students who were willing to risk their chosen career due to personal modesty.
What would they have done if the option to go to a private room wasn't available?
What would they have done if they were REQUIRED to allow a male student to examine them? (how many "real" patients are denied same gender care because "nobody else is available"?)
Jason k
Jason, the medical students are not yet professionals. They are in the process of learning the fact and skills to become professionals in medicine and to have a doctor of medicine degree. The first and second year students are those whom I teach and who practice physical exam on each other. And the students cannot be said to "have seen it all before" any more than any other post grad college student their age in the context of a physical examination since these medical students have never performed a physical exam so they are certainly not "conditioned".
Again, all patients including doctors and students as patients should be examined according to established protocol for the best chance for discovery and diagnosis. The students and doctors when they become patients should not be given "VIP" treatment in which they are examined differently ("examined through clothing" for example) in order to "protect" the student or doctor's modesty.
To be complete in my recollection of the two female students who went into another room away from the male students to practice examination on each other... they did not risk their career..they risked nothing. I, their male instructor, was in the room with them to observe and provide advice during their practice. No problem. It was, as expected, their student male colleagues they wanted to avoid watching their practice not their physician teacher. But, as I indicated, this was unique occurrence since often whatever modesty is expressed is expressed as two female students examining each other but in the same room as the rest of the student group. ..Maurice.
I want to demonstrate to my visitors here that I am actively trying to promote education of the medical system with the views you have presented here. Today, I wrote the following 2 postings to a bioethics listserv. ..Maurice.
When patient physical modesty and safety concerns along with a physician's concern that the performing of intimate physical exams such as genitalia and rectal may be misconstrued by the patient as unprofessional actions the use of a chaperone is advised. The problem then arises as to who should select the chaperone (the patient, the doctor or two chaperones, one from each.} But here is the ethics of this dilemma: justice. How can there be justice for both parties when issues arise with possibly non-objective and perhaps potentially biased chaperone. Does anyone here find that a neutral chaperone could be a sealed video system in the physician's exam room. This issue is currently being discussed on my bioethics blog...I wondered what ethicists might think of this potentially sticky issue that lies in the mind, I think, of many if not all physicians. ..Maurice.
[Two named subscribers], you both brought up the very issues which make how to construct something fair without bias and something therapeutic for those with modesty anxiety or false accusation anxiety and something preventative: preventing even the apparently very rare occurrences of physician professional misbehavior or criminality. This has all been discussed on my blog thread by the patients themselves but unfortunately not by the professionals. It seems that the whole medical system, according to my visitors, is based on the doctor's casual "supportive" comment to the patient regarding intimate anatomy "I've seen it all before". And then there is the missing detailing of a procedure to the patient as part of informed consent regarding the extent of exposure of the body, particularly female breast and genitalia of both genders during some part of the operation or other procedure. And then who, of which gender, is going to be present in the room and may observe the patient's body at which time the patient is not fully conscious and cannot refuse the presence. Want more?: how about "gawkers" in the OR including those "medical students" or those patients or others including staff snooping through the partly open doors of exam rooms or windows of operating rooms.
What my visitors find is missing is simply that with regard to modesty and fears of unprofessionalism, the system neither informs the patient regarding these aspects of the exam nor what changes in protocol will be done to accommodate the patient's concerns or providing caregivers of the asked for gender. And, my visitors, have again and again informed me: this all is serious business. If the patient is ignored in this regard or their wishes not accommodated then, believe it or not, their modesty and gender selection issues will trump any diagnosis or therapy of their symptoms.
Now, it is very likely that my visitors and their demands represent statistical outliers as I am sure those physicians involved in unprofessional and prurient behavior are also in that category. Nevertheless, the issues my visitors present are important even for outliers and yet where is ethical or organizational or governmental signs of awareness, concern and suggestions for directions toward resolution? Not in governmental medical care plans, not in Joint Commission, not in HIPAA and what are the medical/surgical organizations doing to resolve these concerns? With more patients entering the medical system, even if these patients writing to my blog are outliers, I am sure that this issue may well become statistically more common and the system will need attention in this regard and some fixing. ..Maurice.
And later, also a third posting in response to supportive comments and to cover more of what has been written here. ..Maurice.
... yes the issue is on the primary care level (male and female genitalia exams and procedures like colonoscopy). But the concern by patients also extend to examples presented such "why do I have to take my underwear off in the operating room to have shoulder surgery?" (Do surgeons regularly explain such operative necessities or do they assume that the patient is fully competent by signing operative consent regarding such things as preventing infections or having immediate access to the femoral vein or whatever is the explanation) or that the protocol has been long time established, unchangeable and there i no need to provide the patient such detailed information. And yes, patients are aware of surgeons making remarks and not strictly clinical remarks about the patient's bodily appearance or particular parts.
My visitors want "their" representative within the operating room to observe that the patient's modesty is not being violated and that, yes, the patient is being attended with respect to those intimate bodily areas by individuals of the gender selected by the patient. Oh, In over the almost 9 years the thread on "Patient Modesty" has been running I have tried to give all the rational excuses in this regard which I can muster but to no avail.
There definitely is a problem here and, you know, it all boils down to one thing: TRUST. Whether in the doctor's office or exam room or in the operating room or even in the patient's hospital room (where the doors are left open screens between beds unclosed,, and patients are attended by nurses of the "wrong" gender all leads to a general lack of trust with the medical system and its professionals. Again, all this is written to me by what I have always assumed were statistical outlier patients.. but what worries me are they really only statistical outliers? ..Maurice.
Maurice. Just how much intimate exposure is involved with these student exams? I thought you hired test subjects for the intimate exams so just how much of their private areas were exposed? Al
Maurice,
Congratulations on the best commentary on this subject that I've read that you've written to date.
There are two Senators working to get female vets (subjected to sexual assault in the military) special healthcare provisions. One of them is Patty Murray from Washington State. I've been watching this and looking forward to some changes. These changes will spread to the rest of the medical community on how to propagate sound mental health when patients are especially vulnerable.
You should be worried because we are not outliers. Just look at statistics on intimate procedures for both men and women that are avoided.
Never has the medical system tried to research why and the answer is just plain common sense.
How to we "marry" our social norms with necessary procedures in healthcare that is patient centered to relieve the anxiety of illness and reduce the source of embarrassment.
If you ask, what's your most terrible nightmare, often you will hear people talk about being naked in public.
During surgery or a procedure the staff is the public. Are they not human, are they of mixed gender, are they strangers?
Nearly everyone who has been in a hospital has had something happen that while may not have traumatized them, made enough of a mark that they remembered the incident.
Here's an example of no impropriety, however, the patient felt mortified by the actions that were supposed to be educational and I hope you will print this.
She went to the gynecologist (male). There was a female chaperone in the room. She was draped as is customary for a gynecological exam. On examination he found something that he wanted to share with the patient. He took a mirror and placed it so that she could see her own genitalia.
While she knew she was undressed, knowing and seeing it in front of staff was especially upsetting for the patient. There are strong psychological reasons for this, but I'm not a doctor.
It's this kind of thing though that needs to be looked at. I call it "Psychology of the naked body with the mindset of a patient".
Everyone has modesty concerns to a degree. Sometimes the humiliation is provoked by normal things that happen in a hospital like shaving for surgery in an area that is not private and then exposing the patient. This issue needs psychological research; not medical research.
Then a protocol can be developed that might not eliminate the problem but make things less traumatic for the patient.
belinda
Al, your question is quite appropriate for this discussion.
Yes, genital exams and thorough uncovered female breasts are performed on "standardized patient" (teacher-subjects). Other physical exams are practiced by students on each other. This means that the head, neck, chest,abdomen and extremities are directly examined by the students. In the case of male student subjects, the chest is bare and abdomen is bare to examination. In the case of the female students, they are encouraged to wear and their chest is only covered with a "sports bra". The female student's abdomen is also bared. Both genders gowns are serially uncovered to expose these areas for examination. This is the protocol for my school but I am certain this is standard operating procedure for all medical schools. I hope this gives a picture of what is occurring. As I have mentioned, the "laying on of hands" on the student's body may be different between genders: males accept females, females may accept males but some females only accept females but do not request being in a different room away from male students. Laying on of my hands as physician-teacher is seemingly acceptable by both genders. And in the last analysis, they all learn what they need to learn regarding the methods and rationales involved in a proper physical examination. ..Maurice.
Yes Maurice, that was a great commentary, however,
we are light years from bringing that thought process
to the nursing industry. Good luck with that!
PT
Dr. Bernstein, I do not doubt your dedciation to this issue and you have done more in this area than anyone I know. I think the fact that you are so open to trying to understand and communicate this issue makes the issue even more clear. You defend the practice of expempting students from the very things they will ask and expect of their patients in numerous ways. they already know about modesty, it is different among colluages, etc. I am not at all challenging your intetions. I do however challenge your objectivity. You are a MD, and MD for many years, from all the threads you maintain I would guess medicine consumes a large part of your life and defines to a degree who you are. Therefore you views of right and wrong, required and chosen, are from that perspective. You have a perspective on these issues such as student partcipation. I have a completely different perspective, who is right and who is wrong...neither, only what is right or wrong for us. And that I think is THE issue, not trust, not assualt, nothing else effects and cuts across all lines like like perspective. The issue here is providers chose to define this from their perspective, including how WE should feel and accept their practices. Why is your view (which likely mirrors that of providers) of how the issue of exposure between students and patients differs the right one? That is the basis of most of these issues. Perhaps the key to dealing with this and the key to changing it are two differnt things. How you change actions and attitudes are two different things. When the two parties are acting from different points of perspective the issues and solutions rarely line up. The actions may come closer together through compromise, but the difference between how providers view these things and how patients do are vastly different. that may be unreconcilable but coming to middle ground should be achievable. I find it unreasonable that a student who will one day ask many to trust them, to strip and expose themselves, thinks being asked the same to further their and others education to that point is completely unreasonable. You see it other wise and we are not likely to change each other minds. We may however find middle ground on how to deal with it. Rather than spend time asking patients to change their point of view, the time should be invested in how do we deal with it.It starts by asking patients how they feel about it to find that point of perspective. In this case I guess, right or wrong it starts with patients telling..
On a little different note Thresa (?) had an interesting article on her patient modesty thread...it was about a MD becoming furious that a patient asked if they could record their appointment. The MD was furious she would ask...so, I wonder what would be the reaction of most MD's if a patient asked to record the appointment/procedure/exam? I am guessing many would have a problem with it..they would not trust the patient, they would assume bad motives...yet providers routinely expect patients to assume this...Dr. Bernstein, how do you think MD's would react to a patient asking to record these interactions?....don
PT, but also with your help and those of others to both doctor, nurses and (can't forget) techs, too!
Below is my latest response to postings on the listserv from other ethicists. Thst listserv is not public so I really can't identify the writers or their specific comments without their permissions. ..Maurice.
[Named subscriber], the surgeons' comments during surgery that you describe are, of course, part of the "hidden curriculum" presented to 3rd and 4th year medical students and above and in addition contribute nothing to the benefit of the unconscious patient. Would you advise we teach all our students about to be exposed to such "teaching" to "speak up" and disclose to their "superiors" the ethical humanistic concerns about these incidents even with the grading risks to the students? If this surgical behavior is a residual from years past as [Named Subscriber] suggests, shouldn't all attempts be made to wipe out this clean? I worry that this rather casual "introduction to the profession" may well lead some students in later years to be more casual in maintaining professional behavior. Also,[Named Subscriber], from what I read from my visitors, gender requests by patients is not specifically gender discrimination, it is to attend to the patient's own physical modesty concerns and associated symptoms. And speaking of symptoms, PTSD has been frequently described as reactions to "unprofessional and unnecessary" behavior of doctors in the past as a child (such as unnecessary pelvic exams) or in more recent experiences. Professionals in medicine need to be aware and attend to these patient modesty concerns which are out there to one degree or another.
