Patient Modesty: Volume 67
So with Volume 66 reaching some 170 postings,
we should move on to this Volume 67.
What is special on starting this new Volume is the fact that
Artiger joined us in Volume 66. Artiger is a male physician (surgeon)
verified by the Medscape medical website, where we both participate, who has provided
us with the long-needed professional
input and education from the outside of this blog. It appears that those writing to this thread
have found his comments of interest and has accepted his presence here. I have no idea how long Artiger will stick
around but as long as he decides to do so, I will find him most welcome as a
significant contributor to the ongoing discussion. Here is Artiger's last posting from Volume 66.
..Maurice.
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.
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.
NOTICE:
AS OF TODAY AUGUST 3, 2014 "PATIENT MODESTY: VOLUME 67 WILL BE
CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 68
Graphic:
Thom, Robert A.: Paré. Photograph. Britannica Online for Kids. Web. 14 July 2014.
Ambroise Paré was a French army
surgeon in the 1500s who invented compassionate ways to handle wounds and
hemorrhages. The painting was done by Robert A. Thom in about 1954.
posted by Maurice Bernstein, M.D. @ 11:31:00 AM
169 comments
169 Comments:
I wanted to respond to Belinda’s comments:
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
Belinda,
I do not believe that we can change the whole medical system. But it has been encouraging to see some hospitals and medical facilities taking steps to ensure that they have same gender medical professionals for patients who are modest. I believe we should recognize and praise hospitals and practices that are sensitive to patient modesty. For example, if you go to a hospital and your request an all-female team and they honor your wishes, I think you should write them a thank you note and do a good review about them online.
I feel we can play a role in encouraging hospitals and facilities to have medical professionals of a certain gender for patients with patient modesty concerns. For example, hospitals should always have at least one female ob/gyn and one female doctor in ER on call at all times for female patients who do not want a male doctor. The same should be for men. There should always be at least one male ultrasound technician available for male patients. There should be enough male nurses available for male patients at all times. There are some hospitals that meet those criteria. Medical facilities that cannot accommodate patients’ wishes for modesty should be willing to refer them to another hospital that can.
Urology practices need to start recruiting male assistants and nurses for their practices since about 80% of their patients are male. Some male urologists are willing to work with male patients by themselves without an assistant and that is encouraging because many modest male patients do not want an assistant present.
Unfortunately, it is much harder for patients’ wishes for modesty to be accommodated at a hospital in a smaller town.
Misty
Dr. Bernstein,
As you can see, many men have modesty concerns when they go to the urologist. One man on this blog commented how he would rather to have a male medical student present for an urological procedure than a female nurse with 30 years of experience. Have you ever considered having some of your male medical students assist urologists with urological procedures such as vasectomy in your community as a part of your class? I think this would be a great way for male medical students to gain some experience. It also would open their eyes to how important male patient modesty is.
Misty
Sorry Misty, no first or second year medical students "assisting" urologists for surgical procedures. They are still learning how to draw blood on each other. That experience will come in the 3rd and 4th year clerkships
As I have written previously. first and second year instructors talk to the students about attention to modesty as the students learn to take a history and perform a physical exam on a real patient. The second year student also, as I have written, get the modesty issue presented in a direct super-impressive way as they learn how to do a pelvic exam and male genital exam on paid teacher-subjects. I am sure these learning exercises will be long remembered by the students. ..Maurice.
Misty, who benefits when students actively participate in delivering healthcare, the patient or the student? Since it's the student, to the possible detriment of the patient, why would anyone consent to student participation, especially when it's such a personal and invasive procedure? My advice to those who are considering a vasectomy is simply find a physician who will perform the procedure alone. Personally, I don't want another pair of eyes simply observing (male or especially female) and will never consent unless there are damn good objective reasons. And the physicians comfort level rank well below mine, especially when I'm paying the full price anyway!
Ed
Misty, Thanks for responding to my post, however, your response had nothing to do with my post.
I'm interested in learning who, on this blog, or other places, changed the way they feel about modesty in a medical setting due to a negative experience.
Conversely, I wonder how many people changed their view of modesty issues due to a positive experience, however, they wouldn't be looking at this blog.
My feelings changed 180 degrees after a negative experience and I wondered if anyone else felt the same way.
belinda
Maurice,
The majority of people that post on your blog legitimately care about patients. They are open to listening and recognizing what is being said on all these blogs and bulletin boards about patient modesty.
Artiger is no different. What I have noticed is that the one measurable item is time. Artiger , you, and all the "good" providers take time to build the trust and relationship with the patient.
The "bad" providers take the "get over it approach." This response is very indicative of a "you are wasting my time" scenario.
--Banterings
And Banterings, it shouldn't take much time out of the physician's day to say "tell me how I can help you".
This is all about what we teach medical students how to begin history taking and performing a physical exam: BEGIN WITH OPEN-ENDED QUESTIONS OR STATEMENTS. One factor which would diminish the chances of a patient fully expressing their concerns is for the doctor to start the relationship with a DIRECT QUESTION and followed by more direct questions such as: "Tell me when you got sick", "What symptoms did you experience?" and so on. These questions only prevents the patient from an opportunity to express their serious concerns. "Start with open-ended questions" is the best advice we can give to our students to allow the patient the opportunity to "speak up" to the physician. The solution can be as simple as understanding the value of "open-ended" versus starting with "direct" questions. Any questions by my visitors about this teaching point? ..Maurice.
Belinda, I'll address your questions in order.
1) Mandate for same gender care? Why should people who are OK with or prefer opposite gender be compelled to receive care their uncomfortable with. Am I reading too closely between the lines?
2) Definitely yes!
3) I avoided physicians like the plague (other than mandatory annual flight physicals) until concluding I had no other reasonable alternative. I've previously recounted my negative experiences here and simply state never again.
Ed
Ed's comment reminded me of an issue. Belinda brought up the issue of gender; I had taken a couple online surveys and there were questions about chaperones.
I have a really bad medical phobia, and my FIRST choice is neither for chaperone and neither for provider. Like Ed, I avoid doctors, hospitals, etc., (probably more extreme than Ed) even when I know that I need go.
The significance of this is that people who have modesty issues of being seen by anyone are being aggregated with those who have gender issues.
I believe that if you can solve the issues that people like me have, then people with gender issues may be more comfortable receiving care.
Consider that if (as Belinda proposes,) males get male providers and females get female providers, does that really solve the issues if patients are still being needlessly left exposed?
That is why I believe the issue is not modesty, but patient (human) dignity.
I use this example as an example of are we doing things the best way possible, and I have received extremely negative feedback. I pose this idea: how different would procedures be if providers had to be in the same state of exposure as the patient?
I have posed this for over 10 years. You cannot honestly say that procedures would be the same, just the opposite, they would be radically different.
Note: I am not dismissing the gender issue, that would be included in the issue of dignity. What I am saying is that issues of modesty and gender may disappear.
Starting with the 8th edition of ATLS, the DRE is no longer necessary for all instances of trauma, only when indicated. Under the new guidelines and in certain situations, the DRE has been eliminated, therefore the gender issue has been eliminated.
This is a "off the cuff example" showing that the thinking is no longer "ALL instances of trauma." I know that there may still be exposure issues.
Ed "1) Mandate for same gender care? Why should people who are OK with or prefer opposite gender be compelled to receive care their uncomfortable with. Am I reading too closely between the lines?"
Isn't that a bit like arguing against male / female washroom segregation? (for those who are ok with, or prefer peeing a few feet away from someone of the opposite gender)
Pretty sure she meant mandate to make the patients preference the one that's followed, not what the medical side feels like.
