Bioethics Discussion Blog: Patient Modesty: Volume 66

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Monday, June 09, 2014

Patient Modesty: Volume 66














 The inattention to patient physical modesty in the medical system is just one part of a whole system-wide issue of inattention to the patient.  A good example of such inattention in another area is that of the behavior of the medical system to a physical injury is told by a physician who was injured and describes her experience in a hospital emergency room and later on the wards. While this physician's story is not strictly about medical staff ignoring her modesty, I think it does show major causes for inattention in many areas of medical practice: putting more emphasis to attend to making a diagnosis or just be seen as "doing something" for the patient but, because of workload, available time,need to rush ahead, follow protocol and move on, that attention to the patient as a unique individual with their individual needs and requests is simply ignored.  I think that unless the medical system expands its population of available healthcare providers and these providers are trained to think about the patient as an individual person as themselves, the sad experiences described over the years on this blog thread and the "hurt" (not simply the trauma) that this doctor felt as a patient will just continue onward. ..Maurice.

ADDENDUM:  I changed the graphic today for this Volume in order to emphasize what should be the
theme for the Patient Modesty thread: PATIENT  CENTERED CARE.


NOTICE: AS OF TODAY  JULY 14 2014 "PATIENT MODESTY: VOLUME 66 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME67.

Graphic: From Policy and Medicine


169 Comments:

At Tuesday, June 10, 2014 10:51:00 AM, Anonymous Anonymous said...

Just think about all the time that is taken to handle complaints, remedy damages gross neglect, etc.

It's the medical system's job and responsibility to maintain and manage this system with efficiency, premium patient care.

So, why is it that the medical system hasn't investigated one half of their equation and that is the patient experience?

The other half of the equation must be analyzed to run any organization in an intelligent, patient centered environment.

Isn't that what's really at the crux of medical issues?
belinda

 
At Tuesday, June 10, 2014 12:32:00 PM, Blogger Maurice Bernstein, M.D. said...

I wonder how many patients make their half of the equation known to the medical system in a way that is understood and taken seriously sufficiently to rectify promptly. Is there mechanisms in place to establish a method and requirement for each patient/family to provide feedback to the hospital, clinic or medical office after each hospitalization or office visit? I don't recall use of any mechanism to consistently obtain such information. Maybe, if institutions or offices give the patient that opportunity, patients just don't take it. In my own and my wife's experience with doctors and hospitals, we don't remember any feedback opportunity or requirement given to us.
Though I don't remember any "bad events" in my care, I had no required opportunity to even directly acknowledge that except to "wave" thanks as I left.

So, a "patient" and not "disease" centered environment and management cannot be fully orchestrated without that patient/family input. And that is why without the patient "speaking up" to their medical providers in one way or another, one should not expect that there will be investigation and change. ..Maurice.

 
At Tuesday, June 10, 2014 1:10:00 PM, Anonymous Anonymous said...

You're presuming that when patients do make their half of the equation known seriously and understandable there are actually staff who care; ask me how I know?

Ed

 
At Tuesday, June 10, 2014 4:59:00 PM, Anonymous Anonymous said...

Dr. Bernstein I think the medical community used to push the gender nuetral message more vigorously than they do currently. This approach to care still does exist but providers are less likely to openly claim nuetral and more likely to justify from context, to need, to ignorance. If you go to allnurses.com and numerous other blogs, remember Dr. Orange and more to the point Dr. Kegal (?) whom was so indignant that a male patient would have concerns with a female urologist calling him sexist we see it all the time. There are numerous posts on allnurses where a significant number of nurses are offended that they are identified as male or female nurses THEY ARE JUST NURSES and gender has no place in the discussion. These things have and to a lessor degree are still present and still push the message of gender nuetral in the context that the gender of the provider should have no bearing on them providing treatment. That mentality is still present though perhaps not expressed as such. It may not be couched as such but it is the same results, providers acceptance include gender as a criteria.

I was driving through Tenn. this week and heard an ad for a men's clinic. If you google Men's Clinic Tenn you will see their website, click on the experience tab and shock of all shocks they list "all male staff". they deal with mainly sexual issues for males, it is so logical they would have an all male staff, yet the fact that it is such a surprise says a lot. I sent them a comment recognizing this and thanking them, If I get a reply i will forward....don

 
At Tuesday, June 10, 2014 5:34:00 PM, Anonymous Anonymous said...

Currently many hospitals use a company called
PressGaney to survey their patients, what a
joke. This company charges millions of dollars
to call a few of the hospital's discharged patients
to ask them how the taste of the food was. Idiots!

Hospital food is not supposed to taste good. Did your
doctor take the time to answer your questions? If
you read the article above about the injured
physician she couldn't even get an answer
about the injury to her knee in real time, while she
was a patient. What's the point of calling a patient
After they have left the hospital.

Pressganey says " to capture the voice of the
patient and transform the patient experience. Is
that not the dumbest concept you have ever
heard. There is no point in complaining about the
care you got after you have left the hospital. You
complain about it right then and right there other
wise no one cares about some phone call you get
from some worthless agency 5 weeks later.


PT

 
At Tuesday, June 10, 2014 6:09:00 PM, Blogger Maurice Bernstein, M.D. said...

Notice, I changed the graphic to this Volume today in order to emphasize what appears to be the correct approach by the medical system to resolve the issues written here and much of the other issues in the practice of medicine, the approach being PATIENT-CENTERED CARE. And, after all, isn't this what the practice of medicine is all about? ..Maurice.

 
At Tuesday, June 10, 2014 7:00:00 PM, Anonymous Anonymous said...

It's not the patient's job to fix the medical system.

Make a team of psychologists, sociologists, social workers, doctors, nurses. Take a walk down to the assigned risk department.
Analyze all the complaints.

Examine standard of care practices. Examine the social needs with a little common sense and some empathy. It has always boggled my mind of how short sited the medical system is to what patient's need.

It's the whole person who needs fixing. It's established that patients with a positive mindset heal faster. How positive is your mindset when you are humiliated, deceived, and treated like a piece of meat?

Please stop putting the burden of fixing the system on the patients.
What other customer service corporation requires the customer to fix their problems? They might ask for feedback, surveys, but this entire problem evolved from the medical community's gender neutral position and they are the one's who have to fix it.

Hire me. I'll work as a consultant to the industry. My partner (ph.D psychology) and I could whip things into shape in no time. It's really not rocket science. It's a little common sense, tweeking standard of care using social norms that people are used to. Eliminate practices where social norms are not met.

The way the medical system is working doesn't. Why so resistive to what's right, healthy and at the end of the day, once fixed you have less of a problem and a much happier environment for both medical workers and patients.
belinda

 
At Wednesday, June 11, 2014 5:45:00 AM, Anonymous Anonymous said...

Maurice,
You're right. It's patient centered care that must come before healthcare. You can fix a broken leg; not a broken heart.

How can so many doctors who are nice, caring people, not speak up in a culture where people are considered just a "sum of their parts".

What kind of mentality takes people at their most vulnerable times into an environment that is not emotionally safe? That's what's happening.

Congratulations on healing Patient A. Too bad, they will never be healed again because of the degrading way they were treated.

Perhaps patient's could make that choice with an ID bracelet that selects Plan A or Plan B, being A treats the whole person, and B fixes the medical problem? First, they would have to be told that if you choose Plan B, your privacy, dignity and sense of well being will not be considered the same as for Patient A. And patient A will have to know they may not get the best medical treatment if the other considerations must come first.

Why can't everything be considered without compromising anyone? Why can't new protocols be established for the mental and physical well being of the patient?

People are not chattel and shouldn't be treated as such.

Build a safe foundation for all the components that make us human.
Change the medical mindset of treating the whole person. Make common sense decisions by eliminating opposite intimate gender care for those who don't want it and for goodness sake,
stop traumatizing people mentally with ridiculous behaviors that go on everywhere, all the time?

Medical community, stand up and be counted. Which kind of system would you like to enter when ill?
The status quo, or what could be?
belinda


 
At Wednesday, June 11, 2014 8:28:00 AM, Blogger Joel Sherman MD said...

I don't pay much attention to Allnurses anymore, but some may be interested in this discussion labeled Feminism, Nursing and Gender.

 
At Wednesday, June 11, 2014 10:43:00 PM, Anonymous Anonymous said...

This Tennessee mens clinic as well as the all male
urology center that has been mentioned could be
used to our advantage in making a point nationwide
and could become a trend.

PT

 
At Thursday, June 12, 2014 11:41:00 AM, Anonymous Anonymous said...

PT, I mentioned the same thing to you a couple of months ago in another city. It's true. The word is getting out!
belinda

 
At Thursday, June 12, 2014 7:00:00 PM, Anonymous Medical Patient Modesty said...

The men’s clinic that Don referred is Tennesee's Men Clinic in Nashville. We need more all-male staff clinics in the US.

Misty

 
At Saturday, June 14, 2014 2:26:00 PM, Anonymous Medical Patient Modesty said...

Medical Patient Modesty had a silent auction to benefit Medical Patient Modesty at a restaurant in South Carolina a few weeks ago. We also had the privilege of passing out brochures about MPM so it was a great opportunity to educate people about patient modesty. It was a lot of fun to watch people getting good bargains at the silent auction. The minimum bids for most silent auction items were at least 50% off the value. We received many gift certificate donations from restaurants, attractions, and hotels. I enjoyed raising awareness about MPM with managers and business owners of hotels / restaurants in my letters and emails requesting donations. I got some very interesting comments from some of the managers and owners that donated gift certificate. One shared that she did not realize that patient modesty was a major issue.

We still have a lot of gift certificates to hotels in Florida, Georgia, North Carolina, South Carolina, Tennessee, and West Virginia left over so we are doing an online silent auction now to benefit Medical Patient Modesty. You all can check out the online silent auction by going to Medical Patient Modesty’s home page and look for the Green Box on the right side of the home page that says “Online Silent Auction”. Click on that box and it will let you see our online silent auction.

Misty

 
At Sunday, June 15, 2014 7:26:00 PM, Anonymous Anonymous said...

Dr. B.,

Hi. I'm a long time follower of the Bioethics Discussion Blog, and am someone who identifies himself as being ultra modest person in medical settings.

I was recently hospitalized unexpectedly for a perforated diverticulum, requiring emergent surgery where I had asked the attending surgeon (female) about urine discharge during surgery, and she indicated that a Foley Catheter would be inserted, and I indicated that I was extremely modest and was against it. I am additionally concerned that the context of the procedure had exceeded the scope of the implied permission, as I thought it was supposed to be exploratory/laprascopic, not a full opening. I was additionally sedated before being told I was being 'knocked-out', to see if I had any additional questions or concerns.

To make a long story short, I had finally awakened to being catheterized, shaven, and with a full opening.

I am appalled like Misty had indicated in a prior forum that explicit consents aren't required for this sort of thing.

While I haven't had a chance to read the current blog, I had came across a recent prior discussion about giving the medical community et. al. the 'tools' to address some of these protocols.

The question I have is why isn't medical modesty questions made part of a patients medical history when they're admitted to a hospital or at doctors office? i.e., Do you prefer to be attended by the same sex care provider for intimate/invasive care, etc.? Thanks, HS

 
At Sunday, June 15, 2014 7:38:00 PM, Blogger Maurice Bernstein, M.D. said...

I fully agree: modesty issues and gender selection should absolutely be part of the medical record. But it should not be hidden away in a chart but be posted on the chart cover or in EMR computer systems, pop up at first opening. But most importantly, either way, it should be read, acknowledged and attended to. ..Maurice.

 
At Monday, June 16, 2014 5:59:00 PM, Blogger Maurice Bernstein, M.D. said...

I want to point out that "patient centered care" in medical practice is already by name (or more) practiced in the form of "retainer" or "concierge" physicians where the patient pays the physician directly for direct and prompt medical attention and care. Read my blog thread on this medical practice.

Have any of my visitors to the Patient Modesty thread experienced care with these physicians and is the issue of attention to modesty and gender-selection resolved? ..Maurice.

 
At Wednesday, June 18, 2014 8:01:00 AM, Anonymous Anonymous said...

Yes, Maurice and for those who can afford it it's a great option. I do find it as an ethical point, though, because people who have insurance should get the same quality of medical care and shouldn't be reduced to a caste like system.

Hospitalists are becoming more popular. My primary care physician of more than 15 years left the practice and said due to insurance costs and a better quality of life for her, she left and became a hospitalist.

Less primary care physicians are going into the hospital system, so once you get to the hospital you are dealing with a host of strangers.

Patient centered care shouldn't be restricted to those who can afford it. It should be the primary goal of every hospital.

Here is a link to a very interesting study about dignity in healthcare. While it's the UK, all the principles are the same.

It's more than 300 pages, however, it does mention cruel and degrading treatment by healthcare workers. I'm only about 80 pages into it, but it will be interesting to see whether it addresses same gender care to relieve stress.

It also talks about the inability to heal when your dignity is taken from you.

http://www.rcn.org.uk/__data/assets/pdf_file/0006/414645/Baillie_L.pdf

belinda

 
At Wednesday, June 25, 2014 2:11:00 PM, Blogger Maurice Bernstein, M.D. said...

I have written a commentary to Medscape website read by medical system professionals about the issues presented on these Patient Modesty volumes. I have asked for direct responses to our thread. One reader of my commentary was a anesthesiologist who wrote to Medscape the following (reproduced here with the physician's permission. ..Maurice.


In my specialty pt modesty is always a HUGE concern ,, with women in particular.
Men don't seem to care as much ... or they are better at concealing it if they do care.
And we do get the occasional old coot "Flasher"

Why shouldn't a gal be allowed to keep her bra & panties on if she is there for a wrist procedure ??
So we let them. (( I am not big on removing jewelry either --- but that is a subject for another thread ))

If a woman expresses 'modesty issues' and is there for say a cystoscopy ,, I tell her I will
remain at the head of the table behind the drapes and her modesty will be preserved. Of course
extenuating circumstances like an intra-op emergency might necessitate breaking that promise.
But that is very rare

If there is no way to preserve modesty --- fer ex a hemorrhoidectomy --- lots of pre-op sedation usually helps

Maybe docs would be more sensitive to this issue if they started their medical careers like THIS =►



CLICK THIS LINK

 
At Wednesday, June 25, 2014 3:37:00 PM, Anonymous StayingFit said...

There is an interesting story on NPR, which you can find here. It concerns the difference between a patient's perception of how he was treated in a particular case, versus the perception of the medical personnel who were involved in that same case. While this is not specifically about patient modesty, it does touch upon it. For instance, the patient was disturbed by the following:

"When the man arrives in the ER, he is told to take off his shirt. He lies in the hallway, in pain, naked from the waist up. Strangers surround him. They don't introduce themselves, and they talk over him, at each other."

Lack of concern for a patient's modesty is just one outcome from treating the disease, and not the person. Clearly, these folks are doing their best to treat the man's heart, but what about the man?

As is often the case, the article is very interesting, but the comments section is far more telling. You basically have two groups, those who think that the patient should shut up and just be grateful to be alive. And, those who believe that good medical care does not need to come at the expense of a patient's comfort or autonomy. There is little doubt in my mind which group has the stronger argument.

 
At Wednesday, June 25, 2014 5:35:00 PM, Blogger Maurice Bernstein, M.D. said...

The anesthesiologist who wrote the above comment, returned and wrote the following to the Medscape site:

There is a sad yet ancient saying in hospital medicine =►

" There are plenty of bandages
.... it is sympathy that is in short supply "


..Maurice.

 
At Wednesday, June 25, 2014 6:31:00 PM, Anonymous Medical Patient Modesty said...

Dr. Bernstein,

I am encouraged by the anesthesiologist’s comments. I really appreciate that he supports lady keeping her underwear and bra on for wrist procedure.

I find it interesting that he has come to the conclusion that men do not care as much or they are better at concealing their feelings. It is true that many men hide their true feelings about modesty. I think many men feel intimidated to speak up when they have modesty concerns.

I appreciate that this anesthesiologist is willing to honor patients’ modesty by remaining at the head of the table so he cannot see their private parts. Women getting epidural by anesthesiologists can have their private parts covered. Also, it is possible for a women undergoing C-Section to work out a solution for a male anesthesiologist to never see her private parts.

I wish that this anesthesiologist would join our discussion here. Is the Medscape discussion for members who have passwords and user names only?

Based on my observations, doctors are more likely to be okay with the idea of patients wearing underwear for surgeries than nurses. Have anyone here made that observation too? I believe it is because nurses are much more likely to be taught the myth in nursing school that underwear must be removed for all surgeries mainly for infection control.

Misty

 
At Thursday, June 26, 2014 5:59:00 AM, Anonymous Anonymous said...

Maurice:
Can you provide a link to the Medscape article you wrote? Thanks. Jean

 
At Thursday, June 26, 2014 7:30:00 AM, Blogger Maurice Bernstein, M.D. said...

A general surgeon to the Medscape physicians discussion has permitted me to publish here his comment under his pseudonym "southerncookin" By the way, the link to Medscape is medscape.com though you have to provide proof of your professional title to be a participant in the physician's forum. ..Maurice.
From southerncookin:

I usually try to think of this during breast exams for women, and with anorectal exams on all patients. I usually start by talking with such patients prior to having them disrobe, and at that time explaining that I will need to examine the area of concern, which will require removing some articles of clothing. For breast exams, I have my nurse assist the woman with putting on a gown (or giving her the option of doing it herself alone, especially if she is able and has seen me before). For examination of the anorectal region or genitalia, I give the patient a sheet to cover up, and have them position themselves on the table, with pants down but covered by the sheet.

For the examination, I examine one breast at a time, taking care to uncover only as much of the breast as necessary, and also using a sheet to give the woman additional cover. The second the exam is done, the patient is immediately covered back up. For anorectal and genitalia, we take great care to make sure that as little area is exposed as necessary to examine/treat the area of concern (but also keeping in mind that the exam needs to be thorough).

The keys in all of this is to work quickly, to not leave a patient sitting in a gown or sheet any longer than absolutely necessary, to uncover them only as much as needed to properly exam/treat them, and to cover them back up quickly (including letting them get dressed, and then coming back for the final discussion).

Open doors, excessive traffic in the exam room, etc, are not problems for me, as I am in a small hospital.

 
At Thursday, June 26, 2014 7:34:00 AM, Blogger Maurice Bernstein, M.D. said...

And here is the commentary I originally posted on Medscape physicians forum:


Patient Physical Modesty: The Physician's View
Started By: doktormo, MD, Internal Medicine, 9:16PM Jun 24, 2014
I need the help of the physicians on Medscape. I have had a long running thread on my Bioethics Discussion Blog http://bioethicsdiscussion.blogspot.com which now after 9 years and thousands of patient responses, something is dearly missing: responses by physicians. The thread is about the patient's physical modesty issues brought about through their interaction with the medical system. My visitors (and they still could be statistical outliers) find that the medical system is unaware about their modesty concerns or unwilling to listen and attend to their concerns. Over the years of communication on this thread, they describe their personal experiences and to the results the behavior of the medical system has had on them extending from PTSD symptoms to the unwillingness or fear to allow tests or procedures or operations which would be of life-saving necessity where their modesty concerns are ignored. Issues presented by my visitors include: inability to receive healthcare providers (from doctors, nurses, techs, etc.) of the patient's desires, unnecessary undressing, inadequate gowns, operating room issues including prepping and visitors ("gawkers") for which the patient was never given the opportunity for informed pre-operative consent and so on.

From the beginning of this thread in 2005 based on the August 18, 2005 NEJM article "Naked" written by Atul Gawande MD, the topic took off. The reaction of my visitors surprised me. As an internal medicine physician in my 50 years of practice, I never had the issue of patient physical modesty discussed with me by my patients. And following the long standing professional guidelines for genital exams, no patients complained. And never did I think that modesty issues would trump life-saving procedures. After all these years, moderating my blog thread, I am now educated to this patient population.

Though I have written about this subject twice published over the years to the AMA News, I really have had virtually no responses by anonymous individuals identifying themselves as physicians or nurses on my blog thread.
I would most appreciate reading here on Medscape your experience with patient modesty communications and reactions with your patients and your view of the issues. For example, do you think that doctors are well educated and aware of the patient concerns for better attention to modesty, gender-selection issues and whether there are areas for improvement of the medical system in this regard? What would be more valuable to my blog visitors would be to read my blog thread and contribute anonymously (but identifying your profession) your opinions and suggestions.

The link to my current Patient Modesty: Volume 66 is:
http://bioethicsdiscussion.blogspot.com/2014/06/patient-modesty-volume-66.html

I look forward to reading your comments here and especially on my blog thread. Thanks. ..Maurice.

 
At Thursday, June 26, 2014 10:53:00 AM, Anonymous Medical Patient Modesty said...

I am disturbed by the comments of the general surgeon, southerncookin about how he conducts breast, rectal, and genital exams.