And now back again to chaperones. I am aware of the ACOG advice regarding chaperones for either patient or doctor: "The request by either a patient or a physician to have a chaperone present during a physical examination should be accommodated regardless of the physician's sex."
But that gets back to my original concern of the objectivity and full lack of conflict of interest when either chaperone speaks in court.
It may turn out that the only possibilities for full trust to occur on both sides of the doctor-patient relationship is for more time to be taken to "get to know each other" (wishful thinking!) And even what I thought was a "neutral observer" of a camera is strongly rejected by my blog visitors as another intrusion and "gawker" into their modesty concerns. ..Maurice.
Don, I have always thought that patients should audio record their verbal communication with their physicians. This would be the best for patient education and simply remembering what the doctor said about their illness, workup and treatment. It also might help with treatment compliance. I don't see how a video recording by the patient and retained by the patient, if not later modified, would be any less acceptable than a human chaperone of the patient's selection and, indeed, would be considered by the doctor and others more objective.
With regard to medical students allowed not to undress beyond their basic modesty issues and to expect their patients to do so later in the student's career, it is simply because the students at the time they are in the classroom are NOT patients. As I already stated, when the students or physicians become patients themselves, the medical profession would expect, as with all patients, we in medicine should expect an educated patient to allow essential bodily exposure despite underlying modesty issues. When any individual is no longer specifically a patient or an individual who agrees to healthcare screening, that individual should not be expected to defy their modesty in their life experiences. Obviously, after reading all these Volumes, it may be necessary to attend more to patient modesty issues and modify examination and procedural protocols within the limits of still maintaining beneficence to the patient's illness and symptoms in addition to the patient's modesty. ..Maurice.
"With regard to medical students allowed not to undress beyond their basic modesty issues and to expect their patients to do so later in the student's career, it is simply because the students at the time they are in the classroom are NOT patients."
We get that they're not patients, but I think the point we're trying to make that we might not be making clear is that it's possible to go a very, very long time without seeing a doctor, or being sick / injured so it's not inconceivable that someone in med school / nursing school / "med tech" school has never had to undress to any extent infront of a doctor / nurse / tech.
So without "forcing" them to expose themselves to others how will they know what they're expecting of the patient to accept?
Jason K
It might help to equate "fear of exposure" with "fear of snakes".
If someone has a deathly fear of snakes, they're not going to stick their hand in the terrarium with a snake, even if it would somehow benefit them (say there was a check for $2,000 under the snake) explaining the benefits ... or any other soothsaying... won't help them be ok with sticking their hand in with a snake.
Even if someone was introduced to a friends pet snake, and got comfortable enough to hold that one specific snake, throwing them in a room and bringing in some random other snake won't mean they'll magically be comfortable around that snake.
And a snake of the same gender won't make a lick of difference.
Bringing in a second snake (chaperone) won't make things better either.
(if this makes any sense to you... and no, I'm not trying to insult medical people by comparing them to snakes... the best pet I ever had was a ball python, I just know people with the fear of snakes, and it's somewhat comparable to how I feel about exposure infront of med folks)
Jason K
Jason, you write "So without 'forcing' them to expose themselves to others how will they know what they're expecting of the patient to accept?" I can tell you and the others on this thread that medical students in the first two years know all about their modesty and modesty concern of the patients they examine in the hospital. How do I know? Well, I have written this several times in past Volumes. I watch what they do and don't do.
For example, as part of the cardio-vascular examination, they are supposed to palpate ("feel") the pulsations of the femoral artery which is located in the patient's groin. The students uniformly skip that artery since it is down in what I would call a "modesty sensitive" area of the body but move on down to attempt to palpate the popliteal artery located behind the knees. However, when they go to the feet to examine the dorsalis pedis and posterior tibial arteries and look at the color and temperature of the feet and toes, the students fail to remove or have the patient remove the socks. Why? It just seems to them a physical modesty issue both for the patient and themselves.
And there are more examples, such as incomplete inspection and palpation for the apex impulse of the heart in a female patient since the site of the impulse may be hidden under the breast and, well, the breast must be elevated to be detected.
And then I had a second year medical student who did not want to have his abdomen examined by either gender of his student group because he had a functioning colostomy in place with a history of inflammatory bowel disease. Even when I explained to him the learning benefit for the others in the group to see that surgical result, he refused and, of course, his refusal was accepted without academic penalty as is the standards of our medical school.
Jason, you have to be around first and second year medical students for over 25 years, like me, to understand that they are by the age of early to mid-20's quite thoughtful of their own and their patient's general physical modesty issues. Yes, what happens later in their education and career may affect how they "size up" modesty in view of the work they have to perform and responsibility in order to come up with a diagnosis and initiate the proper treatment. They will assume, as I believe most doctors do, that a patient will always sacrifice a bit of their modesty feelings to be satisfactory treated for their illness. But for now, they are demonstrably aware of their own and their patient's modesty. ..Maurice.
Then they must loose something in the transformation from med student to doctor / nurse... in every encounter with a doc / nurse I've ever had that they wanted exposure, they've all looked at me like I was insane when I refused, and I've heard all the usual "it's nothing we haven't seen before", "it's ok, we do this all day every day", "you're not a special little snowflake"... all of it.
For example, when I was 14 or so, I had a pretty bad ear infection... one night I heard a "pop" accompanied with a sharp jabbing pain that wasn't going away after half an hour, and couldn't hear in that ear... I went to emerg, and was told to remove everything and put on a gown. the nurse argued with me for almost 10 minutes about it, without ever giving me an actual reason why I'd need to do that for the doc to look in my ear. The closest I got was "the doctor prefers it this way".
All I can say to Anonymous from 7pm today: if you go to hospital emergency room for pain in your ear expect a wait and expect the nursing staff to do what is protocol to facilitate (including time-wise) any examination which the doctor decides to carry out. In any event, in your case, the nurse should have given a more specific explanation.
I think in all the discussions on this thread of the conflicts between patient and doctor/nursing staff, what is missing is education on the part of each: the patient should be educated more about the details of clinically important concepts of medical/surgical practice and the doctor/nursing staff should be educated much more on all the patient modesty issues, how they affect the patient and how they might affect a thorough medical or surgical management and the outcome. If both parties were educated about the others challenges, I think care, in general, would be greatly improved and there would be less "moaning and groaning" on both sides. ..Maurice.
Dr. Bernstein, there are a couple of things, once again while providers have expertise the physical aspects of the patient treatment, providers do not have anymore expertise into what is the proper balance for modesty than their patients. It is opinion, providers opinion as to what is right or wrong is no more valid than that of the patient. So when PROVIDERS say it is different for students it is their OPINION not fact. And it is providers looking after providers.
The other part of this is it ignores providers using such liberties with what is nesecary and what is not. You say it is not required for students, and yet so many times we feel the exposure is not required and yet defended by providers. When one MD can do a vasectomy by himself and another brings in his nurse. How is that required? Opposite gender nurses, techs, etc do intimate exams when same gender are available without asking...is that required? Yet providers make these choices without asking and then defend expempting students. Of course patients know there will be times when they must be exposed, but the liberties providers take with patients modesty is in starke contrast to what they afford their own. If it were only the required part, not the it's easier for the provider way...this might be different. But it isn't, from requiring patients to strip for cateract surgery to using opposite gender for intimate procedures without asking patient modesty is discounted and justified, but for their own...sorry but to me it is pretty obvious there is a double standard. It goes beyond the actions themselves to the mentality that says students should not be subject to something that makes them uncomfortable but bringing a nurse into a guys vasectomy because it is easier for the MD makes perfect sense....that is the issue that seems to escape providers even you, and you are exceptional on this issue...don
Don, again, it has to do with the context of the activity. Medical students at the time of their practicing procedures on each other are not patients at that time and in a way they are volunteering to be an object for examination. In this context, it would be wrong to order and threaten medical students to undress more than they usually undress for these sessions to teach modesty. By the way the students behave in such sessions and the way they behave with real patients, I see they don't need to be taught further to attend to patient modesty at this point in their learning. Later on, when time and pressure builds on completing their functions, yes, I hope concern for patient modesty persists and they need to be reminded to continue to check with the patient and the patient's concerns.
Finally, as I already have written, once a student or a physician becomes a patient then as with every other patient, the current protocols should also apply to them. Hopefully, any unnecessary exposure in these protocols will be eliminated by pressure and education to the medical system by the patients regarding their modesty issues. ..Maurice.
With all due respect Dr. Bernstein, who defines what that context means? Providers do in both cases. One Dr. does a vasectomy without a nurse obviously understanding it is an emotional and likely embarassing experience for the patient, another brings in his nurse. Same procedure, same context, but different respect for the patients modesty. There is a lot of wiggle room within the context of a patients treatment and modesty. Same context different treatment, so again, remember who defines not only context but what it means. I will ask you again, if I organized all of the people in my retail channel to play loud vulgar music in their stores and this was the only place to get a product or service, are you consenting for me to do this or are you enduring it because you need the service? It is providers who have decided what context means for the patient. I doubt we are going to change eachothers mind. I understand the context changes the need. However what you and providers seem to fail to understand is the context, the need, does not give you carte blanche to make decisions regarding our modesty for your benefit instead of ours. When you do the things that have been listed here use opposite gender when same is available, use nurses for your convenience not our benefit, make no effort to get patient thoughts, do things like force the patient to be nude under those stupid gowns for an endoscopy...what is the context for that? The context is we have a need so providers exploit beyond what is good for us to what is good for them. That is the problem with your context argument...you take the context and expand it for your benefit rather than ours. You (providers) define the context, and you define what limits you CHOOSE to establish, and then justify it with implied consent and context. Context does not relieve you of responsibility to make your patients as comfortable as possible when it does not effect their medical outcome....sorry it is so frustrating that providers choose to make this all about what they have chosen to impose, therefore it makes it fact...don
Don, the solution is a matter of education and accommodation on both sides of the doctor-patient or patient-doctor relationship. It is for the doctor to be educated by the patient regarding the patient's concerns, unknowns about the procedure with regard to modesty and gender selection and the patient should be educated by the doctor with explanation of the procedure in order to eliminate those unknowns but at the same time within that education demonstrating true understanding the basis behind those concerns and together with the help of the patient make an active attempt to mitigate the concerns by finding ways acceptable to the patient but still provide efficacy and safety of the procedure to the patient.
Finally, after education and understanding and attempt at mitigation by both sides, it becomes the responsibility of the patient, primary requester of the service, to decide whether any "noise" is unacceptable. ..Maurice.
I would like to introduce another element into this discussion regarding one of the factors which appears to be part of the issue of patient modesty which is the suspicion of "bad apples" in the medical profession. It is assumed that almost any potential medical encounter will expose the patient to an unprofessional, uncaring and virtually criminally behaving doctor or nurse who is about to take advantage of a patient's bodily modesty even to a criminal extent and that all patients should be "on guard each time for unprofessional behavior".
This conclusion by the patients (and perhaps most of those writing to this thread) can be described by the term "precautionary principle" (which you can read more about this principle and its history and use in Wikipedia.)
The assumption that there could be a "bad apple" doc or nurse in "every barrel" is made not on the basis of documented statistics from scientific study but on the theory that we have heard and read that some exist, therefore they can exist in any doctor's office or clinic or hospital. Therefore out of the need for precaution, all interactions with doctors and nurses should be guarded for the possibility of exposure to that "bad apple".
But what makes the possibility most likely despite the absence of supporting statistical evidence of frequency? It is, in part, due to the application of the precautionary principle to what is called the "availability heuristic". CONTINUED ON MY NEXT POSTING. ..Maurice.
CONTINUED FROM PREVIOUS POSTING.