Jason K
Good Morning
My last post was either stated incorrectly or misunderstood.
What I meant was, what responsibility does the medical community have because of patients negative experience, to create an environment that we on this blog are asking for?
Same gender care is never a mandate for all (but only in the context of what we want on this blog). What it is, is a requirement for some people who need it to feel safe.
What I was asking is whether the medical community should take responsibility in ensuring this requirement, when needed, when the system caused the initial traumatic event whether by omission of information, lack of privacy due to carelessness or whatever.
When someone is upset to the point that they will avoid healthcare because of this issue, generally, something happened. Sometimes, it happened in the private sector and then that patient is triggered.
But for me, there is a clear distinction about how I behaved, what I didn't even question before my experience, to doing whatever I have to, to protect my dignity, privacy and from feeling degraded due to the hands of people I trusted, my medical providers.
So, the question remains. What responsibility does the medical community have to ensure emotional safety for those who have a requirement, whatever that requirement is, when the reason they now require something is because of emotional trauma when something happened to them in that environment that caused emotional trauma?
belinda
M Banterings - I'm the same... I don't care if it's male or female, I refuse to undress further than boxers. (and I haven't dropped my shorts for anyone in the medical field since I was around 10 or so, and old enough to tell them in less than polite terms to back off.)
Jason K
I found that Don wrote the following yesterday after Volume 66 was closed to further comments. ..Maurice.
Belinda, I do not think the medical community has any obligation at all to create a same bender mandate. First off it ignores those who don't care, those who prefer opposite gender, and creates an unreasonable if not impossible burden on the medical community.
Artiger, I wasn't clear on the second part of my question but you answered it in your example of the colonoscopy. I was picturing you get a referral, have the person waiting in the exam room, meet and examine them, then have the consultation. That is what I have seen. It sounds like you meet with them and have a consultation before you do anything which I think is outstanding.
This has been a great conversation as at least for me, it shed light on possible alternatives to what we assumed to be the only option of same gender. Having a conversation for the first time while the patient is in a gown is not the right time, but is what we experience. For me the problem was/is what you provide is not what I have experienced at all. From my experience you are the outlier in the system. More often I feel the approach for the medical community is pretend it isn't an issue so we don't have to deal with it, and if we pretend, it will make it ok for the patient. Practices vary so much between providers it is hard for a patient to predict what will happen. I had an endoscopy and had to remove everything including underwear only the gown, a woman in my office had one at a different place, they had her remove her shirt only, gave her a gown and did it. I teenage kid whose mom works for me had an appendectomy, they shaved him from below the knee to the neck. I have had two surgeries and never received any significant conversation as to what to expect prior, one was explained as I laid on the table gowned right before they wheeled me away, the other I had already gotten the calm down part of the sedative before I was told what was going to happen in any detail....I wish all providers do it like you, some of us would find that sufficient. Unfortunately from experience you are the exception rather than the rule. Now how do we communicate that out to a community that wants to ignore it or provide only how they want..don
ARTIGER,
It is shocking that you do not care for your wife’s private parts to be examined by your best friend who is a gynecologist. It sounds like you have been desensitized to nudity. You probably have seen so many private parts of women that they are not really any different from ear and nose. It is pretty common for medical professionals to be desensitized to nudity.
How would you feel if a male friend of yours who is not in the medical profession saw and touched your wife’s private parts? If you are not okay with a male friend who is not in medical profession to see your wife naked, why is it any different? It’s so hard to believe that you can socialize with your male gynecologist friend who sees and touches your wife’s private parts and that you have no jealousy. Does this not affect your sex life? Are you okay with nudity in other settings such as nudist resorts?
A number of patients choose to not let any people of the opposite sex to see their private parts because they have convictions that their spouse should be the only person of the opposite sex to see their private parts. There is a reason why public restrooms are separated by genders. It’s ridiculous about how morals do not matter in medical settings. The medical system needs to follow moral principles that are applicable in other fields.
-Concerned
Don - you said "I do not think the medical community has any obligation at all to create a same bender mandate. First off it ignores those who don't care, those who prefer opposite gender, and creates an unreasonable if not impossible burden on the medical community."
If it's not up to the medical community to ensure the option of same gender care, then who is responsible?
Sure, patients are free to go elsewhere, but if there are NO hospitals willing to guarantee an all same-gender care team, then what would you suggest the patient do?
As someone said in one of the earlier pages... you can choose your doctor to ensure male / female... but when you're sitting on the table and they call in a chaperone, scribe, or assistant, that's a bit late to do anything other than demand the person get out. (not much good if you were in an exposed state)
Same goes for surgery... I've never even heard of anyone getting surgery where they got to greenlight every single person who was part of the procedure.
We patients have little to no control over the "secondary" people involved. The hospital does.
As for "unreasonable if not impossible burden on the hospital"... is ensuring same gender care is available to those who want it more unreasonable than expecting ... say a female rape victim ... to be ok disrobing and being touched by a strange man?
Jason K
Concerned, perhaps you are just "over-concerned" when you write:
"ARTIGER,
It is shocking that you do not care for your wife’s private parts to be examined by your best friend who is a gynecologist. It sounds like you have been desensitized to nudity. "
I can understand that what you write in this segment and further in your posting represents simply how YOU personally feel about such a revelation. But that is YOU and not Artiger. It is your feeling how your modesty would affect you and your marriage but it doesn't necessarily apply to others in society who may feel comfortable with what Artiger wrote. Some find a necessary physical examination trumps modesty or sexual implications as compared with other situations in life. And this "trumping" may be acceptable because 1) the patient herself has made the selection and 2) Artiger was well aware of the professional and personal behavior of the gynecologist as compared to some physician stranger selected from the Yellow Pages.
What is so important to learn and understand and then practice as the discussions go on here is to realize (as I am realizing) that there are folks whose modesty is #1 when it comes to essential medical management (as most of those responding here have decided} and then there are the other population of folks who are willing to let go of their modesty concerns {and not even being naturists, nude models or porn actors) when attempting to have their illness diagnosed and treated. It is all about looking at things one way or another. one way is suspecting and acting as though the medical provider system is full of sexual perverts and there will always be danger to the patient or accepting that there are sexual perverts in the medical system as elsewhere but with awareness of what is going on and "speaking up", virtually all of medical diagnosis and treatment can be accomplished without incident.
Having the body exposed for an accepted medical purpose, itself, should not be an issue since it may be impossible to diagnose and treat through coverings. What should be understood both by physicians and by the public, is that some patients are emotionally upset with aspects of bodily exposure to others and some patients are not. I doubt we can change these feelings in either population but what we can do is offer ways, as much as possible and practical to be aware and accommodate both groups. ..Maurice.
CONCERNED,
If you have read any of my earlier posts, you will find that I am far from desensitized to nudity. As I had written earlier, I take a much different approach to examining the genitalia and/or perineum than I do the ear or the arm. Again, read the earlier posts regarding keeping patients covered as much as possible, working quickly, etc.
Also as stated earlier, it was my wife's decision whom to see for OB/gyn care. My friend is an OB/gyn, and he is a professional. Lots of his wife's friends would come to see him. In my practice, some of my friends' wives come to see me about colonoscopies and breast lumps. Some of my wife's friends choose to come to me as well for such issues. And we'll be out on the lake or out to dinner the next week. Nobody seems to have a problem with that except you. A friend who is not in the medical field would have no reason to see my wife naked, so you're going to have to come up with a better point than that. And my sex life is just fine, thank you very much.