He failed to address that many women do not want a male doctor to do breast examinations on them under any circumstances. Examining only one breast at a time makes no difference. The doctor still sees the breast.

Many patients do not want opposite sex intimate care even if they are draped by a sheet.

Doing an intimate exam on a patient as quickly as possible does not address the fact that many patients do not even want their private parts to be exposed for a few seconds. Think about this example: What about a man discovering that he forgot to get a towel from another room after his shower and walking in the living room where his wife’s female friend is? This man still would be upset if his wife’s friend saw his private parts for just a few seconds.

Misty

 
At Thursday, June 26, 2014 11:47:00 AM, Blogger Maurice Bernstein, M.D. said...

Misty, you are not reading what the surgeon wrote. He wrote first "I usually try to think of this during breast exams for women, and with anorectal exams on all patients. I usually start by talking with such patients prior to having them disrobe, and at that time explaining that I will need to examine the area of concern, which will require removing some articles of clothing."

Obviously, after this communication with the patient and the patient's now informed consent, he then will proceed with examining the "one uncovered breast at a time" which is a reasonable attempt to provide the best modesty management and still be able to accomplish the task the patient has accepted to be performed.

And there are female patients who will accept a male physician examining their breasts. Think about this: In all my 50 years of internal medical practice and innumerable breast exams of woman patients, not one patient refused my examination (and without a chaperon) either before or after obtaining the patient's informed consent. And no negative feedback after the exam. All this is part of my attempt to explain why no patient ever criticized me about how I handled their modesty issues and why before this blog thread I had been previously ignorant about what my thread writers were going on in their minds and their experiences. And now I know. ..Maurice.

 
At Friday, June 27, 2014 7:06:00 AM, Anonymous Anonymous said...

Maurice, Thanks for your article.
I do feel, it's "sugar coated" to the extent that PTSD symptoms are different than a diagnosis of PTSD and that some "standard of care" procedures are emotionally damaging to patients.

While your article addresses the topic and problems, I think it may be biased to the medical professional mindset in explanation.

That being said, I feel that you have done everything in your experience to address and deal with this issue as well as the proper feedback.

Again, before cruel and degrading medical experience, the gender or protocols of medical system were never in question for me. Now they are the focus of my medical care right behind the medical issues.

So, would you say, that the system itself is creating "outliers"?
belinda

 
At Friday, June 27, 2014 12:47:00 PM, Blogger artiger said...

I would like to respond to Misty's comment above (I am southerncookin from Medscape, but I am artiger in this system).

Misty, patients who are seeing me for breast exams are almost always sent to me by other physicians, or nurse practitioners, the majority of whom are female. The patient is well aware that I am male before she even steps foot into my office. If she does not wish to be examined by a male surgeon, why would she be there in the first place?

If the patient desires to be examined by a female surgeon, she would be referred to one, without delay; however, in a rural area such as mine, that might require a lot of time and travel. I have not had a patient refuse my examination yet, and that encompasses 17 years of practice. If there is ever a first time I assure you that I will take every step to make the patient happy.

I can only emphasize to you that I take patient modesty VERY seriously.

 
At Friday, June 27, 2014 12:48:00 PM, Blogger Maurice Bernstein, M.D. said...

Here is a commentary from a family physician writing to my discussion on Medscape who permitted me to reproduce it here. ..Maurice.


I always try to put the patient at ease, usually with mild humor (such as when they say they hate going to the doctor, I always tell them that I do to -gets them at least slightly relaxed and grinning every time).

As far as modesty goes, the female exam is ALWAYS with a nurse present, and I NEVER have them in a gown until I've been in and talked to them, even if it's someone already known to me. The humor plays a role there to - when I come in with my nurse, I always ask "Are you ready, as much as you can be anyway?" Everyone appreciates that (so far anyway) I understand their position. Then the breast exam as described above - one at a time with only the necessary amount of gown pulled down, and immediately replaced when complete. After I finish the whole thing, I step out, let them change, then come back in to talk about the findings and whatever else is needed to wrap up the visit.

For the males (and females, but I figure it should be a given for the females), when I do a rectal and/or a GU exam, I always pull the curtain, again with a little humor - "Let me pull this curtain, just in case someone opens the wrong door. Hasn't happened yet, but there's a first time for everything."

Oh, and at the beginning of every visit in some rooms, the door is a little finnicky, so I always make sure to get the door latched completely before launching into the actual clinical discussion. I've noticed that some of my patients definitely notice (just by watching their gaze as I do that) and while no one's specifically mentioned it, I'm sure they appreciate it.

More thought - When a woman comes in for a skin issue, and she tells me its on near her bra-line on the back, when it's time to examine it, I always ask if it's easy enough to look at without making her uncomfortable, or if she'd prefer a gown. Sometimes they need a gown to check it, in which case I step out, and come back with my nurse, other times, just moving the shirt a little bit is enough exposure without sacrificing modesty.

As an aside, I always thought the reason for removing the bra during any procedure in the OR was to keep it simple with concerns of metal in the underwire versions - potential concern if using the bovie[cautery] or if disaster and needing shocked to not have to worry about aberrant electrical conduction.


 
At Friday, June 27, 2014 1:01:00 PM, Blogger Maurice Bernstein, M.D. said...

I copied to the Medscape physicians forum Misty's most recent response and, with the family physician's permission, here is his response to Misty. {By the way, southerncookin, the surgeon, indicated he may write a response directly to this thread. I hope he comes.}..Maurice.

From the anonymous family physician:


In the medical setting, an examination of sensitive areas (such as the breasts and genitals, but perhaps other areas as well depending on a person's background and previous experiences) is precisely that - an examination. We are not (at least those of us who are truly professional - the vast majority in my opinion) exposing areas for the sole purpose of getting a glance at these areas. Yes, we want to make sure that our patients are as comfortable as possible, but we also realize that there is no way to completely extinguish the awkwardness/uncomfortable feeling - only to minimize it as much as possible, complete the necessary exam as quickly as possible (while maintaining a quality exam - a cursory poke on one area of the breast does not tell me anything about the remaining tissue) without needless delay (which would of course make the patient even more uncomfortable and could represent crossing the line into abuse of a doctor - patient relationship depending on circumstances).

The case of the man who forgets the towel is completely different - there is no need for the visitor to see the man's genitals, and the man could holler for help, grab a sheet from the bedroom, put on his pants anyway, etc. (of course, depending on the structural setup of the house).

Back to the medical setting, if there is need to examine a sensitive area, my practice is 1 of 2 things: If the reason is for regular check up (such as pelvic exam/Pap smear) I always check to see if women would prefer a female provider (sometimes confirm that they are aware I am male), and if so, arrange for a visit specifically for that. If the reason is for an actual problem, I listen to the description along with what's been tried, and when possible, can sometimes treat without an actual exam (best example would be if a woman comes in for a yeast infection, finished antibiotic 2 days ago, always gets these, hasn't tried Monistat, then I will often just treat, with the caveat that if it doesn't resolve, she has to come back for a more thorough evaluation - which can be with a female if she prefer).

Allow me to pose this question for thought - if you visit the doctor for a breast concern, would you prefer to be in a gown, with one breast exposed at a time, or would you prefer no gown, no bra, no sheet? Again, acknowledging the fact that there will always be some level of discomfort, an expedient exam of one breast followed by the other (with gowning), is much more sensitive than letting it all hang out, so to speak. As is performing a Pap/pelvic exam with a sheet to cover everything - sheet up, exam, sheet down, is still more comfortable than everything visible at all times during the encounter.


 
At Friday, June 27, 2014 1:25:00 PM, Blogger Maurice Bernstein, M.D. said...

Obviously "southerncookin" now "artiger" (12:47pm) has come and written and I thank him for contributing to this blog thread. ..Maurice.

 
At Friday, June 27, 2014 1:33:00 PM, Blogger Maurice Bernstein, M.D. said...

Here is a comment just posted on Medscape physician's forum from the anonymous anesthesiologist whose comments I have previously posted. ..Maurice.


I am a physician but my wife's experiences may be of value here

She is a very attractive woman and she has described several episodes with male doctors where she felt "un·comfortable"

So our solution is ... she only sees female PCPs

She needed a minor throat procedure a few years ago and the best guy for the job was ,, well ,, a guy
... so she consented to that

I will not reveal the details of what she told me ... mostly 'subtle' stuff
that gives me the creeps just thinking about it

 
At Friday, June 27, 2014 6:54:00 PM, Anonymous Anonymous said...

Unfortunately Dr Bernstein these are not the experiences that are driving these discussions. A MD bringing a female nurse in for a vasectomy when it is nor really needed, a female ultrasound tech doing a scrotal ultrasound when a male is present but not even asking, and on and on. Now do not get me wrong, I have had many positive experiences with my MD's, but I have also experienced the opposite. It is awesome to have other providers join us, they seem to be the kind of providers i would value and appreciate. We need to recognize and appreciate those who understand, as well as those who don't.....thanks for joining us...don

 
At Friday, June 27, 2014 7:12:00 PM, Blogger Maurice Bernstein, M.D. said...

The anonymous anesthesiologist wrote the following to Medscape this evening. ..Maurice.


I am retired now ...

But the main thing I always did to set women pt's mind at ease is to ALWAYS have a female "Chaperone"
present during any examination

It sets their mind at ease ... and I know there cannot possibly be any claim that I was some·how
"in·appropriate" in my conduct with them

 
At Saturday, June 28, 2014 10:53:00 AM, Anonymous StayingFit said...

'But the main thing I always did to set women pt's mind at ease is to ALWAYS have a female "Chaperone"
present during any examination
'

I wonder, did the doctor ever ask his female patients if the presence of a chaperone actually made them more comfortable? I seem to recall studies that showed this was true for some women, but not all. I believe that this physician meant well, but I really believe that he should have asked, before simply assuming that a chaperone would be welcome.

 
At Saturday, June 28, 2014 7:16:00 PM, Anonymous Anonymous said...

I wonder if the anesthesologist who said men don't seem to care, ment in general or around him. Since they were same gender it does change the issue.

I noticed that there was concern for female modesty including draping during pelvic exam so everything isn't visable at one time, yet no such accomodation is made for males. you are laid out on the table no draping or curtains. I would love to hear one of our providers address this.

Last these provider/posters see to understand the issue of modesty, especially for women. That said, how do they feel about what many of us have experienced from having female nurses present for a guys vasectomy when it can be and is done with out, having a female tech do scrotal ultrasounds when males are available. Obviously these providers have some degree of recognition, yet it appearss in other parts of the medical world these things happen frequently with no apparent concern for the comfort of the patient. Could they help me understand or at least give me their thoughts on why this seems to be so prevelant. I fail to see how anyone could claim ignorance that a man getting a vasectomy would not be reason for concern in this area....don

 
At Sunday, June 29, 2014 11:37:00 AM, Anonymous Anonymous said...

" I am retired now"

" But the main thing I always did to set pt's mind
at ease is to ALWAYS have a female "Chaperone
present during any examination

' It sets their mind at ease...and I know that there
cannot possibly be any claim that i was some
how " in-appropriate' with them.'

I suspect you are probably not an anthesiologist
and not a provider at all. For if you were you
should know that having a chaperone present
in no way protects you from a sexual assault
charge. Take the case of Brian Finkel, he
was an Abortion Doctor in Arizona for years.

He is serving a 35 year prison term for many
charges of sexual assault. During all of the
alleged cases he had a chaperone with him
for every patient. The chaperone in court had
insisted during testimony that no inappropriate
behavior occurred. He is in prison currently
and has been for many years. There are many
numerous cases I can site whereby the
presence of a chaperone will not protect you.

Again, I will say there is nothing to gain from
these providers, real or imagined. I don't ever
expect anyone to have any kind of a real point
blank discourse on why so much discrimination
exists on this subject regarding male patients.

The mentality is out of site out of mind. It is a
thought process that simply addresses the
legal ramifications to protect providers from
accusations true or concocted. In real life
form most female patient, male provider
interactions are easily avoided by patient
choice. Never the case for male patients in
virtually any interaction due to large female
ancillary staff and their seemingly endless
desire to be ever present for any and every
exam male patients are to have!


PT

 
At Sunday, June 29, 2014 4:11:00 PM, Anonymous Anonymous said...

I think PT's comment provides a glimspe of the challenge providers and patients alike face. The diversity of patient preference creates a lot of uncertainty in how to address the issue. PT feels the out of site out of mind is a bad thing, I feel for me it is a middle ground. While I would prefer a all male team when I am exposed for surgery and such but i can accept with the lack of gender diversity and efficency this can be difficult. That said as long as I do not have to personally experience it i can deal with it. Others find this unacceptable. It does play to Dr. Bernstein's contention it falls upon the patient to make their preference known. On the other hand I stand my my contention that there are situations that seem so obvious that failing to accomodate makes a patient doubt providers sincerity. As I put forth above,, how could a provider recognize the discomfort and need to accomodate a females pelvic exam but not a males vasectomy? A vasectomy is wildly known to be stressful for a male, yet in the procedure unneeded female staff are commonly present with no draping like that for a pelvic exam. So how are we to believe providers are sincerely concerned. Are providers like southerncookin outliers in that they truely care?....don

 
At Sunday, June 29, 2014 6:20:00 PM, Blogger Maurice Bernstein, M.D. said...

To be open to my visitors, in the Comment below by the anesthesiologist writing to Medscape, the identification of Misty's interest was written earlier by me to that physician's forum.

Here is what the anesthesiologist just wrote:


It appears that Misty is the moderator of a website that focuses on patient modesty and gender issues and provides "her" suggestions of how patients can prevent or deal with these issues when they face being a patient. So I think her mind is already made up.



TOLD you it was Women that have most of these issues !!

Just tell your Blog contributors that when they are in an Operating Room ,,
all of us try to do every·thing we can to preserve their modesty & dignity


And honestly, as I have said in the past, in all my observations within operating rooms, I have never seen genitals of either gender left unnecessarily uncovered or forgotten to be covered. ..Maurice.


 
At Sunday, June 29, 2014 6:26:00 PM, Blogger Maurice Bernstein, M.D. said...

p.s. I forgot to note in my last Comment: Misty, you can reply specifically to what was written about you and your website and I will be pleased to reproduce it on the Medscape conversation. If you want to include the url for your site, that can also be included for the physicians' referral. Write it here or send me e-mail. ..Maurice.

 
At Sunday, June 29, 2014 7:05:00 PM, Anonymous Anonymous said...

I wish I could say that all of my experiences have been so considerate Dr. Bernstein, but they have not, and those were personal experiences as well. I have a family member who basically has a glorified CNA certification, she was in preop and talked about how wierd it was seeing people she new naked. Her comment was "I always try to cover them up but the nurses who have been there for a long time just leave them lay there like that, it;s no big deal to them". That was second hand but my personal exleriences were first hand. Consideration for modesty was provided in a manner that was convienent for the provider, not what was best for me....I still have never had an answer of why a MD can do a vasectomy by himself, but brings in a nurse if not just for their benefit, not the patients...and I have a hard time believing ignorance is the answer....don

 
At Sunday, June 29, 2014 8:08:00 PM, Blogger artiger said...

Don, a physician may be able to perform a vasectomy (as well many other procedures) by him/herself, but it is never a bad idea to have another person in the room in the event of a problem. It's simply a safety issue.

Now the gender of that other person, I'd agree, should be in accordance with the patient's wishes, if possible.

southerncookin

 
At Sunday, June 29, 2014 8:48:00 PM, Anonymous Anonymous said...

Maurice

What problem might the physician encounter
that would necessitate the presence of another
during a vasectomy, cardiopulmonary
resuscitation?

PT

 
At Sunday, June 29, 2014 9:08:00 PM, Anonymous Anonymous said...

Artiger

Let's pretend that I don't have over 35 years
of health care experience. What are your safety
concerns during a vasectomy? What are the
credentials of staff employed at a Urologists
office? Do you think they are up to date on
their cpr certifications? Do all urology offices
have a code cart? If they do then who exchanges
the expired meds? What are the policies in place
when a urology office needs to call 911? Who
transports biopsy samples to a board certified
pathologist and what is the required time frame
to transport such samples before the samples
degrade?

Do you think urology clinics hire male ma's?


PT

 
At Sunday, June 29, 2014 9:56:00 PM, Blogger artiger said...

PT, I simply meant having another pair of hands. You never know when you might get unexpected bleeding, may need something else placed on your sterile field, have a patient puke all over himself during the procedure, etc. These are all things that have happened while I have performed procedures in the office during my mere 17 years of practice, as well as during my training. And, since you mentioned it, if a patient arrested during an office procedure, would you want one or two people present?

As for the issue of gender preference, I have no disagreement. I think that if the urologist in question does not have an available male assistant, it would be appropriate to ask the urologist to prep and drape the area himself, and then simply have the assistant come in the room and stand by at a distance. If I were the patient, though, I wouldn't care. I would want the urologist to perform the procedure under routine conditions, in the interest of safety.

southerncookin

 
At Monday, June 30, 2014 12:20:00 PM, Anonymous Anonymous said...

Artiger, I do appreciate having you here to have this discussion. I have several problems with the response, it is not meant to be critical but to put a different side of the issue in the room. The overwhelming majority of support staff in urologist as well as MD's offices are female. I do not know that I ever have met a male "nurse" in these environment. Using nurse in a generic sense. This is meant to give you food for thought just as your comment about the pair of second hands for emergencies did me. The acknowledgement that it was important to drape females so it isn't all out there was made as common sense and practice...yet the possibility of providing the same consideration for males gets questioned in the interest of safety. My MD did mine by himself, he draped me which amounted to a sheet with an opening in it that left me completely exposed. Now since it was just he and I, I was OK with this. The reality is the profession has so long ignored the male side of this equation even discussing it brings completely different thoughts, even from providers whom are trying to recognize it. How did "tenting" for privacy for females become "routine"? Because providers have done it in the past. The only way males get the same consideration for providers to make these accomadations routine for men, as they are for women, is to start asking, perhaps demanding. Some women might not care about draping, but there are many patients who feel differently, same goes for men. I did not intend to turn this into a battle of the genders but the difference between how we view this particular procedure. If urologist were being asked to drape in a manner that protected a males modesty it would become routine just as it is for women, as it should be. Surely there has to be some way to accommodate men, but it will require providers recognizing that just because it was done like that in the past, does not mean it is right and things like gender bias do exist. Artiger, I know you were giving your opinion and what is right for you, I hope we don't come off as two critical and discourage you from sharing them. This has been a long long discussion and has really enlightened and empowered me. I do not doubt few men acknowledge this is important, I covered it as well for most of my life until I stumbled on this site...thanks for joining the conversation...don

 
At Monday, June 30, 2014 3:25:00 PM, Blogger Maurice Bernstein, M.D. said...

Don, I copied and posted your last comments onto the Medscape forum and the anesthesiologist came right back with the following. ..Maurice.


Don ,,

I had a vasectomy done in the office of a good pal Urologist
who owned a sail·boat named NUT·CRACKER

So I had to have my privates exposed for a bit. SO WHAT ???

Believe me ,, Don ... we really DO NOT WANT to see your naked body

Try to 'get it' that medical care will usually involve some compromise
of your usual standards of dignity & privacy

 
At Monday, June 30, 2014 5:41:00 PM, Anonymous Anonymous said...

I would appreciate you posting my response to the anesthesiologist since he had the opportunity to respond to my post. I had my vasectomy by my PCP, guess what it was no big deal either,,why...because he cared enough to consider what I wanted, he didn't need a nurse It isn't about what YOU want or think someone else should be fine with, that is the problem. I have had numerous procedures that did require compromise and guess what I did it because it was reasonable. I have never asked for a all male staff for the several ops as I didn't think that was reasonable, The problem is some providers think they hold such a position of importance they can choose what we should or should not accept or be comfortable with. For me it is not an issue when providers can't, it is when they can but don't because it is more convienent for them to claim "it's SOP, its different because WE are professionals. Their time, schedule, and convenience is more important than patients comfort. Providers have a double standard for gender and justify it without even recognizing it. You proudly announce how you try to make women comfortable by staying behind the curtain then attack a male saying they have concerns about a female nurse present for their vasectomy. Try to get it, it isn't about you or what you want or what you think the patient should be OK with, it is about them. You don't get to define who should get what accomodation. You are in a comfortable, familiar setting, fully clothed, and getting paid. It is about compromise, how about you compromise by going a little out of your way to make the person paying your wage as comfortable as possible...Try to get it, you don't know me or anything I have experienced. Try to get it, you don't have the right to tell me what is or is not right for me..but that is the problem, you don't get it because you think this about you because you are wearing scrubs...don

 
At Monday, June 30, 2014 5:56:00 PM, Blogger Maurice Bernstein, M.D. said...

Don, I get it!
By the way, scrubs are not really "fully clothed" nor formal attire in the usual sense.