The following is from Wikipedia about that "short cut" to a conclusion:
The availability heuristic is a mental shortcut that relies on immediate examples that come to mind. The availability heuristic operates on the notion that if something can be recalled, it must be important. Subsequently, people tend to heavily weigh their judgments toward more recent information, making new opinion biased toward that latest news. [1] Further, the availability of consequences associated with an action is positively related to perceptions of the magnitude of the consequences of that action. In other words, the easier it is to recall the consequences of something, the greater we perceive these consequences to be. Finally, people not only consider what they recall in making a judgment but also use the ease or difficulty with which that content comes to mind as an additional source of information. Most notably, they only rely on the content of their recall if its implications are not called into question by the difficulty that they experience in bringing the relevant material to mind. [2]
The following are three heuristic principles that people rely on in situations of uncertainty. These principles reduce the complex task of assessing probabilities and predicting values to simpler judgmental operations.
Representativeness, which is usually employed when people are asked to judge the probability that an object or event A belongs to class or process B.
Availability of instances or scenarios, which is often employed when people are asked to assess the frequency of a class or the plausibility of a particular development.
Adjustment from an anchor, which is usually employed in numerical prediction when a relevant value is available. [3]
Sometimes the heuristic is beneficial, but the frequencies that events come to mind are usually not accurate reflections of their actual probability in real life.[4]
As more and more about "bad apples" are written on this thread the conclusions about their frequency in the medical system and how to deal with a problem becomes more solidified. And then, the precautionary principle is applied.. each visit or interaction with a doctor or nurse carries a significant risk.
I'm not saying that there are not problems in the way the medical system is handling patient modesty issues for each and every patient but I also wanted to point out a possible heuristic error in coming to conclusions on this subject of patient modesty and what to anticipate and how to respond with every visit. ..Maurice.
Looks like I frightened all my commenters away with my philosophical analysis, though I think that there is logic in considering it as something which may be misdirecting our reasoning.
May I present now a view that might stir my visitors a bit and stimulate some constructive commentary.
How about considering a basic mechanism of patient modesty as shame and to be ashamed to show the naked body and intimate parts to others but particularly those who are clothed at the time? The shame could arise from either that the patient doesn't find him/herself as attractive as they would want to consider their naked body. Or shame may be provoked by fearing a reaction such as signs of embarrassment by the viewing healthcare provider.
We haven't really discussed personal shame as part of what is going on in creating patient modesty. Should we start? ..Maurice.
Well Dr. Bernstein, not sure what the post said, went over my head. just so you know how far this thread reaches,the concept of context... I was sitting in a movie this weekend with my wife watching Divergent. Divergent for those who don't know is a different version of hunger games. The premisis, a young girl goes through intensive training to become a warrior good. My wife says there is to much guys beating up girls in this movie....I don't like it. I said but she knowingly goes into this process, she goes into a military training facility, and there are parts where females attack and beat up on males. She said, doesn't matter, I don't like guys beating up women.
And there you have it...nothing else mattered, from her perspective, men beating up women was wrong no matter what...the differences, Divergent was fantasy, and...in the medical community they force their version on patients...that said, I agree with you completely...it falls on the patient to communicate their version of what is acceptable, and what is not. If you fail to do so, expect providers to insert their version...don
I think shame is definately part of the issue for many, shame and embarrassment are pretty closely related. Many people have insecurities about their body image. This is more likely to be associated with females but males often have similar concerns. Shame can come from your own concerns about your body but it can also come from early teaching or conditioning. If you are taught to be ashamed to be exposed infront of opposite gender, and you don't address it, it rarely has a venue for discussion or to even needs to be addressed...until you come into the medical community. So yes I believe shame has a role in some of these. I beieve it is part of mine. If you go to a topless beach odds are the majority of women will not be topless...why, it is acceptable, the context is right, some would feel shame, judged, others may be comfortable with their breasts but still be ashamed to how them in public.
Got a good case of context from the other side the other night. We went to see the movie Divergent. The premis was a young woman volunteers and joins a para military unit and goes through intensive training. My wife didn't like the part where she was fighting guys in training and getting beat up. I said but it was part of the movie, she was training to be a fighter, ...nothing I was going to say was going to change my wife's opinion that guys should not hit women. It was wrong and the context of it being part of the movie, being part of the training could not of mattered less. The context, even if it was the premis of the movie didn't over ride that basic time honored thought that men do not hit women....sort of like modesty...don
Of course embarrasment is part of the issue. I think that embarrasment is probably the biggest reason people dont like being exposed, especially by opposite gender care. Would most people like to sit naked in front of people. I've heard comments on similiar posts about how this is the 21 century and we should be over the modesty thing by now. I couldn't disagree more. We are now in an age where body image has become so important that most of us have become obsessed with it. Whether its loosing weight commercials, perfect skin commercials, constant male enhancment ads. I bet you people are more self conscious today than they were 40 years ago.
Which is the worst entity, the hospital or the health
insurance company? Few people know this but most
health insurance companies won't pay for a private
room. Hospitals get more for private rooms thus
the relationship between hospitals and insurance
companies is business.
PT
Perhaps you are all missing the focus on where this discussion should be.
Maybe, the shame is based on your complete loss of dignity that is against your will and like a rape victim, self blame is where the shame comes from. One can feel humiliation when someone else is to blame but feels shame when there is self blame.
Psychology is where the focus on this discussion should be. We are not talking about medical issues as much as we're talking about how we feel, why we feel and what we feel when things happen that cause loss of control, bodily exposure (if you are uninformed is essentially against your will without consent).
How do we feel when someone takes away your dignity and we did nothing about it? How do we feel when we lose our dignity and we do something about it? Shame and humiliation are often intertwined when they are two separate human conditions.
Instead of placing feelings of shame on your body, what about shame because you let it happen or feel that you did?
So, doesn't it make sense that once something happens like that you promise yourself that you will do whatever it takes to avoid being put in that position again? How many times do you have to get hit over the head with a hammer to avoid hammers?
Maurice, it's the medical standard of care issues that are not in touch with patients and their feelings and the idea that the industry doesn't care, just reinforces that loss of dignity, respect, worthiness. That's what they want to do.
So, I ask you this. Who, with a healthy mind, would permit themselves to be treated in this way?
It is time for the medical industry to examine itself and they refuse. The population you call outliers just gets bigger and bigger. Eventually, there will be such a backlash that the medical industry will not be able to function. It has already started.
In it's way, isn't this like war? Aren't some people willing to give their lives to stand for something they consider more important? Then why should it be such a stretch to understand why normal, mentally healthy individuals refuse to allow themselves to be treated the way we are all complaining about?
belinda
"Looks like I frightened all my commenters away with my philosophical analysis"
No, not really.
Don't get me wrong... you seem like a nice enough guy, and you seem to be working very hard to educate other doctors about our modesty issues...
but... and I honestly don't mean this as an insult, I'm just not sure how to word it in a more polite way... you don't seem to be really grasping where we're coming from.
I've skimmed back numerous pages, and the majority of your replies suggest "education" and explaining the procedure, and same gender providers / chaperones as the best solution.
I can't speak for anyone else, but from my point of view, that is nowhere near a solution at all, and it really sounds like you emphasize with our modesty issues, but you really do come off as someone who is speaking about something they've read about but never experienced themselves. Do you yourself have a problem with a doctor touching you in your nether regions?
I'm well aware that some procedures (diagnostic included) will require the doctor to see & touch someones genitals / backside.
What I'm not ok with is undressing infront of someone I'm not in an intimate relationship with. (That has nothing to do with a religion either, I'm atheist... it's just the way I was raised I guess...)
Yes, I have a huge issue with my body image.
No, a male doctor will not make it all better, and no, a male chaperone with a female doctor won't do anything for it either.
A doctor (male or female) with a camera in the room is definitely out of the question.
And being covered with a sheet, and only exposed a bit at a time is ... and again, I'm not intending this as an insult... but to be quite frank it's a joke and rather insulting if you think that line of reasoning would actually dissuade someones modesty issues. (sure, you're flat on your back with your genitals hanging out, but your abdomen is covered, so you're not naked. Don't worry about that camera in the ceiling or the door only 3/4's shut... really?)
I have been ignoring a few things I probably should have looked at, but there's no way I'm dropping my pants for something that isn't going to kill me, and in all honesty, I'm not sure I'd go even if it was something I thought might kill me.
I'm sorry if this has offended you, it was not my intention.
Jason K
Honestly, this has been kind of bothering me all day....
"The assumption that there could be a "bad apple" doc or nurse in "every barrel" is made not on the basis of documented statistics from scientific study but on the theory that we have heard and read that some exist, therefore they can exist in any doctor's office or clinic or hospital. Therefore out of the need for precaution, all interactions with doctors and nurses should be guarded for the possibility of exposure to that "bad apple".
But what makes the possibility most likely despite the absence of supporting statistical evidence of frequency? It is, in part, due to the application of the precautionary principle to what is called the "availability heuristic". "
You're saying that we're "suffering from" heuristic error, and statistically we likely wouldn't encounter a bad apple in our encounters.
first - why wouldn't we guard against a violation of our deepest fear? If my modesty wasn't that big of a deal to me, I wouldn't be here. If you wait until AFTER you've had your privacy breached, it's a tad late.
Second - do you lock your house and car at night or when you're not near them? if so, why? statistically speaking there are billions of cars and houses worldwide... odds are yours won't be the "lucky" one to get robbed, so is it a heuristic error to lock your doors to prevent the statistical unlikelihood of you getting robbed?
This is right up there with the nurses claiming "we've seen it all before, you're not special" in that you're trying to downplay our concerns by offering a possibility we're just being irrational. (in a round about way)
Of course I'm not "really offended" by this... it's a discussion on the internet... but it is kind of offensive (in a non-offensive way, and I know that won't make sense... ah well.)
Jason K
I agree with Jason on some points. I do think you are a good person and you honestly are looking for answers. unfortunately I think you are so embedded in the medical community that your perspective is going to be heavily slanted in that direction, It is probably natural that is would be this way. But I have to agree with him that your responses at times are obviously those of a profider whom is justifying as much as discussing. I have a lot of respect for you and what you are doing here,,,but to large degree we are who we are, after decades of being a MD, would we expect much different.
Now this is an interesting coincidence but I was in Indianapolis recently and out side a major mall was a sign that said something like "Millions of men are dying from embarassment" and it had a website to go to about medical screening. Dr. Bernstein, I would challenge you to ask your students what that phrase means to them and report back to us. I think it is really clear, but I would be interested in what it means to you and your students....don
Jason K, keep posting your thoughts and perspective; I think they're interesting and refreshing!
Ed
I encourage everyone here to read this article, “GENTLEMEN DON‘T LOOK UP LADIES’ SKIRTS” at http://modestyxxx.com. This article discusses modesty and male gynecologists.
Especially look at this paragraph in the article: “Decades ago during the male monopoly in medicine, I had a dear female relative who would not go to a male doctor for any intimate exams. “No male is going to look at my private area,” she proclaimed. She never relented, even when troubles began – “down there, up front.” She died of cancer of the reproductive system far too early in life. In my opinion this lady over-valued modesty. She chose to keep her modesty and gave up her life. Too many women for too long were faced with the same dreadful moral dilemma as my relative.”
Can you all please share your thoughts about this article? What are your thoughts?
-Eros Modestica
Eros,
Welcome to the blog as I haven't seen you on here so forgive me if I'm mistaken.
Regarding your posting, yes, depending on one's background and their experience, one might avoid bodily exposure. I recommend highly writing of Dr Evelyn Lindner who did extensive writing on the experience of humiliation.
It is often the underlining issue for the shooter's who suffer from humiliation and it's not uncommon for one to avoid ANYTHING to avoid feeling humiliated.
We do not know the background of this woman, as there are many factors involved into making a decision that one feels is unreasonable.
Many people who feel as strongly as the woman mentioned might have either been raised by strict morality regarding this issue, been subjected to sexual assault or had a previous horrific experience during a medical procedure. We just don't have these answers.