I agree that some people may feel that it is inappropriate for opposite sexes to see each others' private parts; but certainly not everyone feels that way, and I dare say a majority don't. If you or anyone else feels that way, it is your prerogative, and you are free to see the physician of your choice and gender. This is not a moral issue, except maybe for you, wherever you live. Seeing private areas is part of health care. I'm a professional about it, whether I'm treating a close friend or a complete stranger.
Belinda, I didn't respond to your question earlier because it was directed to people with modesty issues, but when you posted the following comment, I felt compelled to respond:
" So, the question remains. What responsibility does the medical community have to ensure emotional safety for those who have a requirement, whatever that requirement is, when the reason they now require something is because of emotional trauma when something happened to them in that environment that caused emotional trauma?"
I also had a 180 degree turn in the way I view health care providers, due to an extremely upsetting experience I had (not modesty related). Thank goodness I am relatively healthy, because I am fearful of ever being in a hospital again or needing a procedure done. Doctors simply don't have time to listen to a patient's concerns, or label them mentally unstable.
Artiger, I do not believe most people are "shocked" that you let your wife see a male gynecologist. We all know the identity of that poster, and while I respect her right to her opinion, she has no right to tell me (a female) that I cannot see whatever doctor makes me most comfortable (female or MALE)...and some of us have modesty issues which are not gender related at all.
LJ
Artiger, your comments for "Concerned" were spot on. Frankly, I'm tired of religious zealots claiming their moral view is the correct one and pissed when they try to impose them on others!
Ed
LJ, Thanks for your response. I'm sorry that you also had a traumatic experience that changed the way you view healthcare.
I would bet that if we sat down and had a conversation, that the underlying reasons for the change in feelings might have the same reasons at the core, though the experience may be completely different in appearance.
Underneath this modesty issue are the underpinnings of respect, dignity, autonomy, and informed consent. When these basic principles are violated for whatever reason, often patients are traumatized because they wrongfully assumed that they were in a caring, trusting, environment.
While individuals who work in that environment may have those qualities, a hospital is nothing more than an institution with systems in place to make things easy for them.
A traumatized individual is not necessarily mentally unstable. What they are, is a product of their experience and instability would need to be measured by a mental health professional.
Most sexual assault victims develop PTSD with a higher incidence in doing so, than any other cause of PTSD (war, natural disaster, or accident. These people are not mentally incompetent but may have special needs because of that.
Those needs are just as important as medical needs and their feeling of safety is important to them.
All of us, as we go through life get bumped and bruised.
So, while the issue may not be about modesty, LJ, if I'm reading you correctly, are saying what I'm saying...that your experience changed the way you feel about healthcare. That being said, do you feel that the medical community has a responsibility to help you in the event you need them in the future?
belinda
belinda
Jason, I guess I live in a sheltered world; not familiar with arguments against restroom segregation here in the U.S. That said, I spend quite a bit of time in Europe & Asia where public restrooms remain segregated but the attendant in the guys is normally female and expected to tip her when leaving. Quite disconcerting the first couple of times but when you have to go... Additionally, there is a major distinction between using a restroom with a female attendant (who can't see anything) and a female nurse actually participating in some sort of exam or procedure requiring exposure.
Ed
Maurice,
I don't think that's the entire issue. Context is key.
Most who never had a negative experience probably don't think too much about it. Enter 5 interns and the expectation that your fine exposing yourself is another issue.
It would be most prudent for the mental health community to investigate the way bodily exposure is imposed and what could be done to mitigate some of the problems.
This would eliminate unexpected trauma, create a mentally healthy way to expose patients by telling them what to expect, who will be in the room and giving the patient the tools they need to make the right decision for themselves.
It's when there is no consideration for patient feelings, or lack of informed consent that the problems arise.
Why not hire a team of mental health professionals to make recommendations, eliminate lawsuits, aid in comfort of patients, and creating the type of respectful environment and publishing standard protocols of disrobing for each type of test as recommended or stated in he article "Naked"?
Art Stump's book is a perfect example of how the medical community took advantage of a patient, humiliating him, did not give him informed consent. What is that? It's inhumane is what it is. It's this aspect of medical care that patient's fear the most.
The problem I have is that there seems to be a disconnect with common social norms and decency. How is that explained?
belinda
Artiger,
I agree with your wife. If I had to have an intimate procedure, I would prefer it be a provider who is a friend versus a stranger.
There is talk about building trust in the doctor-patient relationship. Intimacy is the glue that binds a healthy relationship. A doctor-patient relationship has a different level of intimacy than a sexual relationship.
His wife probably has a better relationship (due to their nonmdical relationship) than most people have with their provider.
Now I am am going to venture into an area that makes most healthcare providers uneasy. I learned a new level of professionalism while working as a research assistant for a study that explored the dynamics of some sexual subcultures.
Surprisingly, participants in the "swingers' " subculture (couples who openly have sex with other people) have a very strong, healthy relationship with their partner.
Despite having sex with other people, it is just a physical act. Many have the rule of no kissing. "You can have sex with everyone in the room, but you can only kiss me, your spouse."
Many couples also have social (non sexual) relationships with couples they swap with. Perhaps there is some insight that can be gained from the study of the dynamics???
I would like Artiger to comment on the relationship he has with his friend, the OB/GYN.
I AM NOT IMPLYING THAT THERE IS ANYTHING SEXUAL.
From what I learned, I suspect that it is a very close, healthy, strong friendship that is well established, has has its challenges, and is many years old.
If there any OB/GYN providers out there, OR you have colleagues that are OB/GYN providers, I would like to know how many (providers) have ever had office portion of a annual/wellness exam that included getting to know the male partner/spouse. I am not referring to instances where the spouse may have to make decisions if the woman is incapacitated (surgery, childbirth) or he may be affecting her health (STI, conception).
Here is an anecdote from my life. I was managing a project. I had a resume from a recent graduate of a prestigious technological institute. I wanted him on the project. He was young (20 yrs old) and brilliant.
He told me point blank he had other offers, and was considering them. I was aware of the one competitor, I could not compete with their bank account, but I know that their corporate culture Was toxic.
I called his house a few times for inconsequential reasons until a time he was not home. This time the call was to invite him to tour our facility. I also invited his mother to come, being she was surely concerned with her son's first job, and his age.
This tour was to ensure that she was comfortable with our facility and our offer. I got him, and she was a big influence on his decision. I formulated that strategy to acquire him based on what I learned from my research on the dynamics of the sexual subcultures from the study.
I want to expand on a few words written by Artiger to Concerned. Here are the words: "This is not a moral issue, except maybe for you, wherever you live." And that reminded me of the possibility that the vast majority of opinions written to this blog thread should be considered in the same light as we should be thinking about modesty from a "cross-cultural" (different cultures interacting) perspective. The folks here are most likely "westerners" whether from England or Australia or Canada or so but that doesn't mean that they have to represent a "western" view of modesty in the practice of medicine. That is, when it comes to serious health problems, giving up a bit of modesty represents providing a bit of self-beneficence (a doing "good" for oneself).
So with this concept in mind, I researched "Modesty in Health Care: A Cross Cultural Perspective", which just happened to be the title of an article written to the Dimensions of Culture website. Modesty in medicine is separately described in the Arab culture, Asian culture and Latino cultures. Marcia Carteret, M.Ed., the author, summarizes the article as follows:
Understanding the cultural aspects of modesty is especially important when dealing with less acculturated individuals, especially recent immigrants and refugees. Though cultural values around modesty are stressed for both sexes, purity, chastity, and lack of pretentiousness in women is greatly emphasized in many traditional cultures. Americans easily apply their own cultural values about independence and equality to people in other cultures, and may judge the restrictions placed on women in many societies as being discriminatory and even abusive. It is important to realize that women in many cultures impose modesty on themselves and others as a way of keeping privacy and respect. The key questions health care professionals can use to be culturally sensitive in handling issues around modesty are: “Is there anything I should know about your privacy or modesty concerns before I conduct an examination?” Or, “In your culture, how would a doctor show respect for a female/male patient during the examination.”