Personally, Don, I am glad to read that you do weigh your modesty issues against the reality of your clinical situation and accept the reality over the modesty. As you know, I have been astounded to read here that some patients writing here have allowed modesty to trump and thus avoid life preserving exams or procedures.

I will again copy your last comment to Medscape. ..Maurice.

 
At Monday, June 30, 2014 6:04:00 PM, Anonymous Anonymous said...

"I had a vasectomy done in the office of a good pal Urologist who owned a sail·boat named NUT·CRACKER

So I had to have my privates exposed for a bit. SO WHAT ???

Believe me ,, Don ... we really DO NOT WANT to see your naked body

Try to 'get it' that medical care will usually involve some compromise
of your usual standards of dignity & privacy"

A typical patronizing and paternalistic response by a self professed medical professional who would never address a female patient who expressed similar concerns with such dismissiveness.

Did his urologist actually perform the vasectomy with a female tech simply observing?

Because he was comfortable with being exposed, so should everyone else apparently.

Should've chose a different profession if he didn't want to see naked bodies.

No Doc, you need to "get it" that we are both the patient and paying customer and the only privacy and dignity compromises I'll settle for are those I define and no one else.

Ed

 
At Monday, June 30, 2014 7:45:00 PM, Blogger Maurice Bernstein, M.D. said...

I must say that I am very pleased to finally after all these years to be getting direct input to the issues described here on the Patient Modesty volume by physicians. I hope the conversation will continue and be educational on both sides.
I just want to advise my visitors to express themselves openly but also in a courteous fashion since the purpose here is not to tear each other apart but, as I said above, to educate both sides. And there is much for each of us to learn from the other side. ..Maurice.

 
At Monday, June 30, 2014 7:52:00 PM, Blogger artiger said...

Maurice, I do understand and appreciate the concerns of those posters on your blog, but I must have a much different type of patient in my practice. Maybe it's because I'm in a rural area, but I have never had such a sense of outrage at a medical professional seeing someone's private areas of anatomy. It could be a cultural thing, but the way I was brought up, if you were going to see a physician, you might have to undress. Period. And since we were in a small town, it didn't matter if the physician, nurse, or anyone else involved was male or female, you just dealt with whoever was there, because it was a long way to find someone else.

I too would be a bit bothered if I were draped for a vasectomy with all my "stuff" just hanging out in the breeze. But if my urologist only has a female assistant/nurse, I understand that he may need someone else in the room. This gets back to a point I made earlier, about working quickly, and only exposing a sensitive area for the minimal amount of time necessary, and only the minimal area that needs to be viewed. If we have to expose any sensitive area at all, minimize it. This is how we perform in our OR and endoscopy room at our facility. Above all, we take the time to explain this all to the patient beforehand. We don't seem to have anyone complaining.

With all that being said, today, in my practice, the patient's wishes will be honored. I have the luxury of working in a hospital, so if a male patient requests that a male nurse be present during an office procedure, I can simply walk down the hall to the ER or the floor, find a male nurse or CNA, and accommodate the patient's wishes. Not every practice (especially one of a solo provider) can do that, it's just not economically feasible.

 
At Monday, June 30, 2014 8:21:00 PM, Blogger Maurice Bernstein, M.D. said...

The following comment this evening was not identified but I assume it came from Don. ..Maurice.

Thanks Ed, that was well put and exactly my point. He proudly stated how he would accomdate female patients.

Dr.Bernstein, I understand your position that it does not make sense to compromise one's health for modesty. But it doesn't make sense to smoke, or drink alcohol, eat in excess, for diabetics to not follow their diet, but some do, and some really want to do better, they know better, but they can't. I am sure there are some here whom are the same. Thanks to this thread I am better equipped to deal with it all. I will ask for what I think is reasonable, I will look elsewhere if i don't like what is offered, and I will accept things i am uncomfortable with if I think they are reasonable, but I won't intentionally jepordize my life, I have to much to live for and to many people counting on me. I have however put off care in the past due to this. Being empowered in a large part by this thread has helped me stand up and get what I feel is right and still get care, I don't know if i ever thanked you or Dr. Sherman for that.

I still feel passionately that providers like the aniesth. need to accept the new reality that patients define what is right or wrong for them in this area, not providers. Ed hit it on the nose when he said he would never attack a female for expressing concern, and he never even realized it.

Oh and I am not sure if you were trying to be funny or serious about scrubs not being fully dressed...go grab a meal in scrubs, naked, or wearing just the open back gown tied at the top in the mall and tell me if you don't feel more fully dressed in scrubs. i was at the local fair tonight with my grandkids, saw two females in scrubs, one pink, the other blue, did not see one naked person or anyone wearing only a gown...scrubs are fully dressed in our society....thanks again Dr. Bernstein

 
At Monday, June 30, 2014 8:49:00 PM, Blogger Maurice Bernstein, M.D. said...

Artiger (southerncookin) what you wrote as your experience with regard to patient examinations is exactly the same as mine. I know that my visitors may not believe when I have repeatedly written here that in my internal med practice, I never, never had any patient tell me or behave that they were concerned or upset about their modesty issues before, during or after my physical examination. This area of personal intimacy was never addressed by either me or the patient. Yes, for a woman patient's pelvic exam, I always had a female chaperone during the exam itself (as per classic professional procedure) but no chaperone for male genital or female breast exams.

As I have previously noted here, particularly since reading the comments here, I have emphasized to my first and second year medical student group I teach the need to bring up to the patient what will be exposed, what will be done and to get the patient's informed approval. We teach for cardiac or other local exams under the woman's breast to have, if possible, the woman to elevate her own breast. I think in all these intimate exams what can be more important than a chaperone is for the physician to devise a protocol where the patient feels and does actively participate in the examination. The exams should be not be unusually prolonged but it also should not be done silently with zero communication between the patient and doctor in both directions. As the students tell their instructors what and why they are doing a segment of the exam, the patient should be kept informed during the procedure.

Anyway, this is my current philosophy for teaching..probably a bit more in this direction than when I first started with students over 25 years ago and before reading these Volumes for the past 9 uears. ..Maurice.

 
At Monday, June 30, 2014 9:18:00 PM, Anonymous Anonymous said...

Artiger


Do you need an assistant to hold an
emesis basin for a patient that is vomiting,
people vomit all the time. Do you need an
assistant to prep a patient for a simple
procedure? Do you require an assistant to
set up a simple procedure tray and to hand
you all 5 instruments on that tray? You can't
draw up your own lido? In fact, you are telling
us that you need help on every simple surgical
procedure and a vasectomy is a simple surgical
procedure. I would question your competence
if you can't prep and set up your own procedure
tray for a simple surgical procedure. Never mind
the obvious interests of privacy for the patient, it
dosen't matter to you, would would you think it
dosen't matter to us. Would it matter to your 18
year old daughter for her female physician to
bring a male assistant to perform every single
simple surgical procedure that she required,
vomiting and all? Wait a minute,female
physicians don't hire male medical assistants
nor do they hire male mammographers to perform
mammograms for your 18 year old daughters
annual exam. It matters to your daughter that
when it is time to deliver her baby in L&D that
there won't be that male nurse to tend to her
personal needs. Nor will there be a male nurse
to take care of her personal needs in post-op
gyn care. It's a plus to you that you have a
95% pool of female nurses to hire from and a
99% pool of female medical assistants to hire
from as well.


PT


 
At Tuesday, July 01, 2014 6:07:00 AM, Anonymous Anonymous said...

Artiger, once again I appreciate you being here. I can tend to respond tersely when I feel I am being belittled or my concerns trivialized so I apologize if I respond as such.
It does not surprise me that you or Dr. Bernstein say no one spoke up. I would guess that is particularly true of males. We are told we should accept this, we don't think we have a option. I related hear how I had a scrotal ultra sound by a female tech that was very uncomfortable for me. I doubt she could tell I was overly troubled other than she commented on my elevated bp. I carried on small talk, etc and even found myself thanking her after. It was very embarrassing for me but it needed to be done. I walked out into the waiting room with her, she picked up a chart and called a woman's name. She identified herself, and the female tech told her "I am going on break for a few minutes, the only other tech available, if you would feel more comfortable with a female I will be back in about 10 minutes". That is the incident that so upset me I started searching and found this thread and that I was not alone.
It shows several things, 1st the double standard, that staff is aware this is an uncomfortable process, and perhaps the most important they often CAN do something to ease the discomfort, they just chose not to. Not because they are bad people, it is just that they haven't had to in the past so they don't. I also live in a rural area. When people do not think they have an option, they are forced to accept what is offer. My friend had his vasectomy with a different MD, he called his female nurse whom the patient knew well and interacted with socially in to "assist", my friend told how embarrassing it was for him and said "all she did was stand there and hold my penis out of the way. Here is my main point, the provider has to know these things are at a minimum uncomfortable, they may not know the depth, but they have to know it makes them uncomfortable. My question then comes back to "If you have reason to believe it makes the patient uncomfortable, and you have the ability to reduce that, why would you not? Even if it is just in degrees? Part of this is our fault as patients for not speaking up, but I cannot hold providers harmless due to ignorance. The depth of the issue may be unknown, but that it exists at all...I cannot accept that. I think the other thing is, while I understand the concerns about the "extra hands" for the rare, on something as routine as a vasectomy shouldn't that be our choice? Shouldn't we be given the option to choose what risk level we are comfortable with? I think efficiency and ease for the provider are often driving factors that providers don't want to recognize, perhaps event to themselves...I would appreciate your thoughts, thanks...don

 
At Tuesday, July 01, 2014 6:19:00 AM, Anonymous Anonymous said...

I, too, appreciate that some medical professionals have come to this site to comment. I agree that it is helpful to get input from both "sides". A few points, however. As I have said before; doctors may not have had this issue brought to their attention before or are aware that it even exists because, by and large, patients can select the gender of their doctor. In other words, a woman who goes to a male doctor for an intimate exam obviously has no problem with a male examining her. And obviously there are many people who do not have an issue with this. But most of the problem, as noted by the contributors to this blog, comes with ancillary staff when having procedures, etc. And in these cases it is nearly impossible to tell how many people feel extremely uncomfortable with opposite gender care. Let's face it: most will not speak up and just accept what they get and, to some degree or other, feel embarrassed, humiliated or worse. Also, doctors cannot know how many people are actually avoiding care for these reasons so it's hard to tell how important the issue is just by the patients doctors do see.
One more point: artiger stated that in his practice and hospital/OR they always take the time to explain to the patient beforehand the extent of the exposure and their effort to minimize it. This is terrific but definitely hasn't been my experience. My impression is that they withhold this information, either feeling that it is unimportant or in an effort to keep the patient from knowing how embarrassing the procedure may be, especially when they will be sedated. I haven't had much experience in the medical arena but I have never had any of this discussed with me ahead of a procedure/exam. Nor has anyone I have accompanied for exams/procedures. If this was actually done I think it would go a long way in helping patients feel respected and give them an opportunity to request modifications if at all possible or assistants of their gender choice if possible.
While I agree with Dr. Bernstein and Don that modesty issues shouldn't trump treatment I do also think that doctors and hospitals should make more of an effort to make those of us with these concerns feel more comfortable so that treatment of physical ailments doesn't result in loss of dignity. If there are people posting about this issue here you can bet there are many others out there who feel the same way but just haven't researched or found this site. Many just feel like they have no choice and either put up and shut up or avoid seeking care.

 
At Tuesday, July 01, 2014 7:07:00 AM, Blogger artiger said...

PT, I don't know if you always write in such a provoking manner, but I'm going to have to ask just what role you had in your 35 years of health care experience. I can do, and have done, just about all of the simple tasks you mentioned above, both when I was an orderly way back when, and now as a physician. That isn't the point. Your suggestion of incompetence is downright insulting. Excessive bleeding, a heart patient who vasovagals during an abscess drainage, an obese patient who passes out, and the need to have someone hold a retractor (so that perhaps I can see, maybe that might strike you as important?) are just a few of the reasons that having another set of hands available, in the room at the time of the procedure, is in the best interest of safety. Anyone who says they have never had a complication is either ignorant, lying, or inexperienced.

How many vasectomies have you done anyway? If a patient vomits during the middle of a procedure, and my hands are occupied with something like control of bleeding, am I supposed to grow a third arm to hold the basin, a fourth arm to get a cold compress for the patient? I have done lots of procedures alone, and can do a lot of them alone, but being prepared for the surprises is what keeps you out of trouble in health care.

As for my daughter and male nurses or assistants, I'm sorry that life isn't fair. I told you what I do in my own practice, which I think accommodates the patient's wishes. One reason OB's don't hire male assistants is might be the fact they don't have male patients. So I'm not going to worry too much about that one when it comes time for me to have grandchildren. But if it's non OB/gyn type of procedure, I don't have any problem with the assistant being male, female, or even Martian. I want the physician to be able to perform whatever procedure under the best circumstances, with adequate assistance from someone he/she is accustomed to working with.

 
At Tuesday, July 01, 2014 7:38:00 AM, Anonymous Anonymous said...

Thank you medical community for stepping up.

I think it's important for you all to know that everyone has their own reasons for this modesty issue. It's difficult because everyone's needs are different.

Chaperones to me, are just another pair of eyes degrading me into an object instead of a person. These feelings stem from cruel and degrading treatment and sexual abuse in a healthcare setting.

Before that time, I would have never thought to ask about the gender of a medical provider. Mom was an RN and I grew up trusting and depending on the medical community. I thought I was in safe hands. Then the absurd, and ridiculous happened to me in a hospital. It changed how I look at medical care and the world.

There is no reason to trust the medical arena due to standard of care practices, gawkers, and lack of caring about the privacy and dignity for patients. Violating one's privacy is not something that might happen, sooner or later, it will.

While on that operating table, I vowed that never again would I be put into such a position.

So now I'm in charge. As an analyst, I took those skills and applied them to my needs, the medical system and made an action plan tailored to me, taking away the medical profession's ability to override my decisions, even if I can't speak for myself. It requires many facets of the law, mental capacity, the way you sign consent forms and a document called a "living directive". Such is stated on a medic alert bracelet worn at all times. It overrides family members for altering my wishes.

What Dr. Bernstein and possibly you, doctors and others, reading this blog, is that once everything is taken from you, your physical well being comes AFTER your psychological well being. It's self protective.

Unlike others who have been traumatized, I took matters into my own hands to see that my medical needs are met, and they are.

I urged on this blog, and urge you to visit the assigned risk department of your respective hospitals and you will find that a large number of complaints are surrounding issues of extreme privacy violations.

Same gender care is a way for some people to cope. Feeling degraded is not someplace I choose to go.
It would compromise my dignity and
privacy to accept opposite gender care for intimate procedures and as protected by Title VII, I have a right to do so. I would be against my will. Now it's time for the medical community to get on board. Will you help?
belinda

 
At Tuesday, July 01, 2014 11:02:00 AM, Blogger Maurice Bernstein, M.D. said...

I am encouraged by the reactions to our professional visitor and the interaction with what is being discussed on Medscape. This extended communication is what this blog thread has needed from the outset.

By the way, whomever wrote an Anonymous message at 6;19AM today forgot to end with a pseudonym so that we all can follow the conversation. ..Maurice.

 
At Tuesday, July 01, 2014 11:45:00 AM, Blogger artiger said...

To Don above...thank you for your comments, written in a non-hostile fashion. To your last point, about "extra hands", I certainly understand how you might feel that you are assuming the risk if you demand that the physician not have anyone else in the room. Unfortunately, the legal system would see it differently. My job is to provide you with the best care that I am able, and more importantly, in the safest manner available. If you are asking me to worry about anything other than the procedure at hand, or are asking me to perform a procedure with less than optimal exposure, you are asking me to work under less than ideal circumstances. Sure, for a vasectomy or other small procedure, most of the time everything will go just fine; but problems don't usually occur in a predictable manner. Being unprepared for those problems often prevents them from becoming bigger problems.

If I succumb to your wishes, and perform your procedure without an assistant and something goes wrong, your attorney will crucify me for deviating from my normal routine. I can say, "but sir, Don asked for it that way", and he/she will respond "Who is the doctor here, and who is the patient?" You can't expect the patient to fully understand the risks as well as you do. You have been trained for this, he has not. Etc." It would be nice if I could defer the risk to you, but the courts just don't see it that way. It's not so much about ease and efficiency, it's about safety and liability.

There are a few procedures that I will perform alone; removing sutures and freezing warts, for example. For the most part, though, if it involves a knife, I'm probably going to want some help nearby.

 
At Tuesday, July 01, 2014 11:46:00 AM, Anonymous Anonymous said...

Sorry, that post of 6:19 was me, Jean.

 
At Tuesday, July 01, 2014 1:49:00 PM, Anonymous Anonymous said...

To artiger,
Thank you so much for your contributing to this website. You stated "For the most part, though, if it involves a knife, I'm probably going to want some help nearby." I pose the question to you. Does nearby have to mean "up close and personal?" Or can it be someone within earshot outside the door?

I am like most of those who have posted here. I have no problem with female physicians but I dislike being forced to interact so candidly and personally with ancillary staff such as receptionists, "nurses" (who may not even have a high school education), and technicians. I have quit seeing my urologist for that very reason. I find it very odd that my former male urologist has not a single male assistant because "They don't exist." However, my female dermatologist managed to find one.

One may count the number of all-male urology clinics in this country on a single hand of a careless sawmill worker. It is this behavior by the medical community that deserves much improved attention.
Gerald

 
At Tuesday, July 01, 2014 2:30:00 PM, Anonymous Medcial Patient Modesty said...

I think it is great that Don was able to get a male urologist who was willing to do the vasectomy by himself. There are not that many risks and complications with vasectomy.

For male urologists or surgeons who feel that it is important to have someone else present for vasectomy, why not ask the male patient to bring in his wife to be present? The wife could help in many ways. In fact, a wife would be useful in making sure that no one else accidentally came in the room while vasectomy was being performed. My personal opinion is that male patients should look into having their wives present for the procedure.

Vasectomy is much safer than tubal ligation so it is a very important permanent birth control.

Artiger, if a male patient was willing to sign a form promising you he would not sue you if complications came up as a result of his vasectomy, would you be willing to consider doing his vasectomy by yourself? How about if his wife was present?

It is very concerning that many male urology clinics will not hire male nurses or assistants. Money should never be the reason to not hire a male nurse or assistant. Male patients deserve modesty as much as female patients. Many women would be outraged if they were forced to have male nurses or assistants for gynecological procedures.

Misty

 
At Tuesday, July 01, 2014 2:40:00 PM, Anonymous Medical Patient Modesty said...

Dr. Bernstein,

I wanted to respond to your comments on Sunday, June 29th. You can share this information on Medscape.

Here’s my reply:

This is Misty. I am the founder of Medical Patient Modesty (http://www.patientmodesty.org), a 501c3 non-profit organization that works to educate patients about how to stand up for their wishes for modesty. We have many articles about how patients can get maximum amount of modesty for procedures and same gender intimate care. We also have an all-female ob/gyn directory that lists all-female ob/gyn practices across the US. We also have some tips on our web site about how medical professionals can work to honor patients’ wishes for modesty.

Some of goals are to reduce unnecessary intimate exams and exposure. For example, many hospitals have a ridiculous policy requiring patients to have their underwear removed for surgeries that do not involve the genitals. Fortunately, some hospitals in the US have revised their policies and are allowing patients to wear 100% cotton underwear for many surgeries.

While it is true that there are many patients who do not care about their modesty in medical settings, there are many patients who do care.



Misty

 
At Tuesday, July 01, 2014 7:27:00 PM, Anonymous Medical Patient Modesty said...

I really appreciated some of Jean’s great points. I wanted to highlight some of her important points and my response.

A few points, however. As I have said before; doctors may not have had this issue brought to their attention before or are aware that it even exists because, by and large, patients can select the gender of their doctor. In other words, a woman who goes to a male doctor for an intimate exam obviously has no problem with a male examining her. And obviously there are many people who do not have an issue with this.

This is true. Women who prefer female doctors for intimate procedures are not going to a male doctor for this in the first place. Take a look at the all-female ob/gyn directory . There are many all-female ob/gyn practices in large cities. Why do you think there are so many all-female ob/gyn practices? Many women from rural areas will drive 30 minutes to an hour to see a female gynecologist. Many women want a 100% guarantee that a female gynecologist will deliver their babies. Doctors who do opposite sex intimate exams are not going to see those patients of course.

One lady has commented some on this blog in the past shared that she had no patient modesty issues because she went to a male gynecologist. Patients who see doctors of opposite sex on purpose for intimate exams usually do not have patient modesty issues.

Also, can you explain why there are some all-male urology clinics in the US? There are not that many, but some have been launched. Those urologists with all-male staff and female gynecologists who work in all-female ob/gyn practices apparently understand patient modesty.

Take a look at the web site of this all-female ob/gyn practice in Texas. You will notice at the top there is a picture with a caption that says “I feel more comfortable with a woman doctor”.