To he poster who wrote about the quote..."Men are dying from embarrassment"...many months ago I spoke of a TV commercial that centered on this issue and the commercial stated something like, "We're just as embarrassed conducting this examination (I doubt it). Don't die from embarrassment, have your prostate exam".
The medical community is well aware of the problems but don't care to fix it because up until now they thought they didn't have to. With the advent of more women in medicine, female providers are more available. Nurses are most often woman too. This creates a pronounced problem for our male friends seeking, dignified, respectful care.
Can the medical community be so stupid that they can't recognize simple common sense feelings that most people have toward opposite gender care? It's written in our employment laws for goodness sake.
So...what's the problem?d
belinda
Belinda, IMO, the problem is twofold:
Expediency and profit are way more important than dignified respectful care and patients are too embarrassed/intimidated to request/demand their care is administered in an acceptable manner.
If we fix the second, the first will take care of itself.
Ed
Ed, let's get down to the "nitty-gritty". How can a proper physical examination of a woman's breast or the male or female genitalia and/or rectal exam be performed if the patient is "too embarrassed/intimidated" by anticipating or undergoing the procedure. What is that "acceptable manner" which can yet be able to yield clinically valuable information? ..Maurice.
Hi Ed,
Either speak up or shut up. Patients must decide what's more embarrassing, speaking up or having and event. Then everyone is on their own.
When I had a horrific experience, including sexual abuse in a heatlh care setting, you couldn't shut me up. Changes were made in the department, the doctor involved was disciplined and I was left out in the cold.
What's so embarrassing about taking care of yourself and your needs? I just don't get it. Perhaps someone can tell me more.
My feeling is that I was not concerned about gender until after I had a bad experience. Therefore, I am in a position to disallow medical students, extra people, require same gender care if needed and am prepared to walk away on the day of any procedure/operation when my needs are not met. They are backed up with letters from various providers to re-enforce what's needed to the extend it's malpractice to try to trick me into something against that would be against my will.
What I need is more important than what "they" need. If patient's would develop this mindset they might not be so embarrassed to speak up or suffer the consequences.
belinda
On the money Ed. Dr. Bernstein, there is nothing you can do to eliminate it, but with a little effort it can be mitigated to make it tolerable. I hate the prostate exam, I just hate it...but I have it done because I know I need to and my male MD is smart enough to keep it just him and me, and does it quickly and efficiently. Being forced to accept a female doing or observing it might be enough more to keep me from having it done. Really, how much effort is put forward in accommodating or even ASKING the patient what would make them more comfortable. You didn't answer my question of what did the phrase on the sign mean that "men were dying of embarrassment mean to you and your students"? I think we all know what it means. So is it possible that while almost everyone on this post has heard it, seen it on signs or TV or other media presentations, those in the medical community have not? I have seen similar things all over the place but evidently since the medical community supposedly is ignorant of the issue or at least the degree they have not. This is the frustration we have here and in general. In your examples you assume that either no amount or no reasonable amount of accommodation will result in the patient allowing the proper examination. No one is saying that. There may be some who are in that category but the majority here are saying same gender is a big step in this. That is what we are saying, with accommodation we can tolerate or accept this but providers are not attempting to offer that. And to that line I am challenging you and other providers that when we see all of this "don't die from embarrassment" stuff on TV, in malls, different high visibility venues...to claim ignorance is suspect in the first place. The failure to recognize or acknowledge the difference between a patient saying I refuse to do this and I refuse to do this unless you provide these acomodations to make me more comfortable only reinforces that mistrust that providers are not being honest as it serves their agenda....don
Dr Bernstein, "too embarrassed/intimidated" is a subjective determination made by the particular patient. What's acceptable for me may be totally unacceptable to others.
We recently moved which prompted the search for new physicians. A PCP is relatively easy; we asked neighbors for recommendations and looked at online ratings. My wife and I both selected the same male physician. However, for OB/GYN care, she selected a different practice with all female providers since they scheduled her annual PAP with a male without asking her preference; no surprise there! Just to be clear, I could care less if my wife sees a male OB/GYN as long as she's comfortable with him (she's seen both).
Selecting a urologist for myself is not nearly as easy; I'm not going to ask my neighbors if their happy with their urologist; too personal. I did ask my PCP for an urologist recommendation; a male who truly believes in and practices informed consent and patient autonomy. He recommended any of the three at the local urology practice. Additionally, I called the practice to inquire about male ancillary staff. The response received, in an incredulous tone, "of course not, we've never had a male apply" which wasn't actually a surprise considering where we live.
Here's my bottom-line: My gender specific health care will be administered by a male. In a pinch, I'll see a female physician; they've earned the professional distinction. There will never be third party female present unless I've exhausted all other options. And you can be damn sure Ill have their full name, qualifications, and know exactly why their there and how I benefit. Otherwise, I'm in the ER knocking on heavens door in which case I welcome whatever care they deem necessary, as long as it complies with my advance directive which specifically forbids urinary catheterization without my or my wife's explicit consent. I never considered the camera issue until Jason's comment; you can be damn sure in all future healthcare encounters to check for their presence. Camera present, we're done. I'm not going to discuss gender specific history or symptoms with female staff. The irony in all this, while uncomfortable, I never questioned a female presence before those negative experiences recounted here. Never again.
Ed
I agree with Belinda's earlier post that differentiated humiliation from shame and the causative factors involved.
Forced nudity is widely recognized as a form of psychological torture. With strictly limited legal exceptions related to safety and security in penal institutions, forcing or intimidating a person to undress against their wishes is a violation of their rights. The venue doesn't matter, be it a Nazi concentration camp, terrorist prison or medical facility, and the intent of those in perceived positions of authority taking such action is also irrelevant: the effect on the person being forced or intimidated is the same.
Body modesty is a personal value and each person has a vested right to their own definition of such as it applies to them. Some people could care less about intimate exposure, while to others it may very traumatic emotionally and even physically. The reaction can vary, but from what many have posted here and many other people I have talked to about this, it progresses from humiliation to shame, then anger. Some will stand up for themselves while others will just avoid medical care situations where exposure might occur.
Unless/until the medical industry recognizes this situation and responds, nothing will change. The bottom line is that it's about respect. The patients' values and concerns need to come first and they need to be respected, not belittled or criticized as happens all too often.
Hex
So Ed has laid out his terms and conditions. Is he refusing care, is he being unreasonable, is he denying needed examinations. I don't think so at all.
So i ask again, with the concept that men are dying of embarassment so well known...how can one say providers are unaware, and if they are truely aware, are they not at least complicit in the problem. While we patients bear the brunt of the burden since it is for our benefit, i find it hard to accept providers are not to blame because they don't know. Just as reporters justify their presence in the locker room and become indignent when it is suggested they don't belong there, they justify it is due to their rights and the context makes it different, providers claim no harm since they don't know and the context makes it right....don
I understand the patient's need for protection against inspection or touching by specific individuals or individuals of a unwanted gender. And I am all in favor of all healthcare providers being made aware and to appropriately attend to the patients' concerns and requests.
But what I am asking my visitors here who have modesty issues, whether their embarrassment is so great if they had a physician or nurse of their wishes who had to expose and touch those sensitive anatomical areas in order to perform a necessary inspection or function which if covered and untouched would not be possible would still reject that inspection or procedure. In such a case, not to allow exposure or touching would defeat the reason to undergo the examination or procedure.
Do my visitors want to be in charge of setting up their own version of the protocol for the inspection or procedure even without knowing or understanding all the details and technicalities of performing the procedure and thus likely to degrade the value or safety of the procedure if attempted to be carried out based on the patient's directives?
Would any woman want a pelvic exam to be done under a cover to deny the doctor the important value of inspection?
I think the answer to this issue is communication of concerns before hand with the doctor or nurse, for example, caring for a hospitalized patient and then allowing the professional to decide how to handle the concern or clearly explain to the patient why it would be impossible to to follow the patient's request. Both sides have to listen to each other and then find a common but still effective and safe conclusion. ..Maurice.
It is difficult to break into this on-going conversation, but I would like to support the comment on April 3 of Eros, suggesting that an article at www.modestyxxx.com is worth looking at. It is entitled "Gentlemen Don't Look Up Ladies' Skirts."
Some years ago when the internet was young, I came across an article that caught my attention: "Why do my wife's genitals excite me, but don't excite her male doctor." As I recall, that article fumbled with the issue rambling along about brief appointments, repetitious exams, etc. On the other hand the article on modestyxxx.com is hard-hitting and filled with provocative ideas, gleaned from anthropology, psychology, and medical literature.
To summarize, human males have evolved a "sight-based" sexual arousal system that is under the control of the autonomic nervous system, a unique sexual system among mammals. Researchers have found that male sexual arousal is hair-trigger fast and immediate when confronted with erotic material - such as the sight of the female genitalia. Scientist can measure this male response with various medical instruments; they have found that even subtle female gestures trigger responses. No scientific measurements have been done in the gynecologist's office, but such an experiment would be conclusive.
Unlike other male mammals that are stimulated by odor, human males respond to sight. Because there is no scientific evidence showing that male doctor have found a way around this sight-based system, the author concludes that male doctor derives some erotic pleasure from the pelvic exam.
To support these scientific allegations, the author quotes from medical association publications in the US, Canada, and the UK supporting the allegation that pelvic exams by male physicians are erotic. It is hard to argue with a National Health Service publication from Great Britain that says there is "nothing unusual about sexualized feelings towards certain patients." The well-noted article "Time and Tide" is used to support these serious charges.
The author notes that male doctor's have contributed to the well-being of female patients - this is not a broadside attack on medical providers and concludes on a positive note that female patients now have a choice of gender when shopping for medical service.
There is absolutely no doubt some male physicians with some female patients are sexually excited. Conversely, the same is absolutely true with some female physicians and some male patients. It's how those same physicians conduct themselves that matters. We ought to be thankful our physicians are human beings with emotions and feelings; that's what makes them caring, compassionate, and ethical!
"But what I am asking my visitors here who have modesty issues, whether their embarrassment is so great if they had a physician or nurse of their wishes who had to expose and touch those sensitive anatomical areas in order to perform a necessary inspection or function which if covered and untouched would not be possible would still reject that inspection or procedure. In such a case, not to allow exposure or touching would defeat the reason to undergo the examination or procedure."
The answer is yes.
I have a couple things that "should be" looked at, but I will not drop my pants for a doctor (being the same gender doesn't make a difference).
I don't care how much school they've had or how many other people they see "sequentially exposed" in a day.... none of that has anything to do with ME letting a stranger see / touch / probe my genitals / rectum.
The only possibly way I can think of to alleviate my issues would be ... well... "might be" since I won't know if it'd work till the time came... if I actually got to know the doctor as a person and they were able to gain my trust and confidence.
5-10 minute appointments every few months / years doesn't really offer a good foundation to build trust.
I know it's not plausible for the doctor to become the best buddy of every one of their patients... I'm just putting out what I think might be the only way for doctors to gain the trust and confidence of someone with as many modesty / privacy / self image issues as I have.
Jason k
Since doctors and nurses are human beings, not asexual machines, and those in active practice have all the nuts and bolts and wheels in their brains fully and normally functional, it should not be surprising to anyone that sexual thoughts can and do enter their minds. It what the doctor or nurse does with those thoughts as they are attending to a patient that makes them professional and of value to the patient or unprofessional and clearly a harm.
Virtually in every case,attending to and investigating complexities in the patient's medical problem as a doctor or completing the task satisfactorily and safely and moving on to another patient as a nurse trumps at the time of the examination or procedure any deviation from professional behavior.
So I agree that doctors and nurses are not inert objects and hopefully all patients are aware about that fact. However, all patients should be aware that in virtually every interaction with a physician and nurse the necessity and in many cases the urgency of making a diagnosis or completing a task trumps any consideration of sexual and thus professional misbehavior.