I think it is important that my visitors here read the entire brief article. (I know from the comments published there that Misty has done so already.) Consider that, in effect, the concerns of most writing here deals with a kind of cross-cultural issue but probably affecting males more than in the other established cultures. And, the medical system should attempt to treat the "culture" which our blog thread visitors appear to represent with the same attention to communication with the patient and attempted mitigation that our system should be applying to those from the Middle East, Asia or the Latin-American cultures. What do you think? ..Maurice.
Belinda, thank you for your comments. To answer your question, do I think the medical community has a responsibility to help me should I need them in the future ? - yes I do, but I am doubtful that they will. You were absolutely correct that I feel there wasn't any "respect, dignity, autonomy, and informed consent." That sums it up perfectly. I read somewhere that the only way someone can get over a bad experience is if it is replaced with a good experience. I haven't lost trust in all doctors so much as I have lost trust in the way the whole medical system works now...and that's really hard to change.
My apologies to "Shocked." It hadn't occurred to me that you might be from a different country and culture.
LJ, I'm assuming the post answering my question was from you.
Yes, there are ways to get the medical institutions to help you.
However, it's up to you to set up the foundation for what you need.
My book, that is taking forever, focuses on how to navigate the health system after doing extensive research on subjects that encompass the medical system and the psycho social negative impact on patients.
It now occurs to me that perhaps the subject matter should be more broad based to encompass the underlying need for the modesty issue. It's complicated.
I have said before, without any cost to anyone on this blog, anyone may e mail me for information as it pertains to them at any time. Just e mail Maurice and he will give you my e mail address. I have had almost 100% success in getting my needs met and when I don't, I walk, write to administration and always get a reponse.
belinda
Please don't get discouraged as a group. Things are chnging. I will say for every ten good experiences I have, and then a bad one, it sets me back. However, progress is being made if it's done in a way that is not adversarial, creates bonding between you and the staff, and the ultimate goal is for the patient to come away without negative feelings after your experience.
You can have a negative experience and still come away feeling great if it's addressed at the time and resolved.
belinda
Ed - maybe I mis-stated what I was trying to say.... What I was trying to get at was that just because "group A" is ok with the available options is no reason to eliminate the choice for everyone else.
If patients were given a section on the admissions form asking about same gender care (same / opposite / don't care ) then the hospital was obligated to follow their wishes or decline offering their services upfront and refer them to somewhere that can accommodate, then the patients would be better off, the medical side can quit pretending that gender issues don't exist, and then the next step of the problem might be able to be addressed.
Artiger - about the wife / gyno friend thing... for me, it'd just be weird having a buddy know what my wife / girlfriend looks like naked, then hanging out with them socially. (it's why neither me nor my girlfriend socialize with our ex's)
Jason K
I think one has to recognize when someone is a provider like Artiger they tend to look at the issue of nudity in the medical system differently. That could extend to their spouse/family so his wife going to a friend of his is probably going to be a bit different. That is not always the case, recall the female urologist (Kiegel girl?) who chided males as sexist for not being willing to be examined by her but she admitted she would not go to one of her male colluages. I think this is part of the problem, providers want to address our modesty from their perspective rather than asking or addressing it from ours. And at the risk of sounding like a broken record, we are all so different.
I find the double standard is applied pretty liberally by the medical community, there is often one standard for us, and one for them, they will recognize and justify accomodation for certain certain religions and cultures but not others. I happen to be Christian and I doubt that would carry any wieght in this issue, but a female in a Burka would automatically get attention...once again providers are determining from their side who will or won't get accomodation.
I think anyone condemning someone who has different feelings like Artiger and his wife are just as wrong as providers condemning or ignoring concerns for modest patients.....dom
Again, I want to stress that most of those writing here could be looked upon as analogous to a different culture in the aspect of modesty. The difference between detecting which modesty culture is operative when looking at most "westerners" is not so easy since the patient does not arrive with a Burka to immediately suggest an alternate culture such as Muslim. So, what is required is that the patient at the outset of the visit should "speak up" (sort of displaying their "Burka") otherwise that culture is hidden until the patient faces the modesty trauma that has been amply described here. ..Maurice.
Banterings,
Whoa, I was not expecting that angle. I'm pretty much a live and let live type of person. I know more than one set of swingers, but unfortunately I am not well versed in the rules and regulations of such. My friend/wife's gyn also is my child's Godfather. That is about as far as the relationship goes. No swapping. Not that there's anything wrong with it, but most state medical boards frown (severely) on such activities.
I knew my friend long before I met my wife. He married while we were in school, so my wife got to know both of them as friends of mine in the beginning. There's really nothing more to it than that.
Maurice,
Yes, that was kind of what I was suggesting, that perhaps Concerned might be from another nation/culture.
Jason,
Weird to you, and probably to a lot of others, but to us it's not a big deal. Keep in mind that we realize our patients may not see things the way we do; therefore, we take modesty seriously.
I find that I am elaborating on some of the words that Artiger uses. Here is another. Artiger wrote "...our patients may not see things the way we do..." I could add, of course, also "vice versa". What is making the patient modesty so difficult for some is that perhaps neither side (patient or provider) can at the time "see things" the way the other party sees them. The urologist staring down at a scrotum with the goal to use the tools to effectively and permanently provide the patient with a vasectomy is a much different view of the patient lying and staring up at the surgeon and possibly an assistant engrossed and about to manipulate one's own scrotum. At that very moment both the surgeon and the patient may have entirely different thoughts: "I don't want a complication here and I don't want the patient to come back later saying his wife became pregnant!" And the patient may be thinking: "How did I get myself in this position so that these strangers are gawking and manipulating my private parts and will this be safe and worth this upsetting experience?" Each with their own thoughts, not, at that moment, seeing things from the same perspective. The solution: as Artiger has previously written, a period of discussion truly communicating with each other between patient and physician about the patient's concerns and the physician's description of what was to be accomplished and how these concerns can be considered to the best for both parties. ..Maurice.
Dr. Bernstein I agree with your different views of the same issue. That is true on many levels, One of the most relevant here I think is as Artiger discussed the need to have other people involved, Artiger see's is at times as needed, other as incase needed so safety net, and other for his protection. A patient only sees someone standing there doing little to help and only adding to their discomfort and humiliation.
Artiger, I can honestly say that the vast majority of providers I have met do not approach this as seriously as you. It feels like it is lets not say anything and get through this so I can get on to the next one and you will get over it. The less you know about this, the less I say about that aspect the better for both of us. Your approach is so different, do you have any idea why that is? I hear Dr. Bernstein say they teach it in school but I don't see it in the field. What is it about you, or your training that makes your approach different....don
Don, yes, modesty is taught in school but how what is taught is applied later on in a physician's career when subjected to all the pressures and uncertainties of treating patients, I would say it has more to do with the physician's personality and past experience as to how the issue of modesty is actually applied to the current patient. I am certain that some doctors would get annoyed and fearing waste of important time by a patient "speaking up" to them about issues not directly related to the symptomatic disease. and treatments. On the other hand, other doctors would be less concentrated on the output vs time and more humanistic and willing to let the patient talk and try to makeup the time later. I think it all has to do with personality. ..Maurice.