My impression is that they withhold this information, either feeling that it is unimportant or in an effort to keep the patient from knowing how embarrassing the procedure may be, especially when they will be sedated.



It is true that they often withhold information about how exposed you will be in surgery. For example, there have been cases where underwear and gown were removed unnecessarily for surgeries.


If there are people posting about this issue here you can bet there are many others out there who feel the same way but just haven't researched or found this site. Many just feel like they have no choice and either put up and shut up or avoid seeking care.


This very true. So many people have found Medical Patient Modesty’s web site. I have had the privilege of helping a number of people. Many people especially men have avoided care. I actually know of a woman who is fed up with the medical system who has decided to avoid medical care. Patient modesty is very important. It is true that many people do not care about their modesty. But many do care.

Misty

 
At Tuesday, July 01, 2014 7:57:00 PM, Blogger artiger said...

To respond to Gerald and Misty:

Gerald, if I am performing a procedure that requires another set of hands to retract, dab away bleeding, or anything else integral to the procedure, I want that second person up close and personal. Sometimes you know ahead of time when it will be necessary, other times you just want to be prepared for surprises. I'm not a urologist, but in the remote past I did do a few vasectomies. I don't do them now, but I have seen the problems that can arise from them (like a scrotum the size of a basketball from a hematoma). It's not a CBC or a CXR. It's a procedure. Some urologists may be comfortable doing them alone. Others may not, and it may be for good reason. It all boils down to comfort level. Do you want your physician stressed, or at ease? It's a reasonable question about the assistant being up close and personal vs. just outside the door. It's one that the individual physician has to answer for him/herself.

As for male urology assistants, I have no answer. If you found one in Derm, I'd say that they probably pay quite well, and the hours are great. I think you've hit on something there though and I'm going to informally poll some urologist friends of mine and ask them that very question. Keep in mind, however, that urology is not the male counterpart to OB/gyn. Women see urologists too. If a urologist has a male nurse/assistant, how's that going to work? Should the urologist hire one of each? Probably not economically feasible.

Misty, I have very little problem with spouses being in the room for minor office procedures, but they are to be seated, so as not to be in the way, and for their own safety, in case they pass out. Unless they are employed by the physician's office, it would be completely inappropriate for them to assist in the procedure, and it would be a liability nightmare. The physician's insurer would have a major fit about something like this. If there was a problem and lawsuit, the insurer likely wouldn't pay, and the plaintiff attorney would have a field day. Very. Bad. Idea.

And Misty, if I could get patients to agree to sign away their "right" to sue, don't you think I would do that for every procedure, surgery, and office visit? The courts have long ago said that it can't be done. It's a nice thought though.

I don't have an answer to the dearth of male urology nurses/assistants, but as I stated above, I'm going to ask some questions about it.

I feel fortunate to live where I do. My wife's friends come to me for colonoscopies, breast exams, whatever, and the next week we're out on the lake or out to dinner, no problem. My wife went to my best friend in med school for her gyn stuff, and then later he delivered my daughter. No problem for her at all. For those of you that can't deal with that kind of thing, I can only say that if you come to me, I will make every effort to accommodate you, or find someone who can.

 
At Tuesday, July 01, 2014 8:26:00 PM, Anonymous Anonymous said...

Artiger, thanks for engaging with us! I asked my urologist what percentage of male patients were seen by the two male physicians in their three physician practice and he stated nearly 80%! And yet EVERY ancillary staff member was female. This practice couldn't be bothered to hire a single male tech or nurse despite the overwhelming majority of their male patients preferring male physicians. Needless to say, I'm no longer a patient with that practice. What's ethical, moral, or legal about granting one gender greater modesty accommodations than the other?

Ed

 
At Tuesday, July 01, 2014 8:48:00 PM, Anonymous Anonymous said...

Artiger, do you feel you have two different standards for males and females? It seems to me that some providers express that openly. Let me ask you, when you had your vasectomy was your friends nurse present? Were you draped as a woman would be for a pelvic exam or draped but not in a manner that provided a degree of modesty. This is something that troubles me, there is a recognition in doing female pelvic exams for example that providing for modesty even when it is impossible to not expose is important. Yet a vasectomy is so personal to many men does not to my knowledge get the same consideration. For me, if a provider would not do my vasectomy either by himself or with a male assistant I would just find one that would. I would consider one who would drape me in a manner that would provide for modesty and have an assistant in the room but not in a area where they could view the procedure...but that isn't offered to men. Do you see that? Do you see providers doing that extra for men's comfort like draping in a manner that provides the same concern for modesty that is afforded women? I don't and wonder why?. What are your thoughts on my experience where the female tech did my scrotal ultrasound but asked the next female patient if she would be more comfortable with a female, these are some of the things that cause me to question motives..curious to hear how you were draped and if his nurse was present....interesting conversation here. I think the common thread is some providers just like patients have different levels of comfort. My MD was perfectly comfortable doing mine. The MD that used a female nurse familiar to the patient also did one for a friend who asked him to do it by himself and he did. I still feel many of the issues brought here are as much SOP and efficiency, but understand your concerns as well, I just don't agree with them. I hope to hear more....don

 
At Tuesday, July 01, 2014 9:16:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, I just couldn't allow your last Comment to be published. It was just too subjective about Artiger and not purely objective regarding the issues involved. Your last statement questioning Artiger being a medical professional is unacceptable. As I wrote to this thread previously, those of us as participants writing to the Medscape physician's forum are screened by established and universally accepted criteria as proof of title.

PT, I have always found value in the views you hold but sometimes I find a tendency to ad hominem remarks and I don't want these kind of remarks to discourage or prevent the med-surg professionals from contributing to our education and allowing them also to be educated regarding those potential patients writing here. ..Maurice.

 
At Tuesday, July 01, 2014 9:21:00 PM, Blogger artiger said...

Ed, I think voting with your feet and your $$$ is the best statement you can make.

Don, I haven't had a vasectomy. I'm sorry if I misspoke or led you to believe that. My experience with vasectomies was on the performing side. As for that, I will say that the way I learned to do them involved exposing only a very small area. The patient was supine (flat on his back) with the penis and scrotum suspended up toward the head with a towel, and the whole midsection was draped to only leave open the backside base of the scrotum, an area about 1x2 inches. A sheet was placed over this area until the very second the procedure was to commence. A Xanax 30 minutes prior to the procedure (for the patient!) was quite useful.

I did go to a friend for a colonoscopy several years ago. He and I were the only men in the room, and I knew one of the nurses. She was professional about it, and I never gave it much though. Still don't, but that's just me.

There probably is a double standard out there, but then again, men and women are different. I'm sorry to hear about your ultrasound experience. If a tech of each gender is available, it is inexcusable, and you should have sent a letter or visited with the administrator about it. The double standard isn't fair but it's not going to change unless you voice your concerns. Those of us in health care cannot read minds, so tell us if something is bothering you, we might be able to find a satisfactory solution.

 
At Tuesday, July 01, 2014 9:46:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, I am publishing what you have just submitted because I think you have brought up an important criticism of this blog which, if the consensus of visitors here find it a valid one, then it would be important to attempt to make changes in my moderation practices. The following is what you just submitted. ..Maurice.




Maurice

I have become very unhappy with the methodology you use on this blog. I know a fake when I see one. There was nothing ad hominem about my comments no more
than the comments that are found on all nurses
that you have said are questionable. That is a
double standard that you have approved of. You are manipulating the content of this blog
for which I. Find very disturbing.

PT

 
At Tuesday, July 01, 2014 10:43:00 PM, Anonymous Anonymous said...

Hi folks... Couldn't pass up the urge to post anymore... a couple posts have been gnawing at me.

"At Monday, June 30, 2014 3:25:00 PM, Blogger Maurice Bernstein, M.D. said...
and the anesthesiologist came right back with the following. ..Maurice.

So I had to have my privates exposed for a bit. SO WHAT ??? "

The fact that this doctor said this in this wording tells me they simply don't "get" the issue. And not to sound argumentative, but I find replies like this to be insulting. (right up there with the nurse who says "I've seen it all before", like you not wanting to drop your pants is about her comfort...)

Imagine someone who just found out a person had been spying on them.. filming them naked, sleeping, etc and when talking to a friend... lets say the friend happens to be a pornstar, and the friend said to them "so you were naked on film... so what???"

How would that not be considered dismissive and insulting?

"At Monday, June 30, 2014 8:49:00 PM, Blogger Maurice Bernstein, M.D. said...

I never, never had any patient tell me or behave that they were concerned or upset about their modesty issues before, during or after my physical examination. This area of personal intimacy was never addressed by either me or the patient."

Ever consider asking them?

Jason K

 
At Wednesday, July 02, 2014 4:39:00 AM, Anonymous Anonymous said...

Artiger, it was my mistake, I confused you with the anesthesiologist who replied in a rather condescending manner, my apology. To answer your previous question, yes PT is always this confrontational and a bit angry. Thank you Dr. Bernstein for maintaining civility and prolonging the discussion. Like Dr. Bernstein you have given me some food for thought. I am a businessman and am subject to trying to apply order to everything. This thread has been going on for several years and the comments, thoughts, and opinions have been so diverse it is hard to sort it all out. There are some who feel providers ignore modesty for control, others to intentionally humiliate, others because they don't care. I personally feel providers as a whole go into the field because they have compassion and want to help. I feel the desire for efficiency has driven changes, male orderlies that provided gender diversity were replaced with females, during the war, males were not allowed in nursing school, it was found providers could get away with it and it was cheaper. It just grew and expanded a little at a time until we are where we are today. What once was accommodated today is not partly due to the gender gap in support staff but more likely due to economics, staffing both genders cuts efficiency and efficiency is money so SOP's kept chipping away at accommodating modesty. We have oft discussed the diversity in patients and their needs, but not the diversity of providers. From the anesthesiologist with the "SO WHAT" statement to your thoughts to some who go all out for patient modesty there is a huge range. What confuses me is I see providers acknowledging and accomodating the issue in some cases (pelvic exams) but then pleading ignorance that it matters to patients in others. I struggle to reconcile that. I think providers tend to be defensive and find numerous ways to justify because often there is little they can do about it. Knowing they are inflicting some degree of mental anquish on the people they are trying to help is difficult. I would assume you recognize it is uncomfortable for patients to be in these situations. You seem to be a provider who understands and acknowledges this, and try to address it in your own way, some don't. I would just ask providers to take a look, are they really doing everything they can to protect their patients modesty and make them comfortable or just following SOPs which while in place for safety also drive efficiency rather than comfort. Are they providing for modesty as fits the patient, or themselves. Thanks for being here..thanks Don

 
At Wednesday, July 02, 2014 5:02:00 AM, Blogger artiger said...

Maurice, regarding PT's criticism above, I'd have to know more details about the whole thing. I don't have any problem with you putting the posts up, offensive or not. We're all entitled to opinions, and whatever was said is probably no worse than anything I've heard before, and I can take care of myself. If it appears that there is a double standard on censorship, It would be best to loosen the filter up a bit. Just my 2 cents.

 
At Wednesday, July 02, 2014 12:11:00 PM, Anonymous Anonymous said...

I have had many male doctors and yes for intimate exams too and never had a problem, until...

Just because a woman will accept an examination from her doctor, whom she trusts, has a relationship and feels comfortable, to mean that she will accept an examination from a strange male, especially in the hospital.

Feelings are neither right nor wrong. I still use male doctors for all specialties with the exception of gynecological exams.

It's about the way a person feels, not about that so and so is a fine physician. I already may know that. You can't change your feelings and I've been watching my male physicans, one of which is the best and still wouldn't feel comfortable disrobing.

How would I feel during an emergency? I won't know until I'm there.

Patients have experiences too. I've found a woman paralyzed both sides from a stroke, laying in bed, no blankets completely
naked. I've been in the OR prep suite where the nurses knock on the wall and promptly open the curtain with a complete disregard
for the patient knowing they are applying antiseptic over their enire body, naked and that the public area is just on the other side of the curtain.

This is common, ordinary behavior in the hospital setting. Many doctors don't see this side of things.

Thanks to all who recognize that there is work to be done.
Belinda

 
At Wednesday, July 02, 2014 1:06:00 PM, Blogger Maurice Bernstein, M.D. said...

Perhaps we should get back to the theme which was started at the top of this Volume: "patient centered care". If we all think that this is a worthy approach for all of the medical system to practice, perhaps it would be wise to define such care including its limits, if any. We are, of course, discussing patient centered care in terms of patient modesty issues including patient gender selection of all of those providing medical care. In addition, patient centered care would also involve truly informed consent by the patient before examinations, procedures and surgery. What limitations do you anticipate with regard to ensuring that patient centered care is practiced? What are the impracticalities of fully operating such a system and should those impracticalities be ignored in our advocacy for patient centered care? And to be sure that patient center care is fully carried out, how and by whom should it be monitored and what should be the consequences of elements of the system that fail to follow such care.

What I am getting at: yes, it is understanding to first "moan and groan" about the medical system and its behavior but finally we must get settled what to specifically advocate for change and how that change should be carried out and enforced.

Let's start, for example, with PT's valid concern about the paucity of male providers for management of male health problems . What should be the approach to increase the numbers and use of male providers for one task or another?

Now that we have at least one writer representative and hopefully more from the medical profession to express views and knowledge of the medical system, we should be able to develop more balanced suggestions regarding patient centered care to advocate. ..Maurice.

 
At Wednesday, July 02, 2014 1:47:00 PM, Anonymous Anonymous said...

"What changes and how they should be carried out / what should be the approach to increase the numbers of male staff?"

Easy. Allow the patient to have a trusted person be at their side from start to finish with a camera. This would ensure no misconduct from the doctors (remember the butt slapping doc?) it would also ensure no unnecessary exposure (remember the story about the OR where the curtains were left open and people walking past could see the naked patient on the table, and the nurses comment was "that happens all the time"? ) it would also ensure the patients wishes of an all female or all male staff be followed, as well as putting an end to gawkers, and non-consensual pelvic exams by students.
And don't tell me there would be no way to make this sanitary... I'm not that daft. The patient and all the other staff are not sterilized from head to toe before entering the OR, nor is all the equipment (just think of the wheels on the gurney and what they track in) - hospitals themselves film some procedures, so cameras aren't a problem when THEY want them....

As for more male assistants / nurses / whatever... thing "gender based affirmative action"... Unless it's a VERY small clinic with one doctor and one nurse, just change the rules so the assisting staff has to be a 50/50 split of genders.

And don't give me that "they hire women because it's cheaper" crap... the job pays what the job pays regardless of who gets it... anything else is just what the employer themselves are allowing to happen.

There ARE males going through nursing school... a lady I work with has a daughter in her 3rd year of nursing school, and her class is about 60% men.

Jason K

 
At Wednesday, July 02, 2014 3:43:00 PM, Anonymous Anonymous said...

Jason,
Great idea, but not so easy. The last thing I would want are photographs and filming of things that I would prefer to remain private.

Remedies should start at the top ith doctors orders after an evaluation of patient comfort levels and how that patient would like to be treated. (This could be achieved by a nurse or tech and review of such with the doctor prior to surgery). Next, on top of your orders gender needs, privacy needs and any mental health needs next.

Followed of course by protocols needed to achieve the medical needs. If someone wants to be photographed, fine but not everyone would be comfortable with it
belinda

 
At Wednesday, July 02, 2014 6:10:00 PM, Anonymous Medical Patient Modesty said...

Jason K: I am so glad to see you back. I hope you will continue to contribute here. You have so many great insights. I agree with you completely that each patient should have a personal advocate present for surgeries. This would force doctors and nurses to respect patients’ wishes. The personal advocate could sit against the door to the operating room to ensure that no one who is not supposed to be there comes in. I am also tired of hearing the sterility argument. The truth is medical professionals often carry more germs than the patient’s personal advocate who has only interacted with one patient. You should check out this article: Health-care launderers call for higher standards after Children's Hospital outbreak. How do we know linens and gowns are really sterile? This article reveals the truth that you cannot trust medical professionals to be 100% sterile.

I think that more urology clinics should look into becoming all-male medical staffed urology clinics since about 80% of 90% of their patients are male. I think that there needs to be more female urogynecologists for women who have urological issues. Those female urogynecologists could work in OB/GYN practices.

All urology clinics should have enough male nurses or assistants available for male patients even if they have some female medical staff. Many men would prefer a male nursing student to assist in their procedures than a female nurse with 30 years of experience.

I personally think that men here should contact different urology clinics encouraging them to hire more male nurses and assistants.

I think that every hospital should look at having at least 2 male nurses on all shifts for male patients who are modest except for L & D and Women’s Health units.

Misty

 
At Wednesday, July 02, 2014 6:45:00 PM, Anonymous Medical Patient Modesty said...

I wanted to encourage everyone to check out this great article about the economic advantages of regional anesthesia that was on Outpatient Surgery. You are more likely to have your wishes for maximum amount of modesty (ability to wear underwear) and all-same gender team for surgeries involving private parts ignored if you are given Versed or under general anesthesia. It is best to opt for local and regional anesthesia for many surgeries. Make sure you are not given any sedatives especially Versed. You are in control of your modesty when you are awake and alert. Also, recovery time is much faster when you have local or regional anesthesia for a number of surgeries.

Also, check out this article that addresses that pelvic exams are not necessary for healthy women who have no symptoms: Stop routine pelvic exams, doctors group says.

Misty

 
At Wednesday, July 02, 2014 7:00:00 PM, Anonymous Medical Patient Modesty said...

arTiger,

I have some questions I would like to ask you since you are a general surgeon.

1.) Are you aware that a patient can avoid having his/her genitals exposed for colonoscopy by wearing boxer shorts backwards or special colonoscopy shorts? Many people are unfamiliar they have this choice. Check out MPM’s colonoscopy article. I have been approached by people who were upset that they were not given this choice for their colonoscopy.

2.) Does your hospital do a lot of urinary catheters on surgery patients? If so, do you have any idea how often that happens? Many patients have been upset to wake up to learn that urinary catheters have been inserted unnecessarily. The truth is urinary catheters have a lot of risks and could even cause death. Informed consent is often absent from urinary catheters. You can check out an article I wrote about unnecessary urinary catheters and lack of informed consent. It is very clear that many people have visited that article based on keywords about dangers and safety of urinary catheters. What are your thoughts? I know some hospitals have worked to reduce urinary catheters due to risks of complications.


Misty

 
At Wednesday, July 02, 2014 7:38:00 PM, Anonymous Anonymous said...

Artiger, i found your statement regarding the double standard but then again...interesting and telling. From a social aspect if it were reversed where men were given special consideration because they were male, would that be acceptable? It also shows why males face these challenges above and beyond gender disparity of staff. How do we know men don't care? Has anyone every really asked men how they feel about this in a manner where they feel free to answer honestly. Consider the similarities of female reporters in male locker rooms. When men protest or object like Reggie White (whom is an ordained minister) they are ridiculed as sexist in the media who controls the airwaves. How likely are other males to challenge. For years as females were breaking into becoming MD's males who did not want a female MD were automatically branded sexist and closed minded. Add a culture that expects men to just suck it up, do we know men don't care or just don't feel free to speak up. Sorry but i think you are a little off and unfair applying the double standard to this. I know it does not acceptable to many makes on this thread, many of my friends, or others but it is in the medical community..
I have to say I do find your approach to be well avove average in concern and accomodation. i want to applaud you for that. I was considering comments about the need to have nurse present during most procedures involving a knife. Believe me I understand your concern about being sued. I have over 200 employees and over 20,000 customers a day, I know how sue happy our society is. But I could not help but think these nurses are there as much or more for the providers benefit as the patients. That being said there is a certain amount of burden that falls on the provider. Two things that have come up here in discussion over and over is the issue is mainly opposite gender exposure, especially support staff, and patients feel ambushed because the do not expect or are not informed of what is about to happen. I had a surgery scheduled and asked for a document of what to expect, I got something that looked like it came off a memeograph machine in the 5th grade about the mechanics of the procedure. i called back and said know i want to know what is going to happen the day of the procedure...i got basically the same thing with a little more...report to this desk and they will let you know, they didn't say I would be asked to sign a release to have it filmed. So knowing your concerns, and knowing my concerns what would you suggest. For me, if I can't get what I want i will go elsewhere. But how do we vet this with providers in a way that will see if we can find acceptable middle ground. Having a female up close and personal during my vasectomy would not have been acceptable. Having her in the room, after I was prepped and draped in a way that protected my modesty with her in a place where she could not view...not my preferance but i could live with it and still respect my provider....how do we get that when providers time is so limited...i think providers should ask but most will not.....any thoughts?....don

 
At Wednesday, July 02, 2014 9:42:00 PM, Blogger artiger said...

OK Misty and Don, one at a time.

Misty, colonoscopy shorts or backwards boxers sound OK, until you have to reposition the patient to allow for cecal intubation. Then it's a major headache and becomes a potentially unsafe situation for the patient.