So, in conclusion, every patient should, virtually every time, enter the relationship with their doctor or nurse with confidence that the patient will be professionally treated. Nevertheless, just as the patient should be open to the caregiver regarding the history of the symptoms and medical experiences, the patient should also feel free to express their modesty concerns and request an attempt at mitigation. If the patient is not so treated, the patient should "speak their mind" directly to the caregivers and supervisors. If the caregivers' behavior is a part of a cycle of misbehavior obviously those who recognize that misbehavior should not remain silent since holding back expressing concern, fear and anger will not contribute breaking cycles. Patients should know they should never consider themselves as an object in their relationship with the healthcare provider. All patients should consider themselves as part of a team with the target to achieve a beneficent goal and any deviation from such teamwork by any member should be attended to. ..Maurice.
"all patients should be aware that in virtually every interaction with a physician and nurse the necessity and in many cases the urgency of making a diagnosis or completing a task trumps any consideration of sexual and thus professional misbehavior.
So, in conclusion, every patient should, virtually every time, enter the relationship with their doctor or nurse with confidence that the patient will be professionally treated"
Wow... really? after all these pages, and all our attempted explanations, you're basically summing up a reply as "Just assume they're too busy to care about your body (as a sexual object or subject of ridicule amongst themselves later)? And you think that's a solution to modesty issues? Really?
this is exactly the type of reply I was referring to when I said that you come off like someone who has read about something but never experienced it themselves. if you really "got" the problem from our side, you'd see just how much your statement doesn't work.
Even your statement "all patients should be aware that in virtually every interaction with a physician and nurse the necessity and in many cases the urgency of making a diagnosis or completing a task trumps any consideration of sexual and thus professional misbehavior." kinda gets thrown out the window by the fact that misconduct DOES happen... and happens fairly often.
If you don't believe misconduct happens all that often, then how about you make it your new goal to find out who it's been done to, track down, and inform every woman who's been given a non consensual pelvic exam that it's been done to her?
How long do you think that'd take you? shouldn't be that long if it "virtually never happens"...
Or go talk to all the patients of Dr Nikita levy.
or Dr. George Doodnaught.
(those 2 are just page 1 of google)
Jason K
Jason, you write "after all these pages, and all our attempted explanations, you're basically summing up a reply as "Just assume they're too busy to care about your body (as a sexual object or subject of ridicule amongst themselves later)?"
What is written here by my limited number of commentators (visitors who have something to write) is no indication of the statistical frequency of the events which they describe in the entire patient population. It is wrong to come to an opposite conclusion. However, the profession should be made aware of even what psychologic, and perhaps physical impacts any personal or read about incidence can have on the appearance of the medical profession even if the incidence numbers are relatively small. And there should be changes in the system with attempts to diminish the incidence further. ..Maurice.
Wow a lot of stuff going on here. I have to admit I do not understand everything written here but there are some interesting points.
As to your question Dr. Bernstein, absolutely if I got what I needed, which is male providers if I am awake and exposed, it would be enough for me to do do whatever is asked of me. I would prefer males when I am exposed awake or not but try to understand and meet half way. I also do the things I need to even if I do not get what I need, but it cause me unnesecary emotional truama. But that is me.
Dr. Bernstein, I appreciate your acknowledge that providers are human, have these thoughts, and the definition of professionalism is how they deal with them. I realize some disagree, but this is natural not deviant. The problem as I see it is providers have contended they did not have these thoughts, that was their representation of professionalism. I defied what I saw as realistic and it allows providers to not make the accomodations admitting this might have required. I understand your points Dr. Bernstein, and I really wouldn't have a problem with them other than they are not acknowledged and used to justify, and cover the truth. All in an effort to get patients to accept what providers want to offer which may not be what the patient would prefer if it was acknowledged. Providers are human, putting on scrubs does not insulate them from their natural feelings and desires, providers deal with their thoughts and desires so they can take care of patients. Isn't that was we have been trying to get a provider to acknowledge? Isn't that the basis for changing all of this? We can not ask or expect providers to check all that is natural, and all that is learned at the door just because they put on scrubs. To do so is just as unrealistic as them expecting us to check all of the inhibitions and feelings we were born with and have learned in our lifetimes when we put on those stupid gowns. So, then it would seem the answer would be honesty, and unfortunately it seems like the burden will fall on us patients to facilitate this. It took what, 9 years and 64 volumes to get to this point. So expecting providers to get there without out help. not goint to happen...don
Jason, I totally get your modesty/privacy/self image concerns in a medical setting. Generally speaking, that's what this blog is about. No disrespect intended but as an adult male, I don't understand your concerns with misbehavior or misconduct with a physician; could you elaborate?
Ed
Maurice,
I would have any exam needed (and do) if my other needs are met, and would refuse completely if they are not.
Additionally, I come prepared so if my needs are not met the liability of refusing me rests on them and puts a burden on the system to help me.
belinda
Belinda, there is no legal liability on the part of the physician if the patient refuses by informed dissent based on the details presented by the physician unless pertinent details are not presented. Refusing consent is the property of the patient and if whatever you have "come prepared" does not meet the standards of the medical system for this particular examination and cannot be accommodated, there is no burden on the doctor except further educating the patient. Certainly no liability is you mean legal risk. For example, consider colonoscopy in which the patient is willing to go along with the procedure but refuses to have prepared her bowel as directed before the exam. She has had every right to "meet her needs" in the procedure but the doctor need not, under any liability,subject the patient to the exam without bowel cleansing.
Belinda, if I misinterpreted what you wrote, please write back what you meant by "I come prepared..." and the "liability". ..Maurice.
Maurice,
What I was saying that with doctor's letters that mandate medical necessity for same gender care due to the nature of a particular health risk (ex. hypertenion, stroke), putting additional stress on that patient limiting their options would not be in the best interest of the patient or the hospital.
There are ways to accommodate needs other than a same gender team, example (prepping in private), draping patient before entire staff present, etc.
There has to be some level of trust to get through what you need. While I'm steadfast in my mindset, I'm flexible on how to make my needs and the hospital's ability to meet my need work.
I wasn't emphasizing legal risk as much as medical, but now that you bring it up, that's a risk too if they refuse to work with that patient.
I hope that clarifies my position on things.
belinda
"Jason, I totally get your modesty/privacy/self image concerns in a medical setting. Generally speaking, that's what this blog is about. No disrespect intended but as an adult male, I don't understand your concerns with misbehavior or misconduct with a physician; could you elaborate?
Ed"
It's not that I'm worried about being "touched inappropriately" by a doctor or anything like that. It's more of a professionalism / mocking thing.
When I was a kid, the family doctor never shut the door behind himself when he entered.
Throughout my life, I've known 3 nurses and a doctor. ( my aunt, 2 of my friends mothers, and one of my girlfriends father)
I've heard them talking to their friends... each and every one of them tell tales, describe specifics, the women discus mens sizes, make fun of body sizes... the whole nine yards... all while using the patients names. (first and last at times)
I could see if a doc / nurse was telling a story about "some guy came in today and he had a dollar bill tattood on his member and he said it was to watch his money grow" or some anonymous story like that... but I really can't trust the person who told everyone in the room that "bob smith the new fire fighter was in for a physical and turns out he has a micro penis" (to a table full of women laughing, not a care in the world of who can hear), nor can I have any kind of trust in an industry that is filled with these kinds of people.
100% of the people I've personally known who work in the medical field DO NOT see the problem with telling the world peoples intimate secrets / medical problems.
So... like I say, it's not that I'm worried about getting touched inappropriately, I just cannot trust them "just because they're doctors / nurses", and being exposed (even sequentially) is an incredible leap of trust for me.
Jason K
Jason,
Have you ever considered moving to
the suburb of a large city? The big hospitals see so many people, nobody will know who you are.
While this doesn't solve the problem of feelinge humiliated by the actions of others, your identity would be basically invisible. Nobody rnmembers the names of the people, nor anything specfic.
belinda
I think Jason's post sums up what a lot of us have been saying. What we hear personally and what we are told by and about providers does not line up creating mistrust of the whole profession when it comes to being treated. I also have heard "professional providers" telling tales. I have heard the practice defended here though qualified by anonimity of the patient. I made the statement then and again, You do not get to claim professional status in getting access to us and then claim we are just human blowing off steam or whatever. We hear providers joking, making these comments, so when another claims professional priviledge...it is hard to believe. This perhaps is as basic of a issue as any. Personally I agree with Jason, I do not trust providers not to judge, talk, or make jokes..I have heard them to it about others. So if we don't trust them to this level, how can we be comfortable trusting them when it is us in the gown? don
Jason, understand and concur; thanks!
Ed
Janson's timing is impeccable:
http://news.yahoo.com/blogs/oddnews/surgeon-accused-of-slapping-sedated-patients%E2%80%99-behinds-181952054.html
Ed
I think the thing that is really disturbing is the behavior went on for over a year. The MD appears to be a deviant. But the culture that would allow this to continue requires complicity at multiple levels. It appears on occasion it was reported. Yet, it was allowed to continue unabated. This is similar to the Dr. Sparks where she sexually abused male patients and kept her job. There was the case where nurses exposed a sedated male because of his "endowment". In all of these cases the partcipants were either one or a few, a few reported it, many ignored it, and the administration did little to nothing. While these are extreme cases...if the culture is to condone or protect our own...once again this supports our concerns...don
Well... after reading the slap happy doctor story, all I can say is ...
"all patients should be aware that in virtually every interaction with a physician and nurse the necessity and in many cases the urgency of making a diagnosis or completing a task trumps any consideration of sexual and thus professional misbehavior.
So, in conclusion, every patient should, virtually every time, enter the relationship with their doctor or nurse with confidence that the patient will be professionally treated"
you were saying?
re: the Yahoo article about the butt slapping doctor, be sure to scroll down to the comment section and read some of what people have posted. Even if only half of it is true, it doesn't make the OR a place I would ever want to be. DLAM
The comment at 7:06 pm by "Anonymous" was, as I was informed, from Jason K. ..Maurice.
Is it really fair to the medical profession to "butt slap" all physicians and nurses because of publicized but isolated stories and their associated directed commentaries? Can one extrapolate and is it fair to do so based on such public discourse? Has anyone looked up to see if there are any sociologic studies providing statistical evidence of wide-spread misbehavior that would require caution on the part of all patient-doctor or patient-nurse interactions? ..Maurice.
Dr. Bernstein,
The problem is that it's not just at St. Joseph's Hospital.
It was reported last week that Legacy Emanuel Hospital in Portland was investigated in conjunction with the actions of Jeffery McAllister, a male RN that worked in their ED, and specifically their failure to investigate patient complaints against Mr. McAllister.
To quote the report from CMS:
"The hospital failed to ensure that it protected and promoted each patient's right to receive care in a safe setting," the federal review found. "The hospital failed to ensure that it had systems in place to prohibit and prevent sexual abuse, including conducting a thorough investigation of an allegation of sexual abuse.''
They found the violations so serious that they threatened to pull the hospital's medicare/medicaid certification, which would cost them something in the range of $250 million a year in funding. Only when faced with this threat did the hospital finally take steps to change how they investigate patient abuse complaints.
The complete article can be found at: http://www.oregonlive.com/portland/index.ssf/2014/04/legacy_emanuel_bungled_patient.html
Mr. McAllister will stand trial in Sept. on multiple counts of rape, sodomy and sex abuse.
As I have stated before, I don't believe that there is widespread abuse, or misbehavior as you call it, but it does exist and there are studies that document that.
The big problem is what happens when it does occur. In the legacy investigation, it was found after they finally looked into it that there had been complaints against the male RN as far back as seven years. Were the failures intentional? I don't believe they were, but more as a result of the mind set that a hospital employee wouldn't do such a thing, so the patient must be lying and their complaint dismissed out of hand without investigation.
Even the CMS investigation I quoted was conducted in secrecy, and the information only came out as a result of FOIA request from the Oregonian newspaper.