Artiger,
I was NOT implying that you were a swinger either. Just as we study disease animals and apply what we learn to human disease, perhaps whe can learn something from them that can help with healthcare.
I will admit that you opened my eyes to the dynamics with providers and their spouses. That might be very insightful as well, especially if the spouse is not a provider. I really never thought of that.
I will also say I am extremely impressed with professional is here. I must confess I was sweating bullets ofer my last post. Worried that someone may misconstrue something. As I said, doing that research taught me a new level of professionalism.
I thank you all for that.
As a provider, we are taught to observe; things such as dress, demeanor, tone, etc. that the can say things the words are not saying. Inspection, Auscultation, Palpation, and Percussion: look and listen are first.
If this is what providers are taught, then why do they not see that there is a problem with patient modesty???
Between the lawsuits, online discussions, complaints, etc., how can healthcare NOT see that there is problem (even if they don't believe there is)??? Something is causing a problem for so many patients.
Patient: I am tired all the time, my joints hurt.
Provider: Your labs are normal, films are clean, and the examination in unremarkable. There is nothing wrong with you.
Patient has Lyme disease.
“Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.” -(Sherlock Holmes) The Sign of Four (1890) Sir Arthur Conan Doyle
So if providers see modesty issues (even with their own families) with "medical" eyes, then why are they not investigating further when patients continue to complain? So many providers not seeing it and not looking further?
Impossible. Not seeing something so blatantly obvious or questioning the complaints as being a symptom of a problem bordering on incompetence.
Let's look at the improbable: healthcare "doesn't want to know," OR "doesn't care (it is just inconvenient)." Maybe providers are taught to ignore these issues, or that complaining is a admission of some defect?
Think of the police officer saying that refusal to comply with a (voluntary) search is probable cause of contraband.
--Banterings
Dr. Berstein & Artiger, there are often a lot of common traits in choice of profession. Just got backe from a business gathering, all type A personalities, overwhelmingly conservatives. If that holds for providers...what causes Artiger to be an outlier, and the same to you Dr. Bernstein....personality, life experience, what are the common triats and what do you see in those who go outside the norm and care about this....don
I remember reading interviews by prostitutes who were sexually assaulted by clients. The violation that they feel is not the sexual aspect, but the "loss of control." They reconcile this event and continue to prostitute by "never losing control again." Many resort to carrying knives or guns.
Among the swingers the biggest betrayal was that of trust. The spouse was either meeting with someone without the other spouse present or telling them.
In my professional opinion the root cause with the gender issues are:
1.) Loss of control, and
2.) betrayal (loss of) trust.
Take any modesty issue and you can define it by one of these. Gender- control, exposure-control, violations while under anesthesia-control and trust, providers walking in or "taking a peek"-trust (I don't know you, I don't trust you)...
I also believe that some people enter trauma (or the regular OR) and push aside their gender and modesty preferences by placing large amounts of trust in them that they will save their lives.
My trust in you is that you will save my life. I now have a high level of trust in you. That trust now alleviates the gender and control issues.
Just like taking aspirin for a headache, it also has the benefit of lowering blood pressure.
Can you picture a provider giving up control? Not any time soon. (Then they would know how the patient feels.)
See my previous comment about the OB/GYN meeting the male spouse during annual.
--Banterings
Don, maybe Artiger and myself are really not statistical outliers but are part of the majority and it is those physicians who are more attuned to issues of their own self-interest rather than attention to patient modesty who are the outliers. ..Maurice.
Maurice - you said "Don, maybe Artiger and myself are really not statistical outliers but are part of the majority and it is those physicians who are more attuned to issues of their own self-interest rather than attention to patient modesty who are the outliers. ..Maurice."
Then that would be a HUGE coincidence that all those medical people outliers just happen to run into all of us patient outliers (as you've called us many times)
Jason K
Perhaps Maurice and I are physician outliers...I know that I don't typically care to be around other physicians in social settings for the most part (my friends who happen to be physicians excluded, of course). Perhaps I don't think like the modern physician.
On the other hand, bad news will travel around the world and before good news will leave the neighborhood, and bad news is 100 times louder. There are a lot of physicians/providers who quite likely share my concerns for the patients under our care, including their modesty, and probably a lot of patients who are very satisfied; yet, we don't tend to hear much from them. Patients seldom write letters when things go well, but they will almost always write when things don't.
Jason, you have reached a worthy and thoughtful conclusion when you wrote today in response to my conclusion: "Then that would be a HUGE coincidence that all those medical people outliers just happen to run into all of us patient outliers (as you've called us many times)"
But I believe I have a reasonable and logical answer to you which is certainly open to further discussion.
I support what I wrote (" maybe Artiger and myself are really not statistical outliers but are part of the majority and it is those physicians who are more attuned to issues of their own self-interest rather than attention to patient modesty who are the outliers.") with this argument:
Who sets the conclusion that the physician is not being attentive to patient modesty? Is it the government, state medical boards, medical associations, hospitals? Of course not. That conclusion is derived from the "eyes of the beholders"--the patients who are interacting with the physician or other healthcare provider. Therefore, it is which I suspect is statistical outlier group of patients who are setting a conclusion about the physician's behavior. Therefore logic would conclude that those physicians defined by a limited group of patients based on the patient's experience will, therefore be also within a limited population, outliers.
This conclusion of possible outliers by the writers to my blog thread is supported by my often stated assumption based on my own professional experience having never heard from or by the behavior my patients concerns about my attention to modesty or their experiences with other doctors
But as I said my conclusions are certainly open for discussion. But importantly, as I have previously written, as you have seen, my assumption of statistical outliers writing here in no way diminishes my interest is finding ways to mitigate the issues set by this group such as patients "speaking up" and forming advocacy groups to educate and change the medical system to attend to their concerns...Maurice.
And reversed, who sets the standards by which the patients level of comfort with modesty offered is judged, the provider. If one provider recognizes the silent patient is uncomfortable but does not see a problem, and another sees it as a problem, what is level by which reasonable patient concern is set? If you see 1,000 patients and observe 950 to be uncomfortable but since they say nothing see no problem, the other sees same patients and the same concern and thinks we have a major issue... consider all of the providers you have brought this topic to, how many have participated, how many agreed, so I would say while you feel you are in a better position to see a broad spectrum you are also defining what constitutes an outlier. To me this issue includes patients whom are made uncomfortable to any significant degree whether they speak up or not. Providers tend to gravitate to the extreme to justify the general. A life and death situation in the ER to justify the routine wellness exam, those who under no circumstance will undress to define the issue Then again if they are avoiding medical care, how do you know the number..to be 100% honest I used the term outlier in this instance on purpose. I think you look at patients one way but evaluate providers another. The nursing student who refuses to wear a bathing suit to practice bed baths is perfectly normal but the patient with very strong concerns about exposing their genitals to a room full of people is not. Your rationalization does not hold water for me but obviously does for you...so who is and isn't the outlier is truly as you indicated "in the eye of the beholder".....don
But Don, if a patient demonstrates that he or she is uncomfortable by their behavior at the time, then, to me, that appears that the patient is "speaking up" and expressing their discomfort. The problem in communication between the patient and the doctor is that it seems that the whole population of patients we see just don't "speak up" either with words or with behavior. If they did, then I would ask them to the effect "what is the matter?" But they just don't communicate at that time and as with me and I presume the other doctors just goes ahead with the exam and procedure. There has to be some form of communication from the patient to the doctor. And in my experience with regard to matters of physical modesty there wasn't and there isn't.