I don't know if you have ever undergone a colonoscopy, but the area exposed is about as minimal with a sheet as it would be with the garment you suggested. It is also worth mentioning that the eyes in the room are on the monitor, not the rear end of the patient. Don't misunderstand me here, I realize that this still leaves someone somewhat exposed; yet, part of a thorough colonoscopy is an examination of the external anorectal region and perineum.

As for urinary catheters, yes we insert them on certain surgical patients, but it is only upon ordering by the surgeon. We don't put them in indiscriminately. If they are placed, it is out of medical necessity. Such reasons might include a lengthy surgery, one where monitoring output is crucial (periopertivley and postoperatively), or anatomic reasons (a colovesical fistula or complicated hernia), just to name a few. You are correct to note that they do have risks, and that is why we have them removed ASAP. If I am seeing a patient for such a procedure, I always inform them that they will require a catheter, and that it will be removed at the earliest possibility. That is my policy as well as my hospital's.

Don, when I said that life wasn't fair, I didn't mean that I liked it or supported it. I'm sure many men care about their physical modesty, and we certainly try to respect that. I have certainly performed procedures alone, but if I need help with exposure or mopping away blood or whatever, I want my nurse right there up close and personal, no matter if we're working on your head or your anus. Again, it's about your safety, not my convenience or benefit. Still, I can only suggest that you speak up if you have concerns about modesty. If you voice your concerns and the physician disregards them, find a new physician. Like I told Ed earlier, vote with your feet and your $$$. Not to be dismissive, but I can only control how I treat patients. You, however, and patients everywhere, can change things by not accepting status quo, as you mentioned above.

 
At Thursday, July 03, 2014 5:26:00 AM, Anonymous Anonymous said...

I've never had a colonoscopy, but for guys, why isn't there a "sterile linen" version of a sock to wear over the genitals to reduce the exposure, but still not hinder the "thorough colonoscopy with examination of the external anorectal region and perineum" ?

(if you want a visual, there was a band that once upon a time wore just a sock on stage... google "red hot chili peppers sock" )

Simple answers like that which simply "aren't bothered with" are what strongly hints that the medical profession just doesn't really care about male modesty.

Quick question for both Maurice and Artiger - We've all seen the paper sheets or changable linen on the exam tables.... why is there just a plastic or metal step stool with no covering to spread who-knows-what between patients feet? (I was recently at a dermatologists appointment, and told to strip down to my boxers... it struck me then how nasty that stool must be.)

 
At Thursday, July 03, 2014 7:11:00 AM, Anonymous Anonymous said...

Whoops... forgot to sign that last post (with the sock thing)

Jason K

 
At Thursday, July 03, 2014 8:21:00 AM, Anonymous Medical Patient Modesty said...

Some clinics actually encourage patients to wear boxer shorts backwards or provide disposable colonoscopy shorts. I did not know that this was possible until I learned about this endoscopy clinic in Knoxville, TN and colonoscopy shorts that were sold. Look at this very important sentence on the clinic’s web site.

Wear boxer shorts backwards. If you don’t want to bare all, boxer shorts can help maintain your modesty.

I had the privilege of helping a man who was concerned about his modesty for colonoscopy. He shared that the receptionist at the clinic did not know anything about colonoscopy shorts. But he talked to his male doctor and head nurse about how he wanted an all-male team and colonoscopy shorts and they honored his wishes. They actually ordered some colonoscopy shorts. This is a good example of why patients must do some research about maximum amount of modesty for procedures and speak up.

Misty

 
At Thursday, July 03, 2014 8:55:00 AM, Blogger artiger said...

Jason, the initial position for a colonoscopy is for the patient to be lying on his/her left side, in what you might call a semi-fetal position, with the knees brought up toward the chest. In most cases, the genitals will be swept forward (in men), and therefore, covered with a sheet. Your point is noted though, as I could see how a patient might require repositioning, which might briefly expose a sensitive area. Even though most of these scopes go without any exposure of the genitalia, I think I'll start asking patients about this beforehand in the office. I do cover the issue of modesty in the office when it comes to colonoscopy, but that discussion has primarily centered on the anorectal region.

I have to say that I haven't given much thought to the step stool thing, but I don't require all of my patients to remove their shoes. Those who do usually do so after they are already on the table. Certainly something else to think about though.

 
At Thursday, July 03, 2014 9:00:00 AM, Anonymous Anonymous said...

Artiger, obviously I was as clear as I should have been. I didn't mean specifically you. I think providers are defensive about this issue, when you read sites like allnurses.com you can read in the posts some, perhaps many take this personal. It becomes more of a personal challenge as to the integrity of provider than being about the concerns insecurities of the patient. Let's face it, it is a lot about us being insecure about our physical appearance as well as some having security fears. Mine is at least partly due to being insecure of how I will be judged. I am less concerned in front of males because I have experienced some of it (sports locker rooms, pools etc) and the other part is I really don't care what men think. My question was meant to ask after reading these posts do you have any suggestions for dealing with providers of different beliefs (don't care, concerned, are very concerned) on patient modesty. Providers still to a degree have a position of power much like reporters. Any suggestions on how we open the dialogue in a manner that brings down the defenses. I would also ask since you are in the medical community if you have the opportunity to share this conversation it would be greatly appreciated. The other thing that would really help is providers attempting to get a read on the level of concern on the front. We all fill out and update intake forms, it would be a great chance to get a little understanding of need. Some patients really do not care, there is no need to invest the time or impose on them what others feel are required. I agree with you 100% today this falls on us to demand and fend for ourselves, but should it. I also agree you vote with your feet but make sure to communicate to the right person that you did it and why. Go to the hospital administrator and board members, tell the MD who benefits from the practice not someone who does not have a financial interest in it...don

 
At Thursday, July 03, 2014 10:41:00 AM, Anonymous Medical Patient Modesty said...

Check out how disposable colonoscopy shorts work from this one medical supply company. You will notice that there is a big hole in the back that allows for colonoscopy to be done. The colonoscopy shorts prevents exposure of genitals.

Misty

 
At Thursday, July 03, 2014 5:21:00 PM, Blogger Jo said...

I'm a first time commenter here - hope this works! I know Misty from a couple of other forums and she is a very caring and helpful person. She shared this discussion and I felt compelled to contribute. To Artiger, regarding your observation that a female coming to your for a breast/pelvic exam knows your gender already, and you would have obtained her consent before the exam; what about a patient who goes to a female doctor (I do not see males for ANYTHING) for a reason that does not require a breast/pelvic exam, and the doctor tries to force one on them? I have experienced this more than once. The very least you will get is a load of verbal abuse, and at worst you will be assaulted - try physically fighting someone off when you are ill or in pain. And the chaperone thing is a JOKE; the chaperone (of the female doctor!) did nothing to restrain the molesting doctor,then proceeded to join her in bawling me out, saying I had "no right to stop her". And of course I couldn't bring a complaint - I tried but there was no witness on my side. Thanks for letting me vent.

Jo

 
At Thursday, July 03, 2014 7:00:00 PM, Blogger artiger said...

Jo, I want to make sure I understand you correctly. Are you saying that you wen to a female provider for an issue that had nothing to do with your breasts or genitalia? And that a complete physical was not in order (and that is entirely possible)? From my knowledge of medicolegal issues (which, admittedly, is not comprehensive), if anyone in health care does something to you without your consent, it is considered battery. Of course, as I have repeatedly said on this site, a thorough discussion before anything is done is invaluable for both the patient and provider.

 
At Thursday, July 03, 2014 7:36:00 PM, Anonymous Anonymous said...

Jo - since you've had this happen more than once, I'd start keeping a digital recorder in your purse and at least audio record the appointments.

If you get that on tape, then I would not only file an administrative complaint, but criminal charges against the doctor AND chaperone. (I've never trusted an organization to actually discipline one of its own, especially when it's not available for the public to verify) Then talk to a lawyer about sueing the pair of them AND the hospital.

Jason K

 
At Thursday, July 03, 2014 8:02:00 PM, Anonymous Anonymous said...

I think Misty's post of the colonoscopy shorts is a great example of what many are saying. These are available, they are under $2 a pair, why would the medical community NOT provide them? What harm could there be compared to making at least SOME patients more comfortable. This is but an example of what could be done, but is not and therefore cast doubts on the sincerity of providers giving modesty true concern to patients wants vs what providers want to provide,,,don

 
At Thursday, July 03, 2014 10:15:00 PM, Blogger Maurice Bernstein, M.D. said...

Here is the news all you women on this blog thread have been waiting for. Two (free) articles in the July 1 2014 issue of Annals of Internal Medicine The first is the recommendations of the American College of Physicians who set the following Recommendations against the routine screening by pelvic exams and the considerations used for high-value care. The second is the statistical basis for the Recommendation. ..Maurice.


Recommendations
Recommendation: ACP recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women (strong recommendation, moderate-quality evidence).
The current evidence shows that harms outweigh any demonstrated benefits associated with the screening pelvic examination. Indirect evidence showed that screening pelvic examination does not reduce mortality or morbidity rates in asymptomatic adult women, as 1 trial showed that screening for ovarian cancer with more sensitive tests (transvaginal ultrasonography and CA-125) also did not reduce mortality or morbidity rates. Because CA-125 and transvaginal ultrasonography found all cancer detected by the screening pelvic examination as well as additional cancer and this earlier detection did not lead to a reduction in morbidity or mortality rates, we conclude that the screening pelvic examination alone would also not reduce morbidity or mortality rates. No studies assessed the benefit of pelvic examination for other gynecologic conditions, such as asymptomatic pelvic inflammatory disease, benign conditions, or gynecologic cancer other than cervical or ovarian cancer. Also, there is low-quality evidence that screening pelvic examination leads to harms, including fear, anxiety, embarrassment, pain, and discomfort, and possibly prevents women from receiving medical care. In addition, false-positive screening results can lead to unnecessary laparoscopies or laparotomies. Note that this guideline is focused on screening asymptomatic women; full pelvic examination with bimanual examinations is indicated in some nonscreening clinical situations. This guideline does not address women who are due for cervical cancer screening. However, the recommended cervical cancer screening examination should be limited to visual inspection of the cervix and cervical swabs for cancer and human papillomavirus and should not entail a full pelvic examination.
High-Value Care

Although screening for chlamydia and gonorrhea traditionally required a speculum examination, nucleic acid amplification tests on self-collected vaginal swabs or urine have been shown to be highly specific and sensitive, and this technique is supported by several organizations (36–40). ACP found no evidence that screening pelvic examination in asymptomatic, nonpregnant, adult women provides any benefit and indirect evidence that it does not reduce morbidity or mortality rates. However, many clinicians include pelvic examination as part of the well-woman visit (41–43), and because pelvic examination is low-value care, it should be omitted from the well-woman visit. Many clinicians also require pelvic examination before prescribing oral contraceptives (44), although this practice is low-value care and not supported by evidence. Many organizations also advise against screening pelvic examination before prescribing hormonal contraception for healthy asymptomatic women (45–46).
With the available evidence, we conclude that screening pelvic examination exposes women to unnecessary and avoidable harms with no benefit (reduced mortality or morbidity rates). In addition, these examinations add unnecessary costs to the health care system ($2.6 billion in the United States) (47). These costs may be amplified by expenses incurred by additional follow-up tests, including follow-up tests as a result of false-positive screening results; increased medical visits; and costs of keeping or obtaining health insurance.

 
At Thursday, July 03, 2014 10:40:00 PM, Blogger artiger said...

Don, with all due respect, if the shorts are only $2/pair, and not everyone wants them, I think the onus is yours to buy them and bring them. A lot of patients would complain about being charged for something that they didn't want or need.

 
At Friday, July 04, 2014 3:52:00 AM, Anonymous Anonymous said...

"Also, there is low-quality evidence that screening pelvic examination leads to harms, including fear, anxiety, embarrassment, pain, and discomfort, and possibly prevents women from receiving medical care."

That they said there was "low quality evidence" that a lady having her business exposed for the entire room to see leads to embarrassment actually made me laugh.

Artiger - About the $2 shorts... how many people know they exist? Would it not make more sense to have them in the office, and sell them to the patient if they want them?

You could buy them for $2, and sell them for $3 if you wanted to make something from the effort of explaining what they are and storing them.

Jason K

 
At Friday, July 04, 2014 5:57:00 AM, Anonymous Anonymous said...

Could not disagree more Artiger, would providers execpt patients to also bring gowns? How many patients would even know they exist or are an option. The thought is providers control the process and we rely on you to tell us what we can and cannot do. My dermotologist always asks me would I like a gown? For that exam since he is male i decline and just go down to my underwear. Really doesn't it make a lot more sense for providers to simply ask "would you like a pair of colonoscopy shorts" or include on the intake statements "we have colonoscopy shorts available for patients who wish to use them", Not being glib here Artiger, but doesn't that make a lot more sense? It is such a simple thing to do for providers, can you honestly give me good reasons for providers not offerring them other than perhaps they also do not know they exist.
I think this is very similar to the statement in the study saying pelvic exams are not needed... leads to harm including fear, anxiety, embarassment.....and possibly prevents (women) from getting medical care". We all know the saying "dying from embarassment" as it applies to this subject. Everyone knows men do not seek medical care like females, what if stuff like this was 5% responsible for that, would it not make sense to provider those little things like offer colonoscopy shorts? The fact that this small thing appears to be unreasonable to someone as aware and considerate of the issue Artiger shows the depth of the problem. If providers like you who actually care don't see the value of the little things...what are we to expect from the large numbers of providers who dismiss the whole issue and tell us to "just get it", that we just need to get over it. I am really interested in your thoughts after you think this through, do you really think providers offering a patient colonoscopy shorts on the possiblity it may make some of them more comfortable and relieve SOME of their anxiety is not reasonable and should fall on the patient, do you really think that is right? I am not trying to antagonize or condemn, I really am interested...don

 
At Friday, July 04, 2014 8:12:00 AM, Anonymous Anonymous said...

Here is the interaction between a male patient who purchased their own colonoscopy shorts and the prep nurse; you can't wear those, they aren't sterile plus you don't have anything we haven't seen before and we're all professionals here.

Ed

 
At Friday, July 04, 2014 8:35:00 AM, Blogger artiger said...

Jason, a hospital can only collect what Medicare or an insurer will allow for costs such as the shorts. We can attempt to mark up the price by a dollar or so, but it won't do any good.

Don, as noted above, but also, do you know how many sizes we would have to keep in stock to allow for a proper fit? More than a few of our patients are 350-400 pounds. Even if the shorts get up to that size, every piece of clothing these people have doesn't fit well, and ill-fitting shorts would quite likely compromise the exam. Similarly, patients sometime have to be repositioned during the procedure to allow for the scope to reach the right colon and cecum. Those shorts are going to make that difficult. An incomplete exam is one of the last things any of us want.

So again, I put the onus on the patient. If the issue is that critical to you, it is your responsibility to find proper fitting shorts/garments.

I do not take any offense at your comments, and hopefully you feel the same regarding mine. But issues like this and more are the reason I see people in my office before scheduling procedures. I want them to know what is being done, who is doing it and why, and talk about any fears or concerns ahead of time. I am shocked at how many gastroenterologists scope people without seeing them before or after the procedure. I just wasn't trained that way.

 
At Friday, July 04, 2014 6:39:00 PM, Anonymous Anonymous said...

Artiger - never considered the insurer / medicare thing.

Would the initial appointment allow enough time for the patient to order, and receive the shorts through the mail before the scope appointment? (generally speaking of course... I can assume there are times where there's a backlog / long wait, and times when the scope is rushed for whatever reason)

You might even consider contacting the shorts website, and ask them to send you some brochures to hand out to the patients, so they can look into it on their own. (not sure if that would be against the rules or not)

 
At Friday, July 04, 2014 7:12:00 PM, Blogger Hexanchus said...

Ed,

"you can't wear those, they aren't sterile"

Since when is a colonoscopy an aseptic procedure?

That nurse is an idiot.

If any medical personnel ever made such a ridiculous statement to me I'd immediately terminate the encounter and leave - and would follow up with a written complaint. If she's that ignorant she has no business anywhere near a patient.

Hex

 
At Friday, July 04, 2014 7:27:00 PM, Blogger Hexanchus said...

artiger-welcome!

I have read your posts and appreciate your candor and willingness to participate in this discussion.

Hex

 
At Friday, July 04, 2014 7:43:00 PM, Anonymous Anonymous said...

Hex, I completely agree but how many patients have the knowledge to recognize BS excuses and then actually challenge them?

Ed

 
At Friday, July 04, 2014 8:40:00 PM, Anonymous Anonymous said...

Good thing Baskin Robbins doesn't think like the medical community or they would only offer 4 flavors. It's to difficult to stock all of those flavors, not reasonable, if you want more than these 4 bring your own.
I say that tounge in cheek but I think it does shed slome light on the chasim between what patients want and what providers are willing to give them. For many years providers were held, and held themsleves at a level somewhere above. They told us what to do and we followed. Then came the day of second opinions and questioning and things started to change a little. Because they were providers and you didn't question they got used to providing what they thought was best for you, in a manner they thought appropriate and expected us to accept it and for a large part still do. In the rest of the world we live in the focus is on what we want, remember the old Burger King slogan, have it your way. The rest of the business world caters to what we want in order to entice us to come to them. The medical community has not had to do that. Between an attitude of "being special" and we are here for the physical not the emotional it resulted in them giving you what THEY think should suffice for you. A consult to tell you what to expect means I don't have to provide you shorts to make you comfortable because thats what I think you need This may seem harsh but I believe it to be representative. There was a thread on allnurses where the nurses were going crazy because they were being asked to call patients guests to try to change the mindset in how they interacted. The backlash was loud and vicious, this is a hospital not a hotel, it you want to be treated like a guest go to holiday Inn. I am a nurse and here to heal your body not pamper you, I don't have time to worry about whether you are happy or not I am saving lives...were some I recall.
Part of my business is retail so we are always trying to figure out, what does the customer want, what can we do to make the experience better, etc. I think we expect the same from providers, but that just isn''t how they operate...no pun intended. I see the issue of shorts from a business perspective, if I offer them to a patient who doesn't want them, they will know I care, if I offer them to someone who does want them it will make their experience better and they might come back. A colonoscopy is $800 up, $2 shorts to make them more comfortable seems like a no brainer. If it makes patients more comfortable, and the cost is reasonable why would you NOT do it? Even from a compassion point regardless of it being good business. If 100 people come in for a colonoscopy how many are going to be 300 lbs+? really, so you can't accomodate 3-5% of your patients so why do anything for any of them? Providers use the exception to justify the rule..well in the ER...maybe this is changing, you hear terms like patient centered care, etc more and more. There there is always just going elsewhere when you find someone that will accomodate. I still find it frustrating that given the cost of medical care something as cheap and easy as $2 shorts seems unreasonable to providers when it could make a patient more comfortable...I hope it is evolving, hopefully using your feet will move it faster, but with providers shortages, I fear we will have to fend for ourselves...don

 
At Friday, July 04, 2014 8:51:00 PM, Anonymous Anonymous said...

I thought about my comments and wanted to clarify, I do not think providers are these evil uncaring people. I feel quite the opposite, however many good people have done the wrong thing with best intentions. I do feel what we see is to a degree of medical arrogance and of a residual "Doctors Know Best" and I am here to heal your physical being not your emotional. That does not mean that they may think what they are offering is sufficent to address both. I don't think they are intentionally inflicting emotional pain, but it doesn't mean they are not nor that it is right. The shorts are just an example of that, the objections seem like excuses. 300 lbs patients, repositioning...like if it is a problem they could not be cut, they are disposable. When I think back of some of the racist jokes I heard as a kid I shutter. Many told by otherwise good people whom would never intentionally inflict emotional harm on someone...the saw little wrong, and yet....I am not saying providers who only want to offer what they want to provide not what patients want or need are as bad as racist...I am however saying good people do bad things without intending to....don

 
At Friday, July 04, 2014 9:27:00 PM, Blogger artiger said...

Ed, I'd agree with what Hex said, and just add to it by saying this kind of situation could have been headed off with a preop visit, to discuss this kind of thing. That way, no one gets surprised on the day of the procedure.

Anon at 6:39pm, yes, in most cases, there would be ample time. In fact, many people are scheduled for scopes weeks in advance, although in my practice I can get almost anything scheduled within a week or less, if the patient requests it (That is because we are a small facility and there are only a few of us utilizing the OR.). I think your idea about brochures is excellent, and I can't see how it's against any rules, as long as I am not getting kickbacks from the shorts company or something like that.

Hex, thank you.

 
At Saturday, July 05, 2014 6:57:00 AM, Blogger Hexanchus said...

Getting back to Dr. B's theme of "Patient Centered Care" for this volume......

The Institute of Medicine defines patient-centered care as: "Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions."

Ideally, if this model was followed then modesty and privacy issues should be part and parcel of the discussion.