What I find unconscionable is the coverup. By their actions, or lack thereof, these hospitals have proven that they do not have the patient's safety and interests first and foremost. It begets the question: Can we trust them?
Are these two incidents isolated? I highly doubt it. Rather, I believe they represent a microcosm of the medical industry as a whole.
I firmly believe that the vast majority of doctors, nurses and other medical providers are truly good people and would not intentionally abuse a patient. That said, if the medical industry wants our trust, then they need to proactively recognize that there are some among them who would engage in abusive behavior, and proactively take steps to weed them out - and that starts with taking patient's complaints seriously.
Hex
"Is it really fair to the medical profession to "butt slap" all physicians and nurses because of publicized but isolated stories and their associated directed commentaries? Can one extrapolate and is it fair to do so based on such public discourse? Has anyone looked up to see if there are any sociologic studies providing statistical evidence of wide-spread misbehavior that would require caution on the part of all patient-doctor or patient-nurse interactions? ..Maurice."
you say it's just isolated, and sure... the "huge news stories" doctors / nurses make up a very small percentage of all the doctors / nurses...
But for every one bad doc / nurse, how many supporting staff (doctor, Nurse, Tech, supervisor, administration, etc) have practically HELPED them in their behaviour by ignoring it? In this last story alone, it went on for OVER A YEAR. That means just about every member of every OR team that guy worked with all made the choice to allow the behaviour, so how many people does that actually add up to? a few dozen? a hundred? more?
And since most of these that come out have been apparently condoned by the administration (they only deal with it when it's been "leaked" or police contacted) this tells me it goes on a LOT more than you're willing to admit, or it would be taken a LOT more seriously.
It basically boils down to this: Sure, I know there's a chance the medical staff who treats me will act professionally, but... as small as you claim it is... there is still the chance they won't. Given that (like I said in a previous post) 100% of the people I've known personally who work in the medical field don't honour the privacy of their patients, AND story after story after story like the butt slapping doc surface, which shows that not only that there are indeed bad docs, but the ENTIRE SUPPORT STAFF AND ADMINISTRATION go right along with them, or at least turn a blind eye to their misconduct, WHY on earth would I just assume I can trust any medical practitioner?
I'm sorry, but it's the medical society with the black eye, and it's up to them to re-build trust and confidence. It's not up to us (the patients) to prove that we're still at risk of being victimised.
Jason K (Remembered to sign it this time ;) )
re: the article hex linked to...
""It seems unlikely that a male nurse would take such liberties with a female patient in the ED. ... The patient's report varies substantially from what was reported'' by McAllister, human resources workers wrote in his file"
They really think McAllister would put in his report that yeah, he was abusing patients?
Really?
This is the exact attitude that creates an "us Vs them" situation, and causes a severe loss of trust.
I sincerely hope that criminal charges are brought against not only the rapist doctor, but each and every hospital staff member involved in the cover up (even if their part was due to sheer incompetence)
Jason k.
Everyone is presumed innocent until proven guilty; at least that's how it's supposed to work!
Ed
People's lives cannot be dismissed as "a few bad apples". I wonder if a physician had a family member, wife or daughter who was traumatized because they were treated with cruel and degrading behavior, suffer for years with emotional and physical illness as a result. Would they blame it on a "few bad apples".
It's the culture that needs fixing and it's just that I find it so disturbing that good doctors can't see it. Are they blind? I don't think so. The second they acknowledge a problem, then they have to fix it.
The medical lobby will do everything to keep the status quo and for us to make things as difficult as possible. Social change doesn't happen when you are compliant.
belinda
"Everyone is presumed innocent until proven guilty; at least that's how it's supposed to work!
Ed"
Not to the extent that they don't bother investigating the allegation.
IF you're referring to medical staff in general, implying we're supposed to trust everyone until we get violated, and then only distrust that one specific individual, yeah... no. Sample representations are often good enough to provide an overall outlook on a group, especially for personal opinions.
Jason K
Dr. Berstein I am still in the camp that these incidents are extreme and not the norm. I believe however as stated the fact that so many in all cases had knowledge and did not step up and defend the patient. In the case on allnurses where numerous nurses took turns taking a peek at an sedated male. As distrubing as the action was, I found the discussion about it even more disturbing. While some condemned it and said it should be reported the majority said do not report it and their comments ranged from you will become a outcast to no harm no foul to just talk to them. To me it was such a obvious us and them mentality. While these extreme incidents, I feel even your comments have an under tone of bias toward providers. This is understandable and probably normal. As disturbing as these publicized incidents are, the ones we hear personally are just as damaging to our trust. When you take these combined and then apply them to situations that we already question but are told by providers and trust becomes very fragile. While you have acknowledged gender nuetrality is a myth, the medical community has trumpeted this for quite sometime. Patients questioned this to themselves but did not challenge it. All of this combined makes the 'context" concept you use much less valid to us. I want to quantify what I mean by trust, to me...I still do not fear "having my butt slapped", not in the least. I do however not trust them to judge me, to not talk among themselves, or other unprofessional things that the community has for so long vehemently denied. I don't know if i would feel differently had the community been as honest as you have of late, but my trust of them should would be better, and if I trusted them more, I might be willing to accept more. It is the whole package, the incidents reinforce the concern we have from hearing them personally and reading things like allnurses which validates the doubts we have with what providers are saying about things life gender nuetral, we are professionals, a penis & a foot are same to us, ...it all erodes trust...don
"a penis & a foot are same to us" is certainly not considered equivalent by any sane healthcare provider. We all know, from our own modesty, that these parts of human anatomy are not the same and particularly if looked at or handled by strangers. The only exception to this expression is, as I have recently recorded here, is that my experience with first and second year med students is that "yes" they find a similarity: suspecting the patient (and of course the students themselves) has physical modesty for both! And that is why the students repeatedly fail to remove or have removed the socks of patients when they are to examine the foot! Otherwise, there is a great difference and all professionals keep that in mind.
I think that we need to keep a perspective regarding everything that we read on these discussion blogs including ours. People who write are generally attempting to get a point across and often it is based on personal experience or experience they have read about and amounts to making heuristic conclusions: assumptions of generality but not based on, for example, statistical facts, would be one way of looking at it.
However, for associates to ignore any behavior by healthcare providers as "part of the profession" is wrong and there should be changes in the medical system to assure that witnessed misbehavior, even if statistically small needs to be attended to toward the best interest of the patient population and to remove the stain from those providers who follow the ethics of the profession. ..Maurice.
A short primer on how not to pay for that private room
Virtually all health plans will only pay for a
semi-private room when you are hospitalized. Once
in that semi-private room your privacy goes out the
door. The other patient and their family, friends will
know your name, dob, medical condition and just
about everything else. You will get no rest as twice
the number of staff enter the room all day and all
night. They ask to look at your wrist ID band and
ask you to recite your name and dob.
If you want a private room then you will have
to pay for that out of pocket. Additionally, you have
to share the restroom with the other patient. Who
decided on this concept, the hospital or insurance
company. Well, they both did, it benefits them and
not you. You get ambushed. After going to the
emergency room you are then told you are being
admitted to the hospital as you are wheeled to
your room surprise, you have a room mate. Or
the other scenario is you have surgery and then
you are admitted to the hospital and surprise, you
wake up in a semi-private room.
Simple solution, you complain to the nurse, but
you must be direct and say your privacy is not
respected, the other patient hears everything. You
threaten to file a HIPAA complaint. You can't sleep
there is too much noise. You get your private room,
you get sleep and privacy. You are discharged and
sent home but several weeks later but get a Hugh
bill in the mail. The out of pocket expense for the
private room. No problem, you call the insurance
company and the hospital and say that it wasn't
your fault your roommate wouldn't let you sleep.
It was the nurses decision and not your fault,
thus they must remove the private room charges
from your bill. Works every time! Now if there is
any Butt-slapping to be done, it should be to the
idiots who gave us this class system of building
private and semi-private rooms in hospitals.
PT
People who work in the medical profession are just that; people.
They gossip, do things they shouldn't etc.
What's disturbing is that the culture has endured and nobody is protecting against patient harm.
Just like PT advised, it's the same thing when you need that same gender care. What you need, why you need it, medical back up.
They will literally "bend over backwards" because the majority of healthcare workers want what's best for their patients.
Maurice, Let's see if we can get our bloggers to write letters to the AMA, especially those who have suffered from emotional issues as a result of treatment. The letter must come from the mindset of fixing what's broken; not anger or sarcasm.
I worked for one of the ten best companies to work for in the state where I was living.
There was a no tolerance for racial slurs, negative comments about internal (co-workers) or external (the public) customers.
You get overheard and you get fired. No warnings. Policies were set in writing, everyone knew what they were. This is exactly what the administrators should do at every hospital. Massive improvements in a very short time.
belinda
"I think that we need to keep a perspective regarding everything that we read on these discussion blogs including ours. People who write are generally attempting to get a point across and often it is based on personal experience or experience they have read about and amounts to making heuristic conclusions: assumptions of generality but not based on, for example, statistical facts, would be one way of looking at it. "
How many times will you get bitten while trying to pet stray dogs before you quit trying to pet stray dogs?
Should you keep risking getting bit and continue petting stray dogs so you don't make a heuristic error / conclusion?
You say that unprofessional behavior / abuse is statistically small...
I say 100% of the people I've personally known who work in the medical field I have heard with my own ears talking about and mocking patients outside of work in great detail, violating their trust & privacy.
There are gobs and gobs of news stories, patients posting their own stories on forums, nurses over on allnurses talking about the things they've seen (and often adding that they took the high ground by not participating, but not doing anything to actually stop the behaviour, but still not reporting the offending party to the powers that be so it can be properly stopped, instead of "maybe" stopped when those two happen to work together...)
It doesn't look "statistically small". Sure, the actual statistical number of patient / medical staff encounter vs number of REPORTED incidents may be small, but there is no way either you nor I could POSSIBLY know how much abuse is actually going on.
The butt slapping doctor for example... he was physically assaulting patients for over a year, and nobody knew until someone ratted.
How many people do you think he worked with over the course of that year? Not patients, but actual conscious staff in the room.
I'm actually looking for you, Dr. Bernstein, to make an educated guess here...
The St Josephs website claims that in 2010, they did 3,459 orthopedic surgeries.
They list 34 Orthopedic surgeons.
3459 divided by 34 means each surgeon does an average of 101.73 surgeries a year.
How many people are in the OR during orthopedic surgery?
How often does the average surgical staff rotate? (new techs / nurses working with the doc)
Best guess, what's your estimate for the number of times this guy was witnessed assaulting patients?
Now take that number, and remind yourself that it's all stemming from ONE doctor at ONE hospital.
Jason K
belinda,
Do you think the AMA is a good target for our letters? The AMA is mainly a political lobby org. They represent MDs and the medical community. I don't think they would be sympathetic to patient concerns, other than a token/marketing response.
BJTNT
Jason, you are right but must keep in mind because things can and do happen, there's nothing wrong with putting procedures in place to limit hospital liability and protect patients. It's a winning combination.
I've wondered how many people are looking for a blog like this and are just putting in the wrong search words to find us."
We are a "snip-it" of all the patient's that come through medical doors. We are drawn to this blog because of all the things said.
The Patient Bill of Rights that nobody pays much attention to, were written for a purpose.
Like PT said, what kind of privacy do you have when you have a roommate? It's ridiculous.
All I know is that there is a significant amount of the population that have issues with nudity (sexual assault victims, abuse victims) and there just has to be a better culture in the medical community to honor and respect both patient autonomy, privacy, and dignity and that people may require different things but if they are properly informed, they can then express their needs.
belinda
I wanted to respond to Anonymous on March 29th. It is ridiculous that they required you to put on a gown for a bad ear infection. I personally have had a lot of ear infections or swimmer’s ears in my life. I never changed into gown for any of those appointments with doctors.