I am about the leave in an hour to participate, as I do regularly, at a free medical clinic in another community for those without medical care resources. I will bear this discussion in mind and observe. ..Maurice.
I am sorry Dr. Bernstein, I can be a little thick at times. I thought you were defining outliers in this context as being those who would avoid care due to medical modesty. II would contend that a majority of patients have modesty concerns, i think the majority of providers know it, they may not know the extent, but I have a hard time believing providers do not know exposure makes their patients uncomfortable. There are may discussions on how to minimize it, there are some cursory efforts to address it, but I see little possiblity it is a complete unknown. My point was more to providers defining what an outlier is, but not seeing themselves as such when patients define. Again all of this does not mean I think providers are evil, I have no feeling at all like that. I think providers live in a state of denial for self protection, for the need of time, because it is SOP, and perhaps with the thought, miguided or not that it has benefit for the patient. Setting the bar so low that exposure makes a patient uncomfortable to me changes the discussion on what is an outlier on the patient side. I can possibly accept that those who avoid at all cost may be outliers. But, there is no way one can make me believe that the number of people who feel uncomfortable are a small minority. The number who say something, I imagine that i a small minority...those that show significant discomfort may not be the majority, but we have had to many discussions for providers to contend they are unaware just does not ply. Recall the discussion sometime back where you made the comment of course providers know it is different when exposing an arm or a penis and they know the difference in how it feels to the patient (paraphrased). I am not trying to be disrespectful at all Dr. Bernstein but I think providers, including you at times dance around issues with symantics and technicalities, patients are hardle ever naked, they have a shirt on, a gown raised to their neck, patients not saying anything and providers not knowing are two different things. While avoiding care, humiliated, and uncomfortable are different the concept and causation have a lot in common.
And congrats on the work you do at the free clinics, dispite our differences of opinion, you are obviously a good man...don
Maurice - you wrote "I suspect is statistical outlier group of patients who are setting a conclusion about the physician's behavior. "
That infers that we're making this stuff up. Not in so many words or to that degree, but more that we're "over reading" things.
I'm re-typing this paragraph as the original draft was full of profanity... and i'm sorry, but when the patients genitals are exposed to non-medical staff, or medical staff that has ZERO reason to be anywhere near you, or even just unnecessarily (do YOU have a reason why I'd need to take my pants off for an ear infection with a possible perforated ear drum?) then that is a violation of the patients right to privacy and modesty no matter how you slice it.
Unless you're condoning things like leaving the curtains to the operating room open, so civilians walking past in the hallway can see the patients naked body as "normal".
http://www.mirror.co.uk/news/uk-news/epsom-hospital-hospital-visitors-saw-3027723
"She also said she informed a nurse on Buckley ward, who said "that happens all the time" and did not take any action to raise the alarm with operating staff."
Or there's this one where a house keeper was taking pictures of naked people in the ER
http://www.kwwl.com/story/26035661/2014/07/16/former-covenant-employee-admits-taking-photo-of-naked-patient
"Niedert said a colleague dared her to" "If someone dares me to do something, I don't want them to think, 'Oh, she's a chicken.' So I did"
Those are both acceptable to you?
And maybe nobody has complained to you because people who are truly modest simply DON'T GO TO THE DOCTOR. Not counting the occasional ER visit, I hadn't seen an actual doctor in over 15 years.
Also, you said "But Don, if a patient demonstrates that he or she is uncomfortable by their behavior at the time, then, to me, that appears that the patient is "speaking up" and expressing their discomfort. The problem in communication between the patient and the doctor is that it seems that the whole population of patients we see just don't "speak up" either with words or with behavior. If they did, then I would ask them to the effect "what is the matter?" But they just don't communicate at that time and as with me and I presume the other doctors just goes ahead with the exam and procedure"
I have never had a doc or nurse in the ER ask WHY I was refusing to undress and put on the gown, they all just tried to order me to (you HAVE to put this on), then went right for the insults. (it's nothing I haven't seen before, you're being childish, and so on)
Jason K
Maurice God bless you for your concern over ethics and sharing your healing gifts.
I would suspect that the people who read and comment are the outliers, otherwise we would see many other people posting here.
Let us take a real life example: American Academy of Pediatrics (AAP) and their Bright Futures program. Bright Futures is the basis for many states' Medicaid Children's Health Insurance Program (CHIP).
If you look at all the state guidance (requirements) they all say "undressed physical exam." Both the AAP and Bright Futures website offer no guidance about the issue of modesty or any in depth discussion about trust. Trust is mentioned only in lip service.
There is a reference to the AAP's policy on the use of chaperones: http://pediatrics.aappublications.org/content/127/5/991.full.pdf
That document only says include the patient in the decision of a chaperone or (if the refuse) let them go somewhere else for care. There may be information for physicians (login in), but nothing for parents and patients.
So does the AAP just pretend this issue doesn't exist? Or do they let the parents "beat" the children into compliance.
If the child (adolescence) refuses, find another provider. No mention of victims of past sexual assault, undress or find another provider.
Then the medical profession wonders why patients don't just get over it?
Some people may say that providers were children and went through the same thing. There are 2 possible explanations here:
CHIP is fairly new. Ted Kennedy started the concept as a way to pave the way for the ACA. The other explanation is that the abused has become the abused.
Still, whatever ever the reason, there is no guidance about modesty or trust in regards to modesty from the AAP, only a door.
--Banterings
Banterings - that AAP policy you linked to made me laugh...
"In certain situations, a physician may request the presence of a chaperone, particularly when a patient or parent is exhibiting mental health issues; has developmental issues; or displays anxiety, tension, or reluctance toward examination.
If the explanation of the scope and confidentiality of the examination does not resolve the tension or conflict, the use of a chaperone during the examination is appropriate"
So... if the patient (in this case a child or young adult) is anxious or tense / nervous about having to get naked infront of a stranger, and letting the stranger feel their genitals, then that stranger should bring in ANOTHER stranger to stand there and watch... that'll fix any problems. Whoever wrote that needs to step back, read what they just wrote and give their head a shake.
Nowhere in this guide does it say to talk to the patient about modesty. Closest thing is "If any part of the examination may be physically or psychologically
uncomfortable, every effort should be made to support the patient and parent, including the use of measures to preserve privacy, such as gowns and drapes."
Also, back to back contradictions...
2. If the patient is an adolescent or young adult and the examination requires inspection or palpation of anorectal or genital areas and/or the female breast, a chaperone is recommended. However, the use of a chaperone should be a shared decision between the patient and physician.
3. If a medical chaperone is indicated and the patient refuses, the patient or parent should be given alternatives,including seeking care elsewhere.
So.... what's the "shared decision"? do things the docs way or get out?
Not much of a shared decision. reminds me of a parent "talking to" their child about doing something they know the kid isn't going to like... like getting rid of the family dog or something.... but the kid has no say in it what so ever.
To whomever wrote the 4:32am posting today and everyone else writing here:
If the American Academy of Pediatrics has displayed IGNORANCE of what patient modesty is all about then instead of "preaching to the choir" on this blog thread, let's see you guys and gals go ahead and contact AAP and tell them your view and why their advice is unacceptable. And then return and tell us how AAP responded.
Don't just sit where ever you are and "laugh" at their policy but I strongly advise that you attempt to do something about it. And, not just one visitor but the "more the merrier".
REMEMBER:
Just writing to this blog DOES NOTHING to change the practice of medicine. ..Maurice.
Have done so already Maurice (written very logical, tempered letters).