What I observe as a major roadblock are the time constraints that providers are being put under. Patient appointment windows have been cut to 15 or even 10 minute time blocks, while at the same being forced to interact with complex EMR systems further decreases their time actually interacting with the patient.

Artiger, if you have reasonable access to an OR, then you are truly fortunate. Most OR facilities are under extreme time availability constraints. There is heavy pressure to reduce the turnaround time between cases - most push for under 30 minutes, and some are pushing hard for 10 or 15 minutes. It's hard to take the time to address the patient's concerns when you have some bean counter breathing down your neck to "do it faster.

Delivery of medical care has become in many cases assembly line medicine - IMHO, this is not a good thing for either the patient or the provider.

Hex

 
At Saturday, July 05, 2014 8:41:00 AM, Blogger Maurice Bernstein, M.D. said...

Hex, ...and the solution to what you have described?:
More college students (with humanistic goals) becoming physicians and particularly primary care physicians, more males to become nurses and less "unnecessary" surgery and other procedures (such as the routine and annual pelvic exams, as I posted above, and media advertised and encouraged cosmetic surgery as examples).

The time element together with professional energy in medical practice has become narrowed and diminished by the lack of professional resources, the increasing number of patients who are directly entering the medical care system and self-serving administrative rules and judgments and the creating of a common "business" of medicine, with primary self-interest and looking at the patient simply as a consumer of a medical/surgical product. All of this has contributed to patient "uncentered" care. How patient modesty issues, as described on this blog thread, are handled has apparently become part of the result of this metamorphosis in orientation. I say "apparently" because there may be something else.

Years and years ago, back in the medical profession "paternalistic" era where patients accepted their doctors decisions and actions as if the doctors were their "parents", did we hear or read much about modesty issues in the medical system? If not so much or even at all, maybe these current modesty concerns expressed here, in addition to the changes in the medical practice itself is also now the death of "paternalism" and the shift to "patient autonomy" where patient are now expected to "speak up" to the profession and if they don't, patients at least know that they should be the ones controlling the patient-system interaction and not the professionals. Does anyone remember or have researched how big a patient modesty issue was 60 to 80 years ago or before compared with now? ..Maurice.



 
At Saturday, July 05, 2014 7:29:00 PM, Blogger Maurice Bernstein, M.D. said...

The following is the experience expressed by the same anonymous anesthesiologist writing on Medscape and from whom I previously posted. ..Maurice.



At one of the biggest hospitals I worked at during my locum tenens career they had
a CCTV camera in every OR

At the front desk and elsewhere were TV monitors. You could 'channel surf' and keep up with what
was going on in every OR in just seconds (( doing it "old fashioned" way --- walking around and
poking your head into every room would have taken much longer cuz there were more than 20 ORs ))

I thought the set-up was muy convenient --- but awfully intrusive on pt privacy

Pts were *never* informed about this. And in the six months I worked there ,, not once did any pt
ever notice that little black camera mounted on the far wall pointing right down at their face

There was never any issues with "voyeurism" tho cuz --- Trvst Me --- most people
you do NOT want to see naked


 
At Saturday, July 05, 2014 7:35:00 PM, Anonymous Anonymous said...

So... the doctor thought it was awfully intrusive, but didn't even try to get the powers that be to justify it, or do anything to help protect privacy.

It doesn't sound like it's too protected as to who can watch these monitors either. "At the front desk and elsewhere were TV monitors. You could 'channel surf' and keep up with what
was going on in every OR in just seconds".

And how does this doctor know there are no voyeurs working there? Just because he / she doesn't find anyone there attractive, doesn't mean others don't.

I bet if there was cameras in the doctors / nurses locker rooms they'd be a bit more concerned about cameras everywhere with no way of knowing who's watching them or if it's being recorded.

Jason k.

 
At Sunday, July 06, 2014 10:45:00 AM, Blogger Maurice Bernstein, M.D. said...

Response from the anesthesiologist writing to Medscape in response to the last comment by Jason K.
..Maurice.


"So... the doctor thought it was awfully intrusive, but didn't even try to get the powers that be to justify it, or do anything to help protect privacy."


Nope ... the quickest way for an anesthesiologist to get fired is to take the pt's / public's side
of any issue against the hospital. I have a family to feed so I will leave the Heroics & the Ethics
up to some·one else

"It doesn't sound like it's too protected as to who can watch these monitors either."


Prolly a bigger issue than the cameras themselves

"And how does this doctor know there are no voyeurs working there?"


I don't know that and do not really care either cuz I cannot be expected to stop all the
Evil in the world. But you will never catch me or anyone in my family ever having surgery there

 
At Sunday, July 06, 2014 11:22:00 AM, Blogger artiger said...

Don, I'm responding to your post just above mine yesterday. I don't think of those of us in health care as "special" (I've heard that thrown around so much I want to puke), but we do play by different rules than many businesses when it comes to getting paid. We can't pass increases in our costs on to customers; we are paid from a fee schedule set by Medicare and insurers. People can and do receive care (goods or a service) prior to paying for it, and then simply not pay for it afterward. I've never tried going to the grocery store and picking up a cart full food, then left without paying for it, but I don't think it would work (nor would I feel right about it).

And Don, the percentage of 300+ pound patients is higher than you think, at least in my practice.

Not to sound chippy, but the modesty concerns discussed here are the exception being used to justify a proposed rule. But again, if you have concerns, bring them up ahead of time. Every patient is going to have unique fears and concerns. We can't read minds.

There are a lot of people in health care that would like for it to be treated completely as any other business. If/when that day comes, your suggestions would certainly be more feasible. But be careful what you wish for.

Jason, I'm not defending the delivery of the anesthesiologist in his post, but notice that he was a locums in the facility that used the CCTV. That means he was a temp. I don't think he was supporting the practice, and you'll note later that he wouldn't go there for care as well.

 
At Sunday, July 06, 2014 12:55:00 PM, Anonymous Anonymous said...

I get the whole "keep your head down and mouth shut if you want a paycheck" mentality, and I really don't fault this specific doc for that (especially if he is a temp) ...

But it does add "one more stone in the bucket" of "evidence" that patients rights to privacy and dignity are discarded on a whim when the "medical side" feels like it.

That all being said, a fake email that can't be traced to him to allow 2 way communications if needed, and an anonymous email to the American Hospital Association (AHA) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) might not do anything, but a slim chance of an anonymous letter working is better than a 100% chance of nothing happening from not letting them know about the conditions and cameras.

Artiger said "Not to sound chippy, but the modesty concerns discussed here are the exception being used to justify a proposed rule."

By all means chip away... that's what discussion boards are meant for.... We may be the exceptions to what normally happens, but pretty much everyone on this board has had repeated "offences" from the health care profession. We're just the ones who came to this board. I know several people who have "sat down and taken" things that I would have called the police over, simply because they have been conditioned since childhood to "just accept" what happens at a hospital.
So between that, and human nature being what it is, if there's a way to violate another persons dignity for personal kicks or whatever reason, someone eventually will.

A simple google search will get you a LOT of results of "bad" doctors who have violated the doctor patient trust.

For every one doctor, there's how many support staff that were also in the room and did nothing?

For every bad doctor busted for assaulting a patient (remember the butt slapping doctor?) how many don't get caught?

Of the ones that do get caught, how many victims have the had?

The numbers will add up fairly quickly, especially if everyone has the attitude of the anesthesiologist from medscape.

THAT is why most of us want new rules and safeguards.

As for talking to the doc about concerns ahead of time.... we can be assured we'll have an all same gender operating team till the cows come home... but once we're under, there isn't a doubt in my mind that hospitals will go ahead and do what they want anyways. Non-consensual pelvic exams have proven that.

Having a trusted person with a camcorder at my side from start to finish would literally be the only way to convince me they honored my wished for same gender care when I was out, as I've been lied to waaaaay to often to ever take a doctor at their word again.

Jason k

 
At Sunday, July 06, 2014 2:52:00 PM, Blogger artiger said...

Well Jason, just as you advised the anesthesiologist to write anonymous letters to report such egregious activities, why haven't y'all done the same? Bad actor physicians certainly exist, I am not that naïve; but they can't be caught unless someone speaks up.

Larger hospitals may be able to accommodate your wishes, such as an a same gender operating team, but my small rural hospital simply can't. Ask yourself this question, though: Do I want the operating team to be all the same gender as I am, or do I want the team that will give me the best possible results? It's often not the same answer.

 
At Sunday, July 06, 2014 3:25:00 PM, Anonymous Jo said...

Sorry to take so long to get back to you, and thank you to everyone who responded to me. Jason, I'm pretty much done with doctors at this point, so no need for recording devices in my purse (I'm not that tech savvy anyway!) I may have been the person to whom Misty was referring who does not accept any medical care. I realise I am more extreme than most people, but I was so traumatised by doctors as a child that I formed the opinion at a very young age that it was better to die, and I still stand by that. There are very few occasions on which I would consult a doctor, and I'm a pretty healthy, active individual who enjoys my life.

 
At Sunday, July 06, 2014 3:33:00 PM, Anonymous Jo said...

Artiger, you mentioned having a discussion beforehand. In the incident about which I posted, I had a pre-existing condition which I will not divulge. I had seen two previous doctors who had satisfactorily taken care of me, but I had not had a flare up in several years and they had both moved, hence my seeking a new doctor. It was nothing to do with my breasts, and neither previous doctor had mentioned them during any visit. I filled out a consent form in the waiting room clearly laying out what I would and would not consent to. The doctor informed me that she had not read it, she said she was under no obligation to (nice if someone has allergies and you then give them a shot that kills them/prescribe some condraindicated medication!) So I then verbally refused the breast exam and she said I "had to" and proceeded to put both her hands on my shoulders and force me backwards onto the table. I was hysterical, but I even apologised to HER saying I had a previous history of abuse. She and her nurse both maintained that I had no right to refuse anything she wanted to do, and they then told me to leave immediately and they would have my money refunded (I had paid cash) I called a lawyer the following morning (still very sick since I had not been given my medication), and he said he didn't see what I was complaining about since she didn't actually do the exam. Only because I managed to fight her off! I'm also pretty sure she would have destroyed any evidence I was there, and the only witness was her nurse who was on HER side. Its a sick joke.

 
At Sunday, July 06, 2014 4:37:00 PM, Blogger artiger said...

Jo, if it happened the way you say it did (and I've no reason to doubt you), that was classic battery. You didn't need an attorney; you needed a prosecutor.

 
At Sunday, July 06, 2014 6:11:00 PM, Anonymous jo said...

Well thank you for your support, Artiger. I believe I still have time to bring a complaint, but apparently the doctor has retired and there is another business (not medical) at the address, so I have no idea what happened to the patients' records. If you are a physician yourself, maybe you can clarify for me what happens to the records of a doctor who retires and has no other doctors working with him/her to carry on the practice? My first step would be to find out if she has a record of my visit. Would my lack of witnesses be a problem? If I hadn't been so sick at the time I might have been better equipped to speak up at the time. I checked the internet for any complaints from other patients, and there were actually quite a few although none about abuse/forced exams. Mostly a horrible manner, yelling and verbal abuse.

 
At Sunday, July 06, 2014 7:30:00 PM, Blogger Hexanchus said...

Dr. B,

Sadly I don't have the answers to the situation I described. I think that some of the suggestions you threw out would definitely help, but the question becomes "How do we increase those numbers?"

I firmly believe that the rise of the "medical industry" is not a good thing - witness that a significant number of physicians, driven by the increased workload and demands, have moved to the practice of concierge medicine instead of continuing to play the corporate medicine game. That's great for those patients that can afford it, but where does that leave everyone else?

I don't know if the respect or lack thereof for patient modesty under the old paternalistic model was much different than the current situation, and I don't know if the data would be available to research it.

My first adverse encounter happened under that system in the early 60's at the ripe old age of nine. I was in the hospital for day surgery (not common at that time) and prior to the surgery a nursing instructor and four nursing students came into my room - she told me that she was teaching them how to do a physical on children and to remove my gown. I told her no. She then tried to physically remove the gown over my objections - I yelled, screamed and physically fought her. I wound up with scratches and bruises and she wound up on her backside on the floor. The floor nurse came running and stopped things from going any further. My family doctor (who was doing the surgery) was called, and when he found out what happened he went ballistic - I could hear him yelling at the instructor from down the hall in my room. By that time all I wanted was out of there. He then came in and told me he had taken care of the situation, and there wouldn't be any more problems. He had been my doctor my entire life, had always been respectful of me as a person, and I trusted him.

50+ years later I still remember it like it was yesterday.....

Hex

 
At Sunday, July 06, 2014 8:08:00 PM, Blogger Hexanchus said...

Jason,

Thankfully, with the advances in local and regional anesthesia, there are far fewer instances where it would be necessary to "go under". They're even doing open heart surgery on awake unsedated patients using thoracic epidural anesthesia. Not many have been done in the US, but thousands have been done in India and elsewhere.

I have had three surgeries in the last 15 years. Upon the initial consult before I even got to see the surgeon, their intent was clearly to use heavy sedation or general anesthesia. Why that seems to be the standard, I don't know. Maybe because it's what they are most comfortable with, or it's more convenient and faster not to have to deal with an awake patient (see my comment in an earlier post regarding assembly line medicine and the push for faster OR turnaround times). Your guess is as good as mine.

In any case, after talking with the surgeon, two were done with local anesthesia only and one with a bier block regional anesthesia - all without sedation of any kind.

My advice to anyone would be to calmly and politely talk with the surgeon, explain your concerns, and ask what alternatives are possible. Any physician worth their salt should be willing to have that discussion. If they're not, and blow you off - find another surgeon.

Hex

 
At Monday, July 07, 2014 12:02:00 PM, Blogger Maurice Bernstein, M.D. said...

Here is a response to Jason K from the anesthesiologist via Medscape today. ..Maurice.


"That all being said, a fake email that can't be traced to him to allow 2 way communications if needed ..."


Hey ,, that is a GREAT Idea ,, Jason !!

An email to the Medical Board and the State Dept of Health might help too

I will get on that sometime this week and let you know how it goes

 
At Monday, July 07, 2014 4:34:00 PM, Anonymous Anonymous said...

Artiger I find your resliance here refreshing. Saldy we have lost interaction with providers who did not want to take the heat that comes from being "on the other side" of this issue. If "chippy" is the right term I appreciate it since you can take it as well.
I understand you defense of the anethisiologist but then apply the same thoughts to racism. A wrong is a wrong and allowing it to occur without doing something makes one complicit. It does appear he is going to act on Jason's comments so that is something. I also understand self presevation so not totally down on him. That said, think back on your statement regarding the double standard, it contained the thoughts that it is present, you did not say it was right...but also "but men and women are different". We all know to a degree that is true, however we as a society have taken the stand that does not justify inequality in the way we treat them. I would suggest that identification with being a provider is stronger than other parts of your identity and makes what might otherwise set off an alarm becomes not only acceptable, but the norm.
I would like to ask you how do you know we are the exception? There are very few studies or research on the issue, How many patients have you asked how they feel about it? Are we the minority in feeling this way or just who speak out? I would venture to say the majority of patients have concerns, feel anxiety, are uncomfortable or embarassed at being exposed to providers of the opposite sex. The degree may be varied but I would bet that it is present is not the exception.
I keep thinking about your position on the shorts. I might understand risk more than you think, my wholesale business routinely puts $30,000 of product in our customers hands and waits to get paid. It is sold before it is due to get paid. I would also put forth that providers are at the upper end of the income scale. I think that is fair, MD's have a ton of education and responsiblity. My PCP is awesome, but I would bet my company makes a ton more than he does and I majored in beer drinking in college. My point is I think there is room to make some accomodations and hope it pays in return visits. But given the shortage of providers that may not be a concern to providers.
I would toss this out with all sincerity, I would be willing to pay for several cases of colonoscopy shorts for you practice if you would like to do a little experiment just to see if how prevelant the concern is. If you would offer them in a muetral manner and see how many people either took them or appreciated the ask...I wonder what it would tell. You seem like a really straight shooter so I am comfortable there would be a good faith effort to be nuetral....enjoy the discussion Artiger, glad to have you here...don

 
At Monday, July 07, 2014 7:04:00 PM, Anonymous Anonymous said...

"Ask yourself this question, though: Do I want the operating team to be all the same gender as I am, or do I want the team that will give me the best possible results?"

Artiger, there are no objective factual based methods patients can utilize to pick the "best" physician, much less OR staff. The absolute best we can do is board certification, gender, and word of mouth recommendations; everything else is a roll of the dice! Do you get to pick the OR team when you're performing surgery or is it whoever is on duty?

Ed

 
At Tuesday, July 08, 2014 7:47:00 AM, Anonymous Anonymous said...

This question has come up from numerous providers, including out honorable host. It assume this is an either or scenario. That same gender can not be the team with the best results. And as Ed indicated this is a crap shoot for us anyway. For the most part we choose our MD/surgeon but we know nothing about their support staff whom in most cases is the concern. Personally I have accepted the surgery team provided as I assumed creating a all male team would be really difficult if not impossible so that was my compromise. For me personally having an all male team would be awesome but I think it crosses into being overly burdensome on providers, but that is just my personal feeing and a compromise I am willing to make. We each have our own levels of comfort. For me when I am awake I want a certain level of consideration, when I am out that level goes down some...but that is me. The statement however is common among providers and goes along with applying what is reasonable in an emergency life and death situation to the common everyday routine exam and procedure...don

 
At Tuesday, July 08, 2014 12:36:00 PM, Anonymous María said...

Artiger,

"When there is a lawsuit". I find your preoccupation with lawsuit disturbing. Mostly because it shows an extremely low concept f the patient.
You stated that you think having an assistant to help would help prevent such thing occurring (a lawsuit, that
is)
WRONG. Having extra people in the room
increases the chance f mistakes, especially if they overstep their boundaries and/or are not properly qualified. If someone has a heart attack while having a procedure performed, it might very well be beyond your scope and will have to call other doctors on him/her.
And frankly, someone sooo
obsessed with not being sued should not practice medicine. Ouch. I must've come across as harsh, and my wording is probably not optimal due to language problems, so I might sound ruder than intended.

María

 
At Tuesday, July 08, 2014 12:47:00 PM, Anonymous Medical Patient Modesty said...

Ed made some great points. It is true that patients often get to choose our surgeon, but they are often forced to accept the OR staff. How often are patients asked who they want to be their anesthesiologist, nurses, scrub technicians, etc.? Hospitals often assign them randomly. The truth is many surgeons of both genders are skilled. It might mean that you would have to drive 3 hours to find a hospital with a good surgeon who is the same gender as you. Skills are very important, but modesty is important to many patients.

It is possible to get an all-same gender surgery team for surgeries that involve private parts or the exposure of private parts, but you might have to drive hours to find a hospital that is willing to accommodate your wishes. Hospitals in rural areas are usually not the best hospitals to go to if you have patient modesty concerns.

Many patients who are uncomfortable with opposite sex intimate care do not mind having medical professionals of the opposite sex present for surgeries that do not involve their private parts. This is exactly why we need to fight the ridiculous policy that you must remove your underwear for all surgeries at many hospitals. Fortunately, some hospitals have revised their policies to allow patients to wear 100% cotton underwear. For example, I am sure that the men here who are uncomfortable with female nurses for male health issues would be fine with having female nurses for a knee surgery as long as they could keep their underwear / shorts on.

Misty

 
At Tuesday, July 08, 2014 12:51:00 PM, Anonymous Medical Patient Modesty said...

arTiger:

I have some questions I wanted to ask you. I know that your hospital has limited choices for patients because it is in a rural area.

1.) Does your hospital allow patients to wear 100% cotton underwear for surgeries that do not involve the genitals such as hand, knee, etc.?

2.) Do you have any idea how many male nurses your hospital employ? It seems like rural hospitals are less likely to hire male nurses than hospitals in bigger towns.

3.) Does your hospital have any female gynecologists? If so, how many? What about male gynecologists? I have noticed that some hospitals in rural areas only have male gynecologists.


Misty

 
At Tuesday, July 08, 2014 1:13:00 PM, Blogger Maurice Bernstein, M.D. said...

Maria, what you wrote " someone sooo
obsessed with not being sued should not practice medicine" is logically wrong. Somebody so obsessed would not be practicing medicine. Yes, lawsuits are undesired but not uncommon. The observation which proves the doctor is not obsessed is the fact that they are nevertheless treating patients and performing surgeries.

Speaking of obsession, one could say that it would appear that a patient who disregards diagnosing or treating a life-threatening illness because of his or her own modesty issues must have some obsession with regard to maintaining and guarding personal modesty despite the risk to life.

But lawsuits, just like modesty, it is around all the time and one has to realistically without obsession deal with it. ..Maurice.

 
At Tuesday, July 08, 2014 5:58:00 PM, Anonymous Anonymous said...

Maurice - you said "Speaking of obsession, one could say that it would appear that a patient who disregards diagnosing or treating a life-threatening illness because of his or her own modesty issues must have some obsession with regard to maintaining and guarding personal modesty despite the risk to life."