Patients have to stand up and say NO to gowns for procedures or exams that do not require the use of gowns. It does not matter what medical professionals want you to do. Patients must be in control.
Misty
I agree that it would be good for other medical professionals to held accountable for not reporting misbehavior of other medical professionals in the Operating Room. But the medical system is so corrupt that it will be hard for this to happen. There are many cases where nurses may know that the doctor has done something wrong, but will not report it because they fear that they will lose their jobs or be treated terribly at work.
I believe the best way to prevent misbehavior or wrongdoing in Operating Room is for every patient to have a personal advocate not employed by the medical facility present for their surgery. Medical professionals will feel they have to be more cautious and on their best behavior if they know that a person not employed by the medical facility is watching them. I believe we would see a significant drop in sexual abuse, patient modesty violations, deaths, infections, and other types of misbehavior in operating room.
I see much more hope in patient advocacy / education than changing the whole medical system. There are certainly some great doctors and nurses who are sensitive to patient modesty. But a patient could get a bad anesthesiologist who does not think that patient modesty is important.
Misty
Dr. Bernstein, I sort of understand your point but the problem is when that mantra is put forth, how many people apply the filter you suggest. When we go into the medical arena and providers attempt to downplay or ignore provider gender, it is confusing. It creates a lot of questions, I have yet to have a provider acknowledge that having a female present when I was exposed may be uncomfortable for me. In fact i would say it is quite the opposite. There have been noticable efforts to act like it is nothing, no issue, no reason to ask if we prefer a male or female when the option exists. So, we have two options, they really don't know or they don't care. To be honest I find your messages confusing and contradictive at times. On one hand you acknowledge providers recognize the difference patients feel exposing their penis or their foot to providers, yet you have on numerous times said providers do not recognize the issue. Are you saying providers recognize the issue but not the depth, or are you saying providers recognize the issue but not that it may prevent some people from seeking care. I wonder if we are not repeating the naked vs exposed conversation. To us exposed and naked have little difference. being unclothed from the waist down is not technically naked but it is just as stressful to me. So would you please clarify, are you addressing mainly the fact that some people are avoiding care or the spectrum including patients being uncomfortable or extremely uncomfortable to avoiding.
Personally I am addressing the spectrum which makes this confusing. If providers know the comfort level for exposure of a womans vagina and her arm give a different comfort level, and they know gender plays a role....why would they not attempt to accomodate them in a way they feel comfortable? Not sure if i explained that accurately.,,,so the crux is if providers recognize it is uncomfortable why don't they ask, acknowledge, or accomodate...don
"I believe the best way to prevent misbehavior or wrongdoing in Operating Room is for every patient to have a personal advocate not employed by the medical facility present for their surgery. Medical professionals will feel they have to be more cautious and on their best behavior if they know that a person not employed by the medical facility is watching them. I believe we would see a significant drop in sexual abuse, patient modesty violations, deaths, infections, and other types of misbehavior in operating room.
I see much more hope in patient advocacy / education than changing the whole medical system. There are certainly some great doctors and nurses who are sensitive to patient modesty. But a patient could get a bad anesthesiologist who does not think that patient modesty is important.
Misty"
It'd pretty much have to be a patients trusted loved one with a video camera being the chaperone, who was put into scrubs and never left the patients side.
Video taping the entire thing from start to finish would be the only way to ensure (almost) no misbehaviour. It'd stop unnecessary exposure, assaults and insults by the OR staff, non-consensual pelvic exams, gawkers, and all the other "dirty little secrets" that the medical world do to people when they're under and can't defend themselves or remember when they're awake.
Because it's the PATEINTS camera / tape, you know it's not going to be put in some database and "accidentally" uploaded to the internet or played at the office christmas party, or sent off to a med teaching school for students to watch for "educational purposes".
If it was a third party chaperone not employed by the hospital, then the patient would still be being exposed in front of a stranger, and expected to put their trust in a stranger... again. Also, if it's only a few third party chaperones at each hospital / doctors office, then they'll eventually become friends with the staff, and will start to let more and more slide... it'd be jokes at first, and all that. Familiarity begets complacency and all that...
Jason K
"so the crux is if providers recognize it is uncomfortable why don't they ask, acknowledge, or accomodate...don "
a few options pop to mind...
1- it's a power trip for them. (which is why so many insist you wear a gown when it's not needed)
2- They're so stuck in the mind set of "But... but... I'm a doctor / nurse...you're SUPPOSED to be ok getting naked infront of me... I went to school and everything..." (naked/ exposed IS the same thing in my eyes)
3- Men aren't allowed to have modesty issues.. just ask society (you see cameras and reporters in athletes locker rooms... when's the last time you saw a camera / reporter in a womans sports team locker room while they're changing?)
4 - waiting for female staff to be swapped out for male staff might delay the doctor by 2 or 3 minutes... nevermind that you had an appointment for 10am, and didn't get in until 12:30....
Jason K
Check out this article about Dr. Clark who slammed patients’ butt in Outpatient Surgery Magazine.
Look at this very important sentence: Other staffers say they didn't report the behavior because they thought nothing would be done or they were afraid to jeopardize their jobs. This does not surprise me. Many medical professionals have the fear that they will be fired if they report misbehavior. This is exactly why third party chaperones employed by the hospital are useless most of the time. It is obvious that one staffer took the courage to report the misbehavior, but the hospital did nothing.
Even if a male patient asked for an all-male team in the operating room, how do you know for sure that his wishes will be honored? The hospital could modify the records to show that only males were there in OR even if it is not true. That is why I have emphasized the importance of having a personal advocate with each patient in OR.
Misty
I agree with 2-4 Jason, not sure about the first one but would add, it's SOP. It is what we always have done, and no one questions if it is what they should be doing. I read a article where a MD was challenging the need for patients to be naked under the stupid gown for cataract surgery. He felt it caused unneeded stress. Several other MD's chimed in they didn't really know why, it was just always done that way.
I would really like your thoughts Dr. Bernstein and perhaps you can ask your students. Do you think patients should be willing to endure a certain amount of embarrassment or perhaps be uncomfortable to accommodate the providers schedule (?), or perhaps desire for a quick turn. I am not talking what you consider the extreme of avoiding care. I am talking about the day to day interaction. I will use an example I put forth before. My friend had a vasectomy and the MD he knew socially, brought in his nurse, they both new socially to help. He said all she did was stand there, held his penis to the side for a short bit, handed the MD a swab, and then left when it was over. Mine was done completely with just myself and my MD. Another friend went to the same MD as the first but asked to not have the nurse present and the MD did it. Now there is no possible way the MD did not know the presence of a female, much less a female both he and the patient knew socially would not be at a minimum uncomfortable for the patient. He had had a previous male patient request she not be present. The only possible reason I can see for having her there was it made it incrementally easier and quicker for the MD so he felt whatever embarrassment it caused the patient was reasonable. I don't know how else to read that. And if it is true in that instance, is it one of the main things driving this problem.
I am not intending to criticize you for this, just wanting to have a conversation. I feel you have shown some of that when we had the discussion of patients allowing students to observe. If I read you right patients should be willing to participate for the betterment of society as a whole. This is similar to me in that providers seem to feel that a little (or a lot) of uncomfortable feelings endured by patients is worth it as providers are so time crunched it just needs to be tolerated.
I have to give you credit Dr. Berstein, your like a fighter in a ring with 4-5 opponents, we keep punching away at you but keep coming back.
On a side note, I recently reviewed the applicants for the scholarship we fund for healthcare students 8 female-1 male applied. The male wanted to be a sports trainer....and I just recently read where a local small college ran an add hosting a program for females interested in science due to the fact that not enough females were getting science degrees...the same school offers a nursing degree and all of their adds feature females. I am writing them to see what they say....don
Misty
I think your intentions are in the right place but there's a better way to handle this. I've seen
Failure to report misbehavior resuts in being written up and after so many times, you're fired.
This way if you have a staff of 8 and something happens and everyone reports it except one, they know who the culprit is.
It's the only way to change the culture. It's the old conquer and ddivide and is used in business all the time.
Now your job is on the line if you don't report, instead of if you do.
belinda
Maurice said
"is it really fair to the medical community to butt-
slap all nurses and physicians because of isolated
stories."
Yes it is and after all we are the ones who are
ill and you are the ones getting paid. How do you
know these are isolated occurrences, you don't and
you ask, why has a sociologist not done studies on
this subject? Is that an assumption or just assuming
for some sociologist it wouldn't be an unproductive
endeavour?
The fact is hospitals have a department that
keeps these behaviors silent. It's called risk
management and along with their Gestapo police
they tell knowing employees to keep quiet or
else. Is that an excuse for the employees or just
a hospitals way of being nontransparent.
Courts do this all the time, jury sequester and
jury nullification, witness tampering. Many states
made it a law that hospitals and other medical
facilities must report sexual assault of a patient
while on hospital grounds, why? Because
hospitals were not complying and that in and of
itself should be more proof than anyone would
ever to come to a conclusion.
PT
Don,I believe no patient should endure embarrassment or discomfort simply for the physician's day to day organizational or other personal benefit. Yes, the patient might have such experiences but only as a non-preventable association that accompanies proper diagnosis and treatment. And, indeed, if such experiences are reasonably expected for that diagnosis or treatment, then this should be part of the informed consent obtained by the doctor from the patient.
With regard to patients participating in medical education, I would discourage anyone to pressure a symptomatic patient would is concerned with his or her illness to suddenly become altruistic to the "greater social good" and allow a non-treating, non-responsible person (a medical student, as an example) to take a history or perform a physical examination. Yes, every patient is asked permission before they are interviewed or touched but are not threatened with any altruism argument. If a hospital in its "teaching hospital" designation is trying to infer that altruism to their patients, I would say that hospital is inferring wrongly. Simple informed consent is all that is needed, legally and ethically. ..Maurice.
I went to a major teaching hospital and had a doctor's office visit. Their practice was to have their Fellows take a complete history.
I had no problem consenting and the Fellow came in and took the history.
The doctor spent a total of five minutes with me and I called and asked for a copy of my records that included the Fellow's report.
What I didn't mention was that the Fellow was foreign and the report was all wrong stuffed with errors.
When I called to make a second appointment with the same doctor I told the office manager that I did not want to participate due to what happened in the past. Their position was that if I didn't want to do it their way I wouldn't be seen. I told them they were violating my rights as a patient and reported the incident.
A couple of weeks later I received a phone call for the hospital agreeing to see me. I had already been to someone else and told them I would never consider coming back to their practice and would share what I learned about their policies with everyone knew and I did.
belinda
T
Belinda,
I think your solution is an excellent idea. But the problem is many hospitals are not willing to implement this policy about requiring staff members to report misbehavior. In fact, some hospitals do not want to deal with misbehavior of medical professionals. I really would love to change the medical system as a whole, but I know it is not a winnable strategy because the medical system is so large and powerful. It is hard to keep the whole medical system accountable. I do believe that some good hospitals could possibly implement this solution you suggested. In many hospitals, many medical professionals are fearful that they will lose their jobs if they report misbehavior. I know this for a fact from an incident involving a negligent surgeon who let my paternal grandmother bleed to death during surgery. A nurse who was present for the surgery told one of my aunts exactly what happened, but she did not want to report what happened probably because she feared it would jeopardize her job.
Even if we had this solution in place, I still think that patients should be allowed to have a personal advocate not employed by the medical facility present for their surgery in OR to reduce the chances that any medical professionals would do something wrong or ignore their wishes for same gender medical team. Medical professionals would feel like they had to be more careful or respect patient’s wishes if they knew they were being watched by someone who was not employed by the medical facility.
I appreciate how you stood up and let the hospital know you would not be using that practice anymore. Patients have to let hospitals and practices know that they will not tolerate them if they do not respect their rights.