First, Anonymous reiterated my point in a more eloquent manner. But more importantly (and frighteningly) is the fact that many states base their CHIP (children's healthcare assistance for low income, disabled, Medicaid, foster care, juvenile correctional system, etc. on the recommendations of the AAP.
I saw that too quote too and I feel that it implies that if you have modesty issues that you are mentally ill. Furthermore it justifies a provider not treating a patient because they are mentally ill.
My second point; I would like to hear your thoughts on the following four questions, especially if you have initials after your name. Citations are very helpful. You will probably see where this is going after the first question.
There are difference between laws, ethics, industry recommendations/accreditation requirements (AAP), and "generally accepted medical practices."
Legally there are federal laws, programs (Medicare), organizations (JCAHO), etc.; state laws, programs, organizations, licensing boards, etc.; and even on the county level.
Question #1: What responsibility does the physician have (legally/ethically) in recognizing and informing the patient of side effects that may occur at low rate, are not generally associated with the treatment/procedure (but known to occur, see question 3), of a particular treatment or procedure?
Question #2: Does medicine recognize that PTSD, emotional trauma, psychological trauma, etc. are possible side effects of exams, treatments, and procedures due to modesty issues?
Question #3: How do lawsuits, social media posts, letters to lawmakers/provider associations/editorials, AND/OR the published opinions of a minority of providers affect the generally accepted medical practices (treatments, procedures, exams, side effects, utility, etc.) when they show the GAPs to be incorrect? I.e. The revised (less) usage of the DRE in ATLS.
Question #4: Is an exam for a specific complaint, disease, injury or wellness considered a procedure or treatment that requires disclosure?
Excellent questions Benterings, if I understand them. Hopefully, when Artiger returns, he may wish to provide is answers.
1. Very low frequency side-effects should be described to the patient as part of informed consent if the magnitude of the injury or other harm to the patient is fairly or greatly significant. Here is an example of a low frequency, low magnitude side effect that need not be part of informed consent: vasovagal syncope reaction (fainting) at the time of a venipuncture (drawing blood from a vein for testing). An example of a low frequency event of great personal significance that should be disclosed to the patient undergoing coronary artery bypass grafting, intentional cardiac arrest with body and brain perfusion by the the heart-lung machine but at the end of the procedure, the heart cannot be restarted.
2. Medicine absolutely does not recognize "PTSD, emotional trauma, psychological trauma, etc" are possible side effects of professionally performed "exams, treatments and procedures due to modesty issues" to the frequency extent as described on this blog.
3. These sources of communication available to and read/heard by medical professionals may cause variable attention for changes in clinical practice, if possibly of significant may cause a call for further research but without scientific or statistical supporting facts and even then may not cause changes in every single practitioner.
4. I think the examination itself should be considered a procedure and as we teach our medical students they must provide the patient information about it and look for consent before and during the medical examination.
In fact, simply taking a patient history is a procedure that requires patient consent even to the asking of questions. For example, on taking a sexual history as part of the routine questioning, the students are told to explain to the patient matters of privacy "and is it OK with you if we talk about this subject?"
To demonstrate, that history taking can be considered a procedure that requires informed consent, there has been notation in the news and elsewhere about parents rejecting pediatricians attempt to ask whether there a guns in the household and if present how they are kept. In fact, some state legislatures have taken up this concern with attempting to pass laws restricting physician's asking such questions. So yes, even history taking is a procedure that needs consent.
I hope these, in part, answer your questions. ..Maurice.
Maurice,
So medicine acknowledges that we all have different thresholds to pain, heat cold, emotionally to sadnesses, grossness, trust, etc. we have different likes/dislikes that are a combination of physical/psychological in taste sexual preference, etc.
BUT every single person, adult or child is perfectly OK exposing their body and intimate touching without any side effects. Therefore anyone who chooses not to consent is either mentally ill or making a decision that is not based in anything other than the "ego."
Let me play devil's advocate...
Can PTSD, emotional trauma, psychological trauma, etc be side effects of professionally performed exams, treatments and procedures that are conducted incorrectly, like withouth consent when the patient has capacity?
Bantrings,
Your postings are on points are of my own similar thinking.
It's not always the bodily exposure by itself, but the context.
It's one thing to expect some degree of exposure when intimate areas are in question. It's a different story when suddenly 5 students show up and you're exposed. It's different, when your left completely naked on an OR table with the door open and awake and aware.
It"s the degrading element that creates what Dr B calls outliers.
The real question is, once something like that happens to you, you would have to be an idiot to put yourself in that position again.
So, if you don't want to be considered an outlier, be an idiot. Isn't that what it boils down to?
Not once have I heard an apology from anyone in the system unless you stand on your head and ask for it.
So, here's the question. Once you are treated in a cruel and degrading way that would constitute psychological torture, how willing would you be to trust the same kind of institutions, with the same people (strangers) to take care of your dignity, your personhood and your mental health?
Maurice, that's why there are outliers. They were created by the very system that's in complete denial that reforms need to be made.
Abuse is abuse in any setting and trying to protect yourself shows strength, not weakness and there are some things worth fighting for, and dying for, even if it seems trivial to the medical community because they are blinded with a false or altered perception of what really goes on in all institutions including hospitals.
belinda
Maurice,
You said:
2. Medicine absolutely does not recognize "PTSD, emotional trauma, psychological trauma, etc" are possible side effects of professionally performed "exams, treatments and procedures due to modesty issues" to the frequency extent as described on this blog.
Do you have any reference of this (Bates, AMA, NIH, CDC)?
I thought it might be interesting for those visitors here to read a posting that came from a lesbian physician today on my blog thread started August 2010
"Would You Accept a Gay or Lesbian Physician as Your Doctor?"
and currently containing 25 comments. ..Maurice.
At Saturday, July 19, 2014 4:12:00 PM, Anonymous Anonymous said...
I am a lesbian G.P. I have acknowledged my sexuality when patients have asked,.
I would like to say that when I was young I had to go to a male heterosexual doctor because there weren't any women docs around. it was a very painful experience with a condescending male that made me realize we needed women in medicine it. All women were expected to just accept that doctors were male. I have trained with male doctors who are pigs and can say from experience that people should be concerned with them more than any lesbian doctor who doesn't have to control testosterone and the brain of a penis.
Secondly, I have treated gay and straight patients and have only ever been concerned with their health and being the best doctor I could be for them.
I have observed through the years that there is a great deal of sexual abuse with so many of the women I have treated ,especially lesbians.. 99 % of the time that abuse was by a male
It is also very often heterosexual men who are sex offenders and pedophiles even religious leaders.
You should really pick a doctor based on how you connect to them and if you feel like you are being heard , respected and that you can trust their knowledge and care. You must also maintain sexual boundaries with any doctor. If you get any kind of vibes that make you uncomfortable find another doctor.
Just my thoughts. DR. L
Maurice,
Your response at first angered me (the arrogance), then I fealty fear; someone else or me might be subjected to someone carving for them that was trained with a "we can do no wrong" attitude.
Perhaps you can post my original questions as a new thread and revisit the sexual orientation as another thread since the original is 4 yrs old.
Banterings, I am not sure which response of mine "at first angered" you? Also, though the thread on sexual orientation of the physician is 4 years old, the issue may be not much different now as then and doesn't require starting a new thread. The polling results within the United States of greater acceptance of homosexuality now than in the past could be part of the new visitor comments on the physician homosexuality topic now but the thread doesn't need to change. ..Maurice.
At Friday, July 18, 2014 11:23:00 AM, Blogger Maurice Bernstein, M.D. said...