My tongue in cheek comment to that would be "thanks for catching up".

Wise arse reply aside, isn't that basically the point of this blog?

If we weren't overly concerned or "obsessed" with our modesty, we wouldn't really be here.

Jason K.

 
At Tuesday, July 08, 2014 7:27:00 PM, Anonymous Anonymous said...

I don't think Artiger's concern for a lawsuit is obsessive at all. From one who deals with the public I can completely understand. Our insurance company has defended and paid some of the most insane claims. You can't surf the channels without coming across some slime ball lawyer wanting to sue for all sorts of things including medicince, ortho joints, you name it.

that said, when someone is there for the benefit of the surgeon, the burden falls on them to protect and accomodate the patient that has concerns when that means an extra peron and an extra set of eyes. ...don

 
At Tuesday, July 08, 2014 8:01:00 PM, Blogger artiger said...

I see that several comments have been addressed to me recently. Rather than create one long post for all of them, I'll simply address them separately in shorter posts. Maurice, I hope this is OK, I am simply trying to make it easy for the other posters. If it's not OK let me know and I'll try to group them.

 
At Tuesday, July 08, 2014 8:06:00 PM, Blogger artiger said...

Jo, from Sunday evening, there has to be a custodian of record for a certain amount of time, 7 years I think, that the records have to be kept and made available to the patient. It's possible that may vary from state to state. In any event, I would suggest contacting the hospital where that physician last practiced (if applicable), as often a physician's practice is purchased by a hospital. Another option would be to contact the state medical board with a complaint. Even though retired, the physician may still keep her license active, and therefore still has to answer to the board.

 
At Tuesday, July 08, 2014 8:16:00 PM, Blogger artiger said...

Don, I am not necessarily defending the anesthesiologist (especially not his style). I was merely explaining that a temp worker would not carry much weight in complaining to the hiring firm.

How do I know that what I read here is the exception? I ask the patients about it. When I ask about there being any possibility, the answer is a resounding NO. Upon your suggestion today, though, I asked a man about if colonoscopy shorts were available, would he want to try them. He looked at me like I was from another planet. I certainly realize that this may just be my rural practice, but it's what I see one day after another.

There is still a difference in the business models. What happens if your customer doesn't pay for that $30,000 in merchandise? Not the same thing as the person who doesn't pay for $30,000 of medical care.

 
At Tuesday, July 08, 2014 8:27:00 PM, Blogger Maurice Bernstein, M.D. said...

Ah! Jason, you conclude: "If we weren't overly concerned or "obsessed" with our modesty, we wouldn't really be here." Well, I hope that many of my visitors to the entire content of the "Bioethics Discussion Blog" including the Patient Modesty thread are looking forward towards a discussion. And discussion is simply that and not necessarily a fight between various views but as a mechanism for learning other views as one presents their own. It certainly has been a learning issue for me. So, no, "obsession" is never a prerequisite for discussion. Yes, holding a view is a requisite and being able to present it to others is the mechanism of discussion..but not obsession.

With regard to the process of discussion, obsession is totally counter-productive since it doesn't allow the individual to understand the counter-view of another.

I have always hoped that my visitors would be able to participate in discussion. To that end, I have always tried to pray for and try obtain visitors with counter or variant views (including naturists, models and pornographic actors)..but it has been hard. Hopefully, currently with input by some physicians, that will change.

Again, remember those visitors "obsessed" with their modesty speaking to the visitors with the same emotional feelings are simply "preaching to the choir" and while the "hymns" are united, that certainly doesn't fit the full definition of a "discussion". ..Maurice.

 
At Tuesday, July 08, 2014 8:32:00 PM, Blogger artiger said...

Maria, have you ever been sued? If you have, you'll understand wanting to avoid it at all costs. In 17 years, I have been sued 4 times. One case I settled because I truly felt that I did not do my best. The other 3 were dismissed, one of which because the opposing attorney couldn't locate his client (you know, the guy who was suing me). About a decade ago, when the liability insurance market was really tight, I had to pay $100,000 for a year of coverage. That's not a typo, that's 100 GRAND. Just think about watching the first $8000 you make every month go out the window, all for the privilege of being allowed to try to take care of people. So, I may have something of a unique perspective here as far as that goes, but feel free to tell me if you have something similar.

Extra people in the room increases the chance of mistakes? You got a study or a reference for that? Where I work, if they are in the room, they are qualified, and they damn sure know their boundaries. When I said I may want an assistant in the room for certain procedures, it is to help me with things like exposure of a wound (like I said earlier, you might agree that visualization is important?), or keeping the patient calm. A happy patient is less apt to sue. That has been documented.

You might call it an obsession with being sued, but I simply call it avoidance. I've been there and learned how to stay out of trouble. And believe me, there are people out there practicing medicine who a way more paranoid about lawsuits than I am. If you don't believe me, just go to your nearest ER and tell them you have a terrible headache, or chest pain.

 
At Tuesday, July 08, 2014 8:41:00 PM, Blogger artiger said...

Ed, I'm sorry I missed your comment. I would agree, there isn't much good data with regard to picking the best surgeon. Board certification is worthless. Word of mouth is often more reliable than anything.

But I wasn't referring to the surgeon, I was referring to the crew. In larger hospitals, specialists often work with the same crew day in or day out. Yes, even OR crews sometimes specialize, not to say that can't crossover when needed. A surgeon's favorite crew may be mixed, all male, or all female. If the surgeon feels most comfortable with a certain crew that happens to be mixed, that's the crew I'd want. Y'all may think that passing instruments and circulating in the room is no big deal, but there is a lot more to it than just handing a guy a knife. It comes with experience and working together for a while, anticipating, knowing what someone wants at certain times, knowing body language, etc. The surgeon is the one who is going to know who the best crew is. That is all I meant by that remark.

And Ed, I work in a rural hospital. With the exception of one of our CRNA's, the entire crew is female. I do have a choice during daytime cases but I feel comfortable with pretty much all of them, having worked with all of them for a long time. At night, there is of course no choice, you get whoever is on call.

 
At Tuesday, July 08, 2014 8:51:00 PM, Blogger Maurice Bernstein, M.D. said...

Artiger, with regard to posting, how you decide to respond to the other visitors should be up to the poster. It may be better to keep response to each visitor in separate posts, if you have the time and interest to repeat the posting mechanisms, since it prevents having a specific response to another visitor "hidden" in a post to another. So go ahead. ..Maurice.

 
At Tuesday, July 08, 2014 8:53:00 PM, Blogger artiger said...

Misty, 1) If it's surgery on a hand or a foot, or something like that, sure, they can wear underwear. Doesn't have to be 100% cotton, but I will say that's what I prefer for myself.
2) I don't know the exact number, but I'm going to say about a quarter to a third are male, but that number has been on the rise. It's not that we are less likely to hire males, there just aren't as many around from which to choose in a rural setting. 3) We have one gynecologist, and she is female. I don't know how true your observation is about mostly males in rural settings, but I wouldn't be surprised by that. We don't get as many female physicians in rural settings, for a variety of reasons, however, I have seen a little of that changing as well (I certainly hope it is).

I do take exception with your comment in the post before, about rural hospitals not being the best choice for modesty concerns. The patients we take care of are often our neighbors, our friends, and even sometimes our fellow physicians and nurses. If we don't take the time to respect their modesty, we're finished. We go the extra mile to protect them because we know them. And they know that. That's why they choose to stay here for their health needs.

 
At Wednesday, July 09, 2014 1:00:00 AM, Anonymous Anonymous said...

Maurice - I'm apologizing in advance if this comes off as rude... It's not my intent, but I know I tend to rant when trying to word my point...

I get the reason for having opposing sides to a debate, but really... can this modesty blog be a considered a debate?

We're not debating which is better... star wars or star trek, we're voicing our opinion on the topic of our own bodies being exposed to people we usually don't know.

That's not a "majority rules" kind of thing. You could bring out all kinds of porn stars, naturalists and models... they're fine with being naked infront of strangers, and I get that... that's fine, and good for them.

They`re not me.

No matter how OK Ron Jeremy is with being naked infront of a stranger or 12, I never will be, and his comfort with it will never have a bearing on mine.

That`s right in the same vein as when nurses say "it's ok, I've seen it all before". Good for them, but that's not the point. My disrobing is about nobody but myself.

(I've decided that next time a nurse says that, I'm going to fib and reply with "I used to work as a camera operator for a porn company, so I've seen lots of people have sex... next time you're having sex with your husband/ boyfriend/ wife / girlfriend, is it cool if I come over and just stand there watching? It's nothing ~I~ haven't seen before, so that should make you ok with it... right?" If nothing else it MIGHT get them to stop using that stupid line,m or at least see how stupid it actually is. )

Jason K

 
At Wednesday, July 09, 2014 1:33:00 AM, Anonymous Anonymous said...

Artiger - Your question was ""Ask yourself this question, though: Do I want the operating team to be all the same gender as I am, or do I want the team that will give me the best possible results?""

You replied to Ed with "With the exception of one of our CRNA's, the entire crew is female. I do have a choice during daytime cases but I feel comfortable with pretty much all of them"


Doesn't really give your patients much of a choice about gender vs "best".

And I'm not sure what you mean by you have a choice during daytime cases.... do you mean you have a choice between this female or that female? Because... and again, not to sound rude... that's not much of a choice for a patient with modesty issues.

Here's something to consider...
You're a rural hospital, so it's safe to assume you're the only option within a half hour drive, right?

What's the rough population of your area?

How many people does your facility see in a year? (counting one individual person as 1, not one person coming 7 times as 7)

What's the number of your population minus the number of people who come to your hospital?

That might indicate how many in your area have some sort of modesty issue, even if it's just because of the small community and you know them thing.

Also, you said "I asked a man about if colonoscopy shorts were available, would he want to try them. He looked at me like I was from another planet."

Maybe he was confused that he was being given options in the doctors office. (yes, that was a joke)

A second step to your test would be to drop the $2 and buy a pair, and just tell a patient to put them on and see if they still looked at you like you were from another planet, or if they just obeyed the doctor like so many people have been conditioned to since childhood.

Not sure what you're set up for where you work... but have you considered swabbing the step stool and see what grows out of the culture? (or just wipe it with a wet paper towel to see what the towel looks like when you're done)

Jason K
(sorry for the long post... kind of got on a mini rant)

 
At Wednesday, July 09, 2014 7:52:00 AM, Blogger artiger said...

Jason, as for your first comment, I agree entirely that the attitude of "don't worry, I've seen it all before" is insensitive as well as inappropriate. Nobody in my office or in the OR at this hospital uses such language, and if they do, it will only happen once.

When I made that comment to Ed, I was referring to situations in larger hospitals (in the past, I worked in one of those places). My current hospital is small, so yeah, the choices are limited, both for me and the patient. Yes, during daytime surgery there are two, maybe three people who can function as a scrub tech, and the same number who can circulate, and they are all female. In an effort toward gender diversification, I once took two male nurses hostage at gunpoint and tried to force them to work in the OR one day...then the police got involved and it turned into such a mess that I just dropped it there.

That last bit was a joke, before anyone gets to riled up.

I don't have the numbers, I only know our local following is strong. The nearest hospital that gets close to offering similar surgical services is an hour away, and they don't really have as much as we do. It's realistically an hour and a half to get to a bigger hospital. Our service is area is probably about 25K, maybe more, and we are a level 3 trauma center.

Yeah, I could drop $2 for the shorts. And we can give them the bowel prep kit for their colonoscopy rather than making them go to the pharmacy. And we can give out free vaccines like people think we should. And we can go pick up patients at home to bring them in for their appointments. Etc. You see, everyone has their "$2 pair of shorts" issue that they think we should be giving out for free. After a while, we're working for free.

If it makes you feel any better, I have asked our housekeeping supervisor to clean the step stools thoroughly.

 
At Wednesday, July 09, 2014 8:15:00 AM, Blogger Maurice Bernstein, M.D. said...

Jason, I too don't want communication on this blog to be functioning as a debate (where each party presents and argues their view and attempts to knock down the conclusion of the other party). A discussion is not a debate but each party may present their observations and conclusion but then considers what was heard and may learn from the others. I would like this blog to function as a discussion. ..Maurice.

 
At Wednesday, July 09, 2014 8:41:00 AM, Anonymous Anonymous said...

Artiger:
With all due respect I hardly think one gentleman's reaction to the colonoscopy shorts offer is a significant representational sampling. Probably the only way to truly know if this convenience would be meaningful to enough patients would be to send out a questionnaire to a large population segment, thereby capturing not only those who voluntarily go in for the procedure but also those who avoid it. I have read that only 60% of those 50 and older are up to date on the screening. While there may be many reasons for that, I would venture to say that affording a patient more options (same gender team, shorts, etc.) would increase that number. Let's face it: many recommended screenings are of a very intimate nature (mammograms, pelvic exams, pap tests, DREs, colonoscopies, etc.) and the patient's perspective on this is quite different than that of the doctor or other medical personnel. I can understand that after many years of working in the field, doctors probably do have a "business as usual" attitude and are somewhat used to the nature of it all. That probably helps them when they actually go in for care, also. After all, they know what to expect at all points whereas the ordinary individual (especially ones who seldom need care) does not know what to expect and may feel frightened and "ambushed" in some circumstances, especially when having to disrobe.
One other thing: I also live in a rural area, approximately 100 miles from a major city, and there are basically no women doctors in this area. I have driven that distance in the past to obtain a woman doctor and would do so in the future (especially for sensitive care). It means that much to me. I still maintain that the people who go to opposite gender doctors do not have significant modesty issues or they basically have come to accept it and do not feel they have choices or can speak up. I personally know several people (of both genders) who do not get recommended screenings or visit a doctor regularly and modesty coupled with the nature of the screenings is one of the reasons for their reluctance.
To me, when all is said and done does it really matter how many people feel this way? The way I look at it is that those who do not have modesty concerns are not going to be harmed if they are given more options, more respect and more "coverage" but those that do have concerns run the risk of suffering from a huge degree of embarrassment, humiliation, indignity and/or anxiety. The status quo has a lot of room for improvement.
As far as the cost issue on the shorts: I think people that would want them would be willing to cough up a couple of dollars for them. I know I would. You may even be able to charge a dollar over what you paid and make a profit. Just give us the choices.
Jean

 
At Wednesday, July 09, 2014 9:38:00 AM, Anonymous Anonymous said...

Artiger,
Thank you for contributing to the blog.

The question, "Do you want a same gender care, or the team that can give you the best medical care", is the point.

Some of us have had such cruel and degrading experiences in a healthcare setting, that we have chosen to put our mental health needs first.

Without a safe, caring environment many of us choose not to move forward with procedures that compromise our dignity, make us feel degraded and jeopardize our emotional safety.

That being said, the best choices are ones we make with our doctors and those doctors work to establish a protocol based on patient need and medical availability.

This isn't a issue of request it's an issue of requirement. We are not saying "No" to be difficult. We are saying "No" because we find standard of care issues unethical due to lack of information, loss of control from unexpected traumas that cause psychological damage.

When you couple and recognize that issues do exist, you are creating an environment where patients want to do their part in helping the system change. It's when we are met with resistance, ridicule, and an attitude that we run in the opposite direction.

Anyone would. Just read Evelyn Lindner's humiliation studies, triggers that cause PTSD, and attitudes of sexual assault victims. I'm not saying that everyone is assaulted in a medical environment. What I am saying is that every door that is opened when it's not the patient's wish to be exposed , every time student's march in when the patient is undressed without notification, is a circumstance that happens against that patient's will. They are traumatized from the unexpected nature and many turn away from the healthcare system.

I know that's not the wish of the healthcare system, but a by-product of it; just like me.

The medical system is creating their own problem. Resistance from patients will get worse and worse, and unfortunately, some doctors don't understand how one might jeapordise your health for your mental health.

Try talking to some rape victims who happen to be doctors. Perhaps they can educate the rest of you.

Once everything has been taken from you, you put the pieces back the best way you can. The medical community should be screaming for change to support patients. Instead, they want to pretend it doesn't exist and want us to go away. We don't run from resistance, we stand up to it.

There are many kind, considerate, understanding physcians. They need to be educated in how to do their job "to do no harm" when it
when it comes to these psycho social issues that are more important than healthcare. What good is a healthy body without a healthy mind?
belinda

 
At Wednesday, July 09, 2014 10:57:00 AM, Blogger artiger said...

No, Jean, I can't charge extra for the shorts and make a profit. Medicare and insurers have rules against that.

I have no problem at all if you want to drive 100 miles to get a colonoscopy from a woman rather than me. I have plenty of patients, male and female, who are more concerned with a quality exam rather than my gender. And if you've read the posts above, I take quite a bit of time to determine the fears and concerns of the patient, and we go to great lengths to keep people well covered during such procedures, such that I do not feel that shorts are necessary. For reasons stated above, there are some situations where these garments could compromise the exam. That is an unacceptable trade off, in my opinion.

You are correct that many screening tests and procedures have low compliance. Modesty might be a part of it, but a much greater issue is cost.

 
At Wednesday, July 09, 2014 12:07:00 PM, Anonymous Marfía said...

Wow, I'm struck that the word
"obsession" would trigger such
a reaction! Perhaps I'd should
have worded it better.
To Artiger: No, I haven't been
sued:
a) because I'm not a health provider
and I'm not connected to any health industry in any way;
b) should've introduced myself. I'm
writing from across the world, and
almost NOBODY ever sues physicians
over here, even in cases where autopsies show blatant negligence and/or incompetence. It's also exceedingly difficult, unless you're wealthy, to get lawyers involved in your case.
Still, I'm surprised that the fear of a lawsuit, even when there's not
much chance of them, or high odds that they'll be dismissed, drive so
much physician behavior.

María

 
At Wednesday, July 09, 2014 2:04:00 PM, Anonymous Medical Patient Modesty said...

I have really appreciated Jean’s great insights and comments. I wanted to comment on some of her points.


With all due respect I hardly think one gentleman's reaction to the colonoscopy shorts offer is a significant representational sampling. Probably the only way to truly know if this convenience would be meaningful to enough patients would be to send out a questionnaire to a large population segment, thereby capturing not only those who voluntarily go in for the procedure but also those who avoid it. I have read that only 60% of those 50 and older are up to date on the screening. While there may be many reasons for that, I would venture to say that affording a patient more options (same gender team, shorts, etc.) would increase that number. Let's face it: many recommended screenings are of a very intimate nature (mammograms, pelvic exams, pap tests, DREs, colonoscopies, etc.) and the patient's perspective on this is quite different than that of the doctor or other medical personnel.



This is true. I have done some research and there are actually some colonoscopy clinics that offer colonoscopy shorts or either suggest that patients wear boxer shorts backwards. You are right that many people avoid intimate procedures. There are actually many people who absolutely refuse to have colonoscopies and other intimate procedures. Many people who avoid medical care are not going to come to your hospital or medical facility so it is hard to know how many people actually avoid medical care because of modesty concerns. It is true that many people may avoid doctor due to costs, but what about those who are insured and money is not an issue?


One other thing: I also live in a rural area, approximately 100 miles from a major city, and there are basically no women doctors in this area. I have driven that distance in the past to obtain a woman doctor and would do so in the future (especially for sensitive care). It means that much to me. I still maintain that the people who go to opposite gender doctors do not have significant modesty issues or they basically have come to accept it and do not feel they have choices or can speak up. I personally know several people (of both genders) who do not get recommended screenings or visit a doctor regularly and modesty coupled with the nature of the screenings is one of the reasons for their reluctance.

 
At Wednesday, July 09, 2014 2:05:00 PM, Anonymous Medical Patient Modesty said...


One of the reasons I started Medical Patient Modesty was due to my concern about rural areas not having a few or no female gynecologists. I used to travel through rural areas in Western North Carolina and Northeast Georgia for business many years and I was disturbed to notice that many hospitals in those small areas only had male gynecologists or not enough female gynecologists. I am grateful to see that some female gynecologists have been hired in some of those areas, but a woman who wants to have a 100% guarantee that they would have a female gyn for the birth of their child still has to drive at least 30 minutes. Many OB/GYN practices have both male and female doctors so you have to take whoever is on call for the birth of your child. You have to choose an all-female ob/gyn practice that does not rotate with other practices that have male doctors. Check out this article I wrote about this issue on Dr. Sherman’s blog. It is true that many women who are modest from rural areas will drive to bigger towns for medical care. I agree with Jean that people who go to opposite sex gender doctors for intimate health issues do not have significant modesty issues. Some people feel strongly about their modesty deep down, but they have been trained by the medical industry to give up their modesty. I know of some people who were very modest earlier in their life and refused opposite sex intimate care, but gave in because they felt they had no choices or accepted it.

I wanted to share a case from a lady who had a miscarriage the other day. It is pretty common for ER in hospitals in very rural areas to have no or not enough female doctors.