Misty
I wanted to share this article: Patient was accidentally tipped off the operating table onto the FLOOR during surgery. This article does not indicate what kind of surgery this patient had. But I would assume that he/she was probably naked under medical gown if there was one. It is very likely that this patient’s private parts were exposed when she/ he fell on the floor.
Misty
It has been awhile, but I have posted another article on the website that Doug and I co-moderate. This is about the use of medical scribes and patient privacy. Go take a look.
Dr. Sherman, great to hear from you again. I was just thinking about you the other day. I stuggle to reconcile all of this. In the case i referred to of the different approaches to a vasectomy, one MD does it by himself, another brings in a female nurse apparently just for his convenience rather than requried. Another uses a nurse unless asked not to....same procedure, surely all 3 have to realize the emotional aspects for the patient, yet 3 different approaches....so, i guess it pretty much up to the MD to decide and us to defend...no commond SOP here....don
Misty, sorry, your comment yesterday concerning the article you linked, demonstrates exactly what I have been writing about concerning comments written to this thread: no facts, only assumptions. The point of the two sentences in the article was that the patient slipped off the operating table and nothing more was described, the type of operation, the degree of undress, the gender or even whether the patient was injured. Your assumption is clearly a combination of two types of heuristic errors: "Ascernment Bias-When thinking is unduly influenced by prior expectations" and "Visceral Bias-When emotions overly intrude into making a conclusion." Again, random news stories which are not detailed and assumptions made without facts hardly meet criteria for a convincing or even supporting argument in a discussion. ..Maurice.
Maurice
On the other side of this equation isn't it fair
to say the medical community makes guess
work, assumptions that patient privacy is
irrevelant. Just another heuristic error made
in the sake of medical necessity, lacking
professional judgement and ethics.
PT
PT, the medical community uses heuristic thinking to arrive at conclusions virtually all the time (most importantly hopefully for the patient's benefit in the emergency room!). However, I wouldn't say that the medical profession assumes or considers patient privacy as irrelevant. But, yes, in terms of medical necessity, my impression would be that most doctors would have a hard time believing (just as I did almost 9 years ago at the start of this thread) that any patient would sacrifice having their symptoms diagnosed and treated simply on the basis of their privacy and physical modesty. Now I know better. ..Maurice.
"However, I wouldn't say that the medical profession assumes or considers patient privacy as irrelevant"
Then you and I have encountered some VERY different doctors and nurses.
Let me know when you've been told to "strip right down" and put a gown on, have the nurse leave... ignore the request and keep your clothes on as you're there to see the doc to get an antibiotics prescription renewed for an ongoing ear infection... but 30 seconds or so after leaving (right about when you'd be totally naked if you were actually undressing like you were told to), the nurse walks back in without knocking, opening the door into the hallway as wide as it goes... or you find your doctors office has installed cameras in the ceiling.
Jason K
Jason, your story is truly imaginative since there is no logical medical professional reason for a patient to fully undress for with such a history. I can't imagine any doctor requesting that action since even with other upper or pulmonary complications this request would not be necessary. ..Maurice.
Don't care if you believe me or not, but presented with the same basic premise (told to undress and gown up for no reason when seeing a doc about the ear) Back on march 29th @ 7:30pm, you said...
"All I can say to Anonymous from 7pm today: if you go to hospital emergency room for pain in your ear expect a wait and expect the nursing staff to do what is protocol to facilitate (including time-wise) any examination which the doctor decides to carry out."
But I guess you gotta defend your profession whenever you can.
Post this... don't post this... I don't care. I'm done here.
Good luck in your efforts.
Jason k
Jason K,
I understand your frustration. There was no reason for you to undress for an ear examination.
It is often unnecessary for patients to wear gowns for many procedures.
I have appreciated your contributions on this blog.
Please do not give up on fighting for patient modesty. You should email me through Medical Patient Modesty at this link to discuss your concerns about patient modesty and the medical system.
Misty
Maurice
I always thought the medical community, emergency rooms, icu's etc follows protocols rather
than thinking heuristically. Secondly, I believe what
Jason said and I will add that happened to me only
the two female nurses watched me change the entire
time and never closed the door. I at the time didn't
realize it as I thought they had closed the door and
left. Now, I believe you Maurice when you say that
9 years ago you would not imagine patients willing
to forgo medical care for the sake of privacy. What
I sense is that you question the motivations that
have led us to take these kinds of stands.
PT
Jason
Please don't leave this blog, we are going to need
your help soon!
PT
PT, sure. There are protocols in emergency rooms to initiate a deliberation of "what is the diagnosis?" It deals first, in a potentially critically ill patient, with taking whatever information is available, obtaining vital signs and beginning a focused physical while meanwhile attempting to support any sagging vital signs and drawing blood for routine studies as well as holding for later studies and arranging for radiologic studies if appropriate. And all of that is part of a protocol for this type of patient but throughout all of this (with fragmentary history, with a focused physical and while observing the patient's immediate course), the differential diagnosis is being created in the minds of the physicians not fully created by immutable facts but heuristics (guesses,assumptions). An initial heuristics in the ER is performed by the nurse in a role of triage in a sick but stable patient. There are triage protocols which would include at least vital signs. But in the case of a painful ear I am certain there is no protocol requiring the patient to undress and if I was the patient so requested I would ask "why?" and reject some unsatisfying answer. Even lavage of an ear would only require a paper cape to protect the underlying clothing from getting wet.
In clinical office visits, heuristic thinking is involved in the initial development of a differential diagnosis which becomes the basis for a more focused physical examination. This kind of thinking is the basis for clinical reasoning until more and more facts are known and then the diagnosis is created by the facts. But with all such heuristic assumptions, there is always the possibility for misguided thinking which can lead to error. It is always more reliable to have all facts which then can define a diagnosis. ..Maurice.
PT, moving on to your last comment "I believe you Maurice when you say that
9 years ago you would not imagine patients willing
to forgo medical care for the sake of privacy. What
I sense is that you question the motivations that
have led us to take these kinds of stands."
I do not question the motivations for forgoing medical care for the sake of privacy. These are decisions moved by underlying psychologic,emotional thinking based on fear, deep habits or past experience and are not decisions based on some secondary gain for some trivial benefit. I know now that such emotional thinking exists and I believe that all doctors should be aware of this even if not directly informed by their patients. And I think that those patients deserve special attention to attempt to mitigate their concerns and move along to provide beneficial diagnosis and treatment. ..Maurice.
PT, Thank you and I agree with you.
I don't think the thinking is so complicated when it comes to hospital gowns. My daughter hit her head and because of a prior concussion she needed to be evaluated.
A young teen at the time, the regular doc was not in that day, but the male doctor covering was happy to see her. The nurse walked in and said everything off from the waist up. My daughter looked at me and asked me why she had to undress. I instructed her to ignore the nurse (that it was probably just an office policy so that the less trained didn't have to decide whether a gown was necessary. The doctor came in, did a thorough exam and didn't say a word about why she wasn't wearing a gown.
belinda
Belinda,
Thank you for standing up for your daughter years ago! It is true that a medical gown is often unnecessary for many examinations.
Some of the gowns are so immodest especially the paper gowns.
Misty
I had two different doctors rip a gown right off my body during a doctor visit. One doctor was male; the other female!
belinda
Belinda,
I am sorry to hear about your bad experience. That was wrong for those doctors to rip the gown off your body. I think this should be considered battery. What do you think?
Misty
belinda,
When the "nurse" [I'm sure she is just an aide] tells me to remove all my clothes and wear a gown,I say nothing and retain my shorts and no gown. The MDs never comment on this, let along criticize me.
If the MDs don't seem to mind and the administrators couldn't care less on this topic, who instructs the aides?
Who decides that a patient has to remove all clothes for an ear or elbow procedure? Is it just a long standing tradition of power and control within the medical community.
BJTNT
BJTNT, I think it's the "keep it simple stupid" policy. Uniformity and less training needed.
Why do you feel you must strip down to shorts? Unless your exam requires disrobing, why do it at all just because they asked you to put on a gown?
Each medical facility makes their own policies and there are no standards in the USA regarding state of dress for certain procedures.
Once, I went to a neurologist and she put a gown on the exam table. I took the gown and put it back n the pile. She came in and did it again, and I did it again. Never a word was spoken by either the doctor or the nurse.
You don't need to be in a gown to check reflexes and watch your gait. In fact, the doctor, might get a better viewing if you were to wear shorts and a top.
My experience has been that older doctors are into the gown thing and younger ones not so much.
Any loose fitting clothing offers the same access to the body. Wearing cotton for x rays is a good idea because thicker fabrics may alter the films.
Other than my personal repugnance for gowns that is understandable due to my experience, I find it equally repugnant to wear clothing that someone else wore, thus, you'd never see me shopping in a consignment store or wear a hospital gown.
belinda
Belinda,
I appreciate many of your excellent points about gowns.
I wanted to respond to this good point you made:
I find it equally repugnant to wear clothing that someone else wore, thus, you'd never see me shopping in a consignment store or wear a hospital gown.
I am so tired of hearing the lie that gowns are sterile. It is very possible that some of those gowns may be contaminated with germs. I'd rather to wear my own clothes for doctors' appointments. You are right that doctors may get a better viewing if you wore shorts. For example, it is easier for a doctor to tend to your knees when you are wearing shorts.
Misty
I always found it amusing that we need to wear a sterile gown while providers circulate from one sick person to another. I am in for a sprained knee, they just treated someone with the flu or worse and are wearing the same clothes....ah the oddities of protocol from the opposite side of the looking glass....don
Belinda,
I wear my shorts for dermatological checks and for annual checkups when I was younger. Now that I'm an old man, I no longer get checkups; just lab tests at my yearly checkup.
BJTNT
You may be interested in expressing your answer to the question posed by my new thread "A Doctor's First Words to a Patient". What do you think about the first words spoken by the doctor in the establishment of a doctor-patient relationship. If interested, go to the thread and write there. ..Maurice. p.s.- keep the back and forth about patient modesty issues on this Patent Modesty thread. However, explain on the new thread the basis for your response.
http://www.psychologytoday.com/blog/food-thought/201202/the-high-incidence-post-intensive-care-unit-icu-anxiety-and-depression
Hello everyone. I came across this article and I wondered how it relates to our discussion on modesty in the hospital setting. Have a look. Take care. AL
I wonder what women in general, as well as female nurses ,female techs, and other female providers would think if the gender numbers were reversed?
Imagine you go in for a routine exam with your female doctor because you don't want a male doctor. A male chaperone or student is brought in to the room to observe.
You either ask for him to leave or because you were blind sided by it you say nothing and go through it. Only to be angry about it later.
During your exam the doctor finds something and recommends a vaginal ultrasound. You ask for a female but there is only male sonographers that work there. You can say no or swallow your pride and do it. Another male will be assisting you find out at the last minute.
Time for a visit now to a gyn/urologist for a more invasive exam and a cytoscopy. Once again you choose a female doctor but when you arrive all the assistants will be male.
You are found to need an operation. When you arrive a male will be prepping you and another male catheterizing you. By this time you hate the medical system for having to go through all these embarrassing procedures with so many males involved. You say nothing because you are told all the men have seen it all before and your body is nothing special. They have seen it all before so it is silly and immature of you to feel this way.
This is what almost every male has to deal with when we go into the health system. They wonder why men do not go in for their exams. I wonder how many women would hesitate to go if this is what it was like for them?
Oh wait. I think there was something called affirmative action. Now they have female choice for doctors and a support staff of 95 percent women.
I sympathize with the issues of women posting to this site but being a male is even worse.
Paul
You forgot to mention mass school physicals
and sports physicals that males have endured
not to mention unnecessary female observers
during military induction physicals. This is all
before males actually enter the health care
system with real medical problems.
PT
NOTICE: AS OF TODAY APRIL 15 2014 "PATIENT MODESTY: VOLUME 64" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 65.
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