I recently had a miscarriage and had to go to the emergency room for excessive bleeding and complications. To my absolute horror there was only a male doctor on staff to accommodate me. I have always had female doctors for female problems and am very uncomfortable with a male. My question is, what's are you supposed to do in an emergency and there no female doctors? Why isn't ere female doctors on staff in emergency rooms ?



“To me, when all is said and done does it really matter how many people feel this way? The way I look at it is that those who do not have modesty concerns are not going to be harmed if they are given more options, more respect and more "coverage" but those that do have concerns run the risk of suffering from a huge degree of embarrassment, humiliation, indignity and/or anxiety. The status quo has a lot of room for improvement.”


I agree with your excellent points. It is true that we do have a population of patients who do not care about their modesty in medical settings. But the medical industry should not neglect those who do care. We all need to keep in mind that there is a population of patients who value their modesty very much. Many patients who are modest do not want opposite sex intimate care even if the providers are compassionate. That does not make a difference for patients who value their modesty.

Misty

 
At Wednesday, July 09, 2014 7:00:00 PM, Anonymous Medical Patient Modesty said...

arTiger: Many patients still prefer same gender intimate care for procedures even if they are partially covered. I do not know if you have read any of Dr. Joel Sherman’s articles on patient modesty. I encourage you to check out Patient gender preferences for medical care and Male Modesty .

I wanted to respond to some of your answers to my questions. I have more questions I wanted to ask you.

I am glad to hear that you support patients wearing underwear for surgeries on body parts such as hands that require no access to the genitals. Most patients who are modest do not mind having opposite sex surgeons operate on them as long as private parts are not exposed.

I find it interesting that your hospital only has one gynecologist and she is a female. I assume that your hospital does not have a Labor & Delivery unit. Is that correct? Hospitals often must employ at least 3 gynecologists in order to be able to provide OB Services.

Check out two hospitals in rural areas that only have male gynecologists:

1.) Northern Hospital in Mount Airy, NC (hometown of Andy Griffith)

2.) Northridge Medical Center in Commerce, GA - This hospital apparently does not deliver babies. They only have one gynecologist who is male. Women in this town do have a choice of driving about 15 minutes to a bigger city that has some female gynecologists though.

What is the population of the town your hospital is in?

I want to respond to your comments below:


I do take exception with your comment in the post before, about rural hospitals not being the best choice for modesty concerns. The patients we take care of are often our neighbors, our friends, and even sometimes our fellow physicians and nurses. If we don't take the time to respect their modesty, we're finished. We go the extra mile to protect them because we know them. And they know that. That's why they choose to stay here for their health needs.


What do you think would happen if the female gynecologist at your hospital was replaced with a male gynecologist? Some of the women would move on to another town for a female gynecologist. Does the female gynecologist at your hospital do all of the gynecological surgeries?

Again, many patients who are concerned about modesty do not care about opposite sex doctors and nurses for non-intimate procedures. I’m sure that a certain percentage of patients in your community drive to another hospital with more choices due to patient modesty concerns.

Misty

 
At Wednesday, July 09, 2014 8:54:00 PM, Blogger artiger said...

Maria, obviously, no, you don't understand what it's like to practice where lawsuits are ubiquitous. Move over to this side of the globe and maybe your perspective will change.

Misty, yes, we only have one OB/gyn, and she does all of the gynecologic surgeries, as well as deliver babies. Yes, we have L&D here. I don't know where you got your information about having to have 3 of them, but it's incorrect. Believe me, though, our OB/gyn would love to have some help.

The town in which my hospital is located has about 3000 people. That is a bit misleading though, as many people here live outside the city limits, but will still be considered associated with the town. The county population, which is a bit more significant, is about 14,000, and we also serve an area that gathers in the rims of 2 or 3 adjacent counties, so we're catching about 25,000 total population.

I don't think our OB/gyn is going anywhere, although I have noticed that some of the affluent women here drive an hour or more to see their MALE gyn's. They don't have a problem with a local male surgeon, however. Still, we know that we can't just up and replace and OB/gyn of any gender easily, so our current female is here until she decides otherwise.

 
At Thursday, July 10, 2014 3:52:00 AM, Anonymous Medical Patient Modesty said...

arTiger,

Most hospitals have at least 3 OB/GYNs who rotate to take turns delivering babies. Do you have any idea who fills in when the OB/GYN at your hospital is sick or out on vacation? I know that there is no way that she can be available 24 hours for 365 days?

Does your hospital have any midwives who help your OB/GYN deliver babies? Are there any other doctors who help to deliver babies? I know that some family doctors deliver babies at certain hospitals.

Misty

 
At Thursday, July 10, 2014 5:32:00 AM, Anonymous Anonymous said...

You asked what happens if I don't get paid, the same as you I write it off or I sue for payment. My product like your services are gone once it passes hands. I also understand insurance, our premium for the business is over 200K a year and another 350K for medical insurance. Slip and fall is the suit of choice in my industry, we get 6-10 a year so I really do understand your part of that.
I think we are peeling back some layers of the onion. I had to take statistics and recall how results can be skewed by how data is collected. How you ask the question can be as important as what you ask. I have been asked twice to allow students shadowing a MD to observe my visit. One asked "you don't mind if Bob joins us do you?" the other the nurse asked "Doctor has a student wanting to be a NP shadowing him. She is a female. Would you be comfortable having her observe". There is a subtle difference but the first makes it more difficult for a patient to deny participation. You asking say an older man if they were available would you... could likely get a whole different response than a nurse putting a pair on the exam table and just saying here are a pair of colonoscopy shorts if you would like them, or better "if they would make you more comfortable". Likewise, you asking patients, especially patients you know if they are comfortable with you may not be representative of the population or even accurate. They may be more uncomfortable telling you no than with the procedure. That is different than being comfortable.
The other aspect of this is what it says to the patient. If I was offered shorts, I am not sure I would take them, the fact that they were offered would give me a level of comfort that the issue was understood and respected may be enough. My dermatologist had this little hand out my first visit about his policies. Included was a note women would be provided a gown, men would be asked to strip down to underwear (paraphrased). That always bothered me a bit. After a couple visits the nurse took me back and said it was time for a full body I needed to remove all clothing except my underwear and would I like a gown. I was a little taken back and said "No but thank you for asking". It changed my whole attitude that they understood, they took MY feelings seriously. My point is to truly understand how patients feel simply asking one or more may not give an accurate answer.
I am a different patient than I was several years back in a large part because of this blog. I am 58 and it will be 10 years soon and due for a colonoscopy. I will not ask my MD for shorts, I will however have a discussion with him and get his assurance he will keep me as completely covered as possible.
Artiger, I think part of the problem here is not all or possibly even most providers have the same concern you do. We have all experienced things like in my case a female tech for a scrotal ultra sound when a male was available not even asked. A nurse participating in a vasectomy where the patient is laying there with "it all hanging out" rather than just a small square. Modesty being while maybe not completely ignored, at least not a significant concern. If more MD's treated the issue as you do, there might be less concern among patients, it doesn't take to many bad experiences to taint how we view the whole medical community. My experiences with the medical community overall have been very positive, very nice, respectful people. I do however feel the medical industry has pushed the concept of gender neutrality for their own benefit. You made the comment that you didn't care if someone drove 100 miles, you had plenty of patients who...I think this is telling of the industry. We do not have to provide concern for modesty from the patients perspective, we can provide it from ours as we have more patients than we can handle so they get what is efficient for us.
Thanks again for being here, this is an awesome opportunity for us, I hope you feel the same.don

 
At Thursday, July 10, 2014 7:00:00 AM, Blogger artiger said...

Misty, our lone OB/gyn is almost always available, but when she needs to take off the hospital pays for coverage. And I'm sorry, but sometimes that coverage is a male. We don't have any FP's doing OB, or any midwives (although either or both would be welcome). It's hard to recruit to areas like this. I don't know what you consider to be rural, but my hospital has 25 beds, the town has about 3,000, and the entire county has about 12,000. Maybe "most hospitals" that you are familiar with have 3 OB's, but very few of them that are our size have even 2.

Don, I can't sue for payment. I can send someone to collections, and hope to get 60 cents on the dollar, but rarely do. When I was in self-employed solo practice, I didn't see much from that. I did get a lot of bankruptcy notices.

I don't know how big of a business you run, but when I was solo self-employed, I was bringing in about $300K gross revenue. After insurance, and paying all the other overhead, it didn't leave much. That $100K year sent me reeling for a long time, I have just recovered from that in the last few years. It certainly was a factor in deciding to go to work for a hospital later on.

I do the best I can, but I think you have hit the point. Tell the physician about your concerns. If he/she is worth a damn, he/she will take a few moments to talk it over. Yes, it's possible that they were trained in a way that or by someone who never considered modesty to be important. That's something that I think will change in upcoming generations. But these docs won't know if you don't tell them. If they disregard you, tell them goodbye.

 
At Thursday, July 10, 2014 10:02:00 AM, Anonymous Medical Patient Modesty said...

arTiger,

It makes so much sense to me about why your hospital has only one female OB/GYN. It is very apparent your hospital is very small with only 25 beds. Most hospitals in rural areas or small towns are bigger than your hospital.

Aren’t you the only general surgeon at your hospital? I found it interesting that you do colonoscopies because in most towns gastroenterologists do the colonoscopies rather than surgeons.

Misty

 
At Thursday, July 10, 2014 2:30:00 PM, Anonymous Anonymous said...

Artiger - "In an effort toward gender diversification, I once took two male nurses hostage at gunpoint and tried to force them to work in the OR one day...then the police got involved and it turned into such a mess that I just dropped it there."

No offence, but that sounds like quitter talk right there. Just because something doesn't work the first try is no reason to give up... look what went wrong, alter your plan, and try again. I suggest better locks on the doors as a start ;)

But jokes aside, what you said at the end of that post about the slippery slide.. do this, they want that, then that, then that...

I didn't mean drop the $2 for everyone, just a pair or two and just hand a pair to someone who hadn't had a scope done by you before (so they don't question the change) and see if they look at you like you're weird, or just treated it like the gown and put it on without a second thought.

Jason K

 
At Thursday, July 10, 2014 2:57:00 PM, Anonymous Anonymous said...

Artiger - you commented "Yes, it's possible that they were trained in a way that or by someone who never considered modesty to be important. That's something that I think will change in upcoming generations. "

I'm not so sure I agree with that.... I see more and more disregard for personal privacy among young people.

I'm friends with a young lady in her early 20's (coworker that had a lot in common, She moved so now we're "facebook friends")... through her facebook posts that show up on my feed I'm fairly certain I've seen her and all her friends naked, and they seem to have a trend of posting selfies while going to the bathroom... Not to mention they also post pics of themselves (at a party) on the toilet while there's people of both genders just standing around.

So I really can see the upcoming generation seeing personal modesty as a totally alien concept.

Jason K

 
At Thursday, July 10, 2014 5:13:00 PM, Anonymous Anonymous said...

Artiger, the scale of business is hard to do apples to apples. My business has much more gross but nets about 1-1.5% of sales and is very capital intensive with millions going into capital improvements each year. We sue vs collection agencies but our goal is the same, get me pennies on the dollar.
I have been trying to reconcile the past weeks discussion. I think we are on the same path to a degree. I wonder if your success in treating people you know as well as other patients isn't much like my dermotologist offering a gown. If through your consultations you make your patients comfortable enough that you will do what you can to make them comfortable and only expose as absolutely needed they can accept. While I am still uncomfortable, being exposed when I feel providers have done what they can i something I can accept. It is when I feel they have not that i get wired. I understand your position on a nurse in the room. I may not be comforable with it but I can accept it if i felt my provider did what they could for me. If you need a nurse to mop blood, i understand she can't do it from the other side of the room with a 10' pole and a blindfold. And while a male may wish you had a male nurse, the reality is on a little over 10% of the current nursing staff is male. If you really feel it is important to have a nurse present during a vasectomy just in case, if you have me draped with only a small area exposed and have her enter the room and stand away from me unless needed, you and I have reached a reasonable compromise. I prefer her not to be there at all, you do what you can to make me comfortable...I can live with that. I think if all providers acted as you, this would have been a short blog rather than years upon years. While I think we still have a chasim in who should be asking vs telling, the reality is if patients want to be accomodated at this time in history we need to educate providers by asking and walking. perhaps for us this is a little like the 3 blind men discribing an elephant. Our experiences and what you provide seem to be two different things. Someday hopefully the gender diversity in the medical community will strike a better balance and men can ask and recieve same gender in most situations, until then I think providers like you will help deal with the limits on the current system and patients like us may drive change and maybe, just maybe we will someday meet in the middle...don

 
At Thursday, July 10, 2014 5:51:00 PM, Blogger Maurice Bernstein, M.D. said...

Jason K, are you telling us that all the worries, frets and other reactions that have been described here over the past 9 years regarding personal modesty and gender selection will become anachronistic shortly as the Millennium Generation and beyond will invade our population? Hmmn. If so, interesting prediction. ..Maurice.

 
At Thursday, July 10, 2014 8:18:00 PM, Anonymous Anonymous said...

Not sure if my last post went through... I got a network error message when I clicked submit, so if it went, ignore this one.


Maurice- I wouldn't be surprised in the least to encounter more, not less young doctors / nurses/ med staff... even non medical related people in general... who simply can't grasp the concept that not everyone is ok with exposure.

Jason K

 
At Friday, July 11, 2014 7:34:00 AM, Blogger artiger said...

Misty, it kind of depends on what you consider to be "rural" and "small town". 10,000 is small town to a lot of people, but if it's a suburb, it's not really rural. I haven't seen many rural hospitals in towns of 10,000, even 15,000 that have 3 OB's (not that they don't exist, but it's not that common in rural areas).

There actually is another surgeon here. I was brought in 7 years ago so that he could "retire". Here he is, about to turn 78 next month, and showing no signs of wanting to quit. Fair enough, that's just someone else to be on call half the time. One day, he is going to have to quit, I just hope he is able to realize it when that day comes.

Gastroenterologists are uncommon in towns that have less than 20,000, maybe even 30,000 (again, unless we are talking about affluent suburbs). Surgeons, and even family practice docs fill in the gaps for endoscopy in those areas. Surgeons in rural areas do a lot of colonoscopies and EGD's, mainly out of necessity.

Jason, what I was suggesting is that medical schools and residency programs do a lot better job at teaching modesty issues than they used to. Or at least that is what I have observed from being around today's residents and students. It may not necessarily be what you have seen. I suppose, as the upcoming generation also becomes patients, they might be less concerned with modesty and exposure. Unfortunately, there will still be a lot of older people who are.

Don, good post. Thank you.

 
At Sunday, July 13, 2014 1:17:00 PM, Anonymous Medical Patient Modesty said...

arTiger:

Thank you for contributing to Dr. Bernstein’s blog! I am sure that many of the readers would love to hear you answer this question. What things have you learned from this blog that you did not know before? Has this blog made you more aware that there is a population of patients who care a lot about their modesty? I have talked to some doctors that did not really think that much about patient modesty before. Dr. Bernstein mentioned that many years ago that he did not really think about patient modesty.

I really appreciated Jean’s great comments last week. Many patients who are modest will not go to a doctor of the opposite sex for intimate procedures so doctors who do opposite sex intimate care will likely not interact with patients who are modest. There are so many all-female ob/gyn practices in the United States especially bigger cities. Many patients who value their modesty will drive farther to ensure they can have same gender medical professional for intimate procedures.

Misty

 
At Sunday, July 13, 2014 2:21:00 PM, Blogger Maurice Bernstein, M.D. said...

Misty, you write "Dr. Bernstein mentioned that many years ago that he did not really think about patient modesty."

A correction: I have never forgot about patient modesty either in my practice nor in my teaching to the first and second year medical students. Never! What I had no awareness, until reading this thread, was the extent in which modesty was characterized here and to the extent modesty would affect the patient's decision for participation in their important medical care. ,,Maurice.

 
At Sunday, July 13, 2014 4:27:00 PM, Anonymous Medical Patient Modesty said...

Dr. Bernstein,

Look at some comments you made on June 26th:


And there are female patients who will accept a male physician examining their breasts. Think about this: In all my 50 years of internal medical practice and innumerable breast exams of woman patients, not one patient refused my examination (and without a chaperon) either before or after obtaining the patient's informed consent. And no negative feedback after the exam. All this is part of my attempt to explain why no patient ever criticized me about how I handled their modesty issues and why before this blog thread I had been previously ignorant about what my thread writers were going on in their minds and their experiences. And now I know. ..Maurice.



Did you ever think about how there were a number of women who refused to come to see you in the first place for breast exams because you were male and that they went to a female doctor instead of you? Female patients who choose male doctors on purpose for intimate exams usually do not have patient modesty issue or have come to accept that they can let go of their modesty in medical settings. I know you have done many genital and rectal exams on male patients. I am not sure if you ever had a female assistant or nurse present with those male patients. Did you ever think about how those male patients may have been okay with you doing their genital and rectal exams, but that they did not want a female to be present? I am sure that you have learned from this blog that a number patients are not okay with even brief exposure of their private parts to the opposite sex.

Misty

 
At Sunday, July 13, 2014 5:14:00 PM, Anonymous Anonymous said...

Artiger, I am curious, during your consultation do you discuss what some here are troubled by, lets say shaving the pubic region for surgery or being cathed. Many here feel ambushed when some of this occurs unexpectedly. Is that the kind of stuff you also cover during the consult or is it more the mechanics of the procedure.

I assume you get patients via referrals, are these things discussed during the prelim. exam prior? Just curious as to how you approach these things vs springing them on the patient when it is to late for the patient to have a choice...don

 
At Sunday, July 13, 2014 6:07:00 PM, Blogger Maurice Bernstein, M.D. said...

Misty, you write " I am sure that you have learned from this blog that a number patients are not okay with even brief exposure of their private parts to the opposite sex." Yes, of course, isn't that related to much that is written here by my visitors? As far as your initial questions, I have no idea of whether female patients did not select me since I would be their male doctor. Certainly, now I see that some who write here probably would not select me. And finally, since I never used any chaperone, male or female for performing genital/rectal exams on males, I have had no feedback from men about a female chaperone. ..Maurice.

 
At Monday, July 14, 2014 6:58:00 AM, Blogger artiger said...

Misty, participating in this blog simply reinforced my current practice. I work on the assumption that everyone cares about modesty. If you'll go back to my original comments (posted by Maurice on June 26 at 7:30am), you'll see what I am thinking about during an examination or procedure. When discussing breast incisions with women, I tell them about where the scar will be, and my method of closure to achieve the best possible cosmetic outcome. Many of them tell me that they don't care what it looks like, and I respond by telling them that I care what it looks like.

I certainly understand if a female patient wants to drive another 100 miles or more to see a female surgeon. Like I said, I've got plenty more here that come to see me because of the service and courtesy I provide, not to mention how quickly I get them in to see me or get their procedure scheduled. Some people care more about that than gender. As an example I may have already mentioned, in an area we used to live, my wife drove 100 miles (past 2 female OB/gyn's) to see my best friend from medical school. Why? Because he gave her the best in care and service. I didn't have to convince her, seeing him was her idea. Never bothered either of us in the slightest, even when we would go visit them socially or take trips with them.

Don, yes, discussing these issues and concerns are about half of the office visit. Although we don't shave (we use clippers) we don't remove any more hair than necessary, just enough to allow for a clear field for the proposed incision. As for catheters, that is always discussed ahead of time as well. Catheters are useful but they are not without their risks, and they are not to be taken lightly.

No, the referring providers usually don't cover these things (they really wouldn't have a clue where to begin, I'll tell you candidly), as it's not their place to do so. That is what the office visit with me is for. If they could discuss all these things adequately then they could just call and schedule the procedure. I have never felt comfortable doing it that way, but there are a lot of places where you can get a colonoscopy without ever meeting the person who will do it. That's another part of my office visit that I feel is important...I want the patient to know me, who I am, what I look like, have all of their questions answered, and be comfortable with me as their surgeon.

 
At Monday, July 14, 2014 7:45:00 AM, Anonymous Anonymous said...

Here's an interesting thought. What responsibility does the medical community have in creating this mandate for same gender care?

How many of us on this blog have taken this stance AFTER a negative experience in a healthcare setting?

What were your attitudes about healthcare before your negative experience.

All these questions as mentioned in my book, are issues that one must ask themselves.

As I've mentioned before, I saw all medical personnel for who they were regarding medical ability without any thought to provider gender for all intimate exams, exploratory gynecological surgery.
After my experience, I vowed never to be put in that position again.

Please...if you have changed your mindset based on previous experience, it's important to understand why and what caused you to change.

Comments anyone?
belinda

 
At Monday, July 14, 2014 11:41:00 AM, Blogger Maurice Bernstein, M.D. said...

NOTICE: AS OF TODAY JULY 14 2014 "PATIENT MODESTY: VOLUME 66 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 67.

 

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