"The problem in communication between the patient and the doctor is that it seems that the whole population of patients we see just don't "speak up" either with words or with behavior."
Until I read this blog, I thought that you either accepted the intimidation of the medical community or did without medical care. Of course, you could go to another facility, but my experience was that they are all the same [it's their way or the highway]. However, I have spoken up too many times [minor issues] in the medical community and been on the receiving end of retaliation for that. In fairness, the MDs are not the problem, other than they allow this disrespect of patients which seems to be inconsistent with their profession. I have sent many letters/e-mails of praise and complaints to retailers, media, and politicians, but never wasted my time sending complaints to the medical community administrators/bean counters because a form letter response just rubs salt in the wounds. Being an old man with average amount of experience with the medical community [including one clear violated of my modesty], I firmly believe the medical culture is so ingrained that I can't conceive the administrators would have a positive response. Of course, "customer service" is part of marketing [and marketing only] for administrators. By responding with a letter, the administrators feel they have done their job, in other words, no further action is necessary.
[Perhaps, one exception to my sending letters to the medical community. I sent a letter to Norman Cousins when he was trying to "humanize" the med students at UCLA. He answered, but unfortunately died before we could continue our dialogue.]
BJTNT
BJTNT, do you have a copy of Cousins' reply you would share with us here? ..Maurice.
I am not sure what the purpose of your post was Dr. Bernstein but lets change male for female. If the intent was to show how we paint with a broad brush then it goes both ways, providers paint patients with a broad brush and we do the same. I hope I never run into this man hater when I am in need of help. That is a truley disturbing post from someone we should be able to trust comes to us without any predetermined anomosity to us because of our gender. To her point, no way I would ever feel comfortable with a MD who posted that.
The fact remains we are labeled as outliers because we speak up, I believe feeling uncomfortable in these situations is the norm not the exception, I believe providers know it, and choose to find all sorts of ways to justify it from pleading ignorance, to promoting that what THEY choose to offer for accomodation should and is sufficient to placate the patient.. I have presented multiple times how I was given a scrotal ultrasound by a female tech when a male was available and never even asked. Do you honestly, and I ask you to think this through rather than answering from a providers perspective, do you honestly believe that those involved were so unaware that there might be some degree of discomfort in the procedure with a female tech that it would not even warrent asking? Really, reverse it would anyone say a female getting a transvaginal ultrasound would be just as comfortable with a male as a female so why even ask? Is that what you are trying to say, that providers are so oblivious to the issue that there is no reason to even consider asking? Is that what you are saying Dr. Bernstein? don
Don, when you write " Is that what you are trying to say, that providers are so oblivious to the issue that there is no reason to even consider asking? Is that what you are saying Dr. Bernstein?"
Not at all, I have repeatedly advised those writing to this thread to "speak up!" ..Maurice.
Maurice,
What angered me was the fact that the medical community believes that no harm can come to a person from doing an exam in a professional manner. I am living proof of the fallacy of that.
These things haunt some people because a provider assumes that the patient exposing themselves.
As for sexual orientation, I would almost prefer a gay physician. I think they may be more sympathetic to modesty issues.
--Banterings
"2. Medicine absolutely does not recognize "PTSD, emotional trauma, psychological trauma, etc" are possible side effects of professionally performed "exams, treatments and procedures due to modesty issues" to the frequency extent as described on this blog."
Of course they don't recognize it... that would be admitting they are the ones causing most of the issue, and would have to change how they do things.
And my refusal for exposure aside... a doctor / nurses sexual orientation wouldn't make a lick of difference to me.... but that man hater above... there's no way in hell I'd consent to see her a second time.
Jason K
Clicked send then realized I forgot to add something..
"2. Medicine absolutely does not recognize "PTSD, emotional trauma, psychological trauma, etc" are possible side effects of professionally performed "exams, treatments and procedures due to modesty issues" to the frequency extent as described on this blog."
If there is absolutely no negative side effects from exams and procedures involving exposure, then what was the excuse again for why medical students don't practice intimate exams on each other?
Jason K
A couple comments:
1. I agree with the expressed opinion that while the so called "outliers" may be those who aggressively avoid medical care due to modesty issues, there is a significantly larger percentage of the population that is very uncomfortable with intimate exposure, especially to those of the opposite gender. While they might grit their teeth and go along with it, I believe the vast majority would opt for same gender care if it was offered as an option.
2. While patients speaking up is important, it is only half of the solution - providers need to recognize the patients' concerns and have an open dialog as how to accommodate them. While there are some physicians like Dr. B. and Artiger that obviously do care, in my experience and that of many relative and friends, there are many more that don't, and when the patient does speak up, react in a condescending and sometimes verbally abusive manner such as Jason described. In fairness, this appears at face value to be more a problem with the support staff than the physicians themselves. That said, the physician is still responsible for the behavior of their staff.
Hex
Forced or coerced nudity is internationally recognized as a form of psychological torture.
It's not something new and dates back millennia. More recently the Nazi's used it, and the US has used it in facilities such as Abu Gharib and Gitmo.
IMHO, whenever a medical provider or staff member reacts to a patient's expressed concerns with bodily exposure with condescending or demeaning comments such as those described by Jason and others, they are attempting to intimidate the patient into complying, and in so doing are engaging in a form of psychological torture of the patient.
Blindsiding a patient by failing to inform them ahead of time of any expected exposure requirement and them hitting them with it at the last second isn't any better, IMHO.
Likewise, failing to get a patient's explicit prior informed consent prior to allowing non-essential personnel such as students or others to observe a procedure falls into the same category.
These things must stop.
Hex
Hexanchus, I have always been a supporter of informed consent by the patient and that is what we are teaching our medical students from the first day in school when they are to interact with a patient. Informed consent should be available to every patient except those unconscious and need of treatment and in those cases appropriate surrogates should be deciding for the patient. Even the demented or those whose capacity to make their own medical decisions is found wanting still must be verbally informed regarding what is to occur and their responses should be attended to appropriately.
There is no need for physicians or nurses to intimidate their patients. Patient intimidation is not part and should never be any part of a medical or nursing curriculum or protocol. Patient may be in sufficient distress by their illness and need not to be stressed further by intimidation.
Compliance is accomplished only through education and facilitation (making it easier for the patient to comply if the patient desires.)
By the way, in practice, if full compliance cannot be established, partial compliance may still provide benefit to the patient. But as I said, that still requires education and facilitation. (An example of the latter which has occurred on my watch, if the patient is shy fully exposing her breasts for a cardiac exam, placing the stethoscope head under a loosened bra or having the patient elevate her breast herself for examination beneath it can still be of value. } Medical management of the patient need not always be "all or none" and there is always opportunity to compromise with the desires of the patient. ..Maurice.
Dr. B,
I actually submitted two posts a few minutes apart - don't know what happened to the first post.
The first item in the post was a comment relative to the "outlier" discussion.
Essentially what the 2nd item in the post said is that I appreciate the attitude that both you and Artiger and providers like you show when patients indicate they are uncomfortable with a situation requiring exposure by engaging the patient in a conversation to come to some mutual agreement as to how to proceed as you most recently commented. This is how it should be.
What I also said is that in both my experience and that of many friends and relatives, what happens far too often are condescending, sarcastic or disrespectful remarks such as have been described by Jason and others. In my experience, the majority of these remarks do not come from the physician, but from support staff. Regardless, the physician is responsible for the conduct of their staff and should set clear expectations of how the staff is to interact with the patient.
Hex
Maurice,
At what point does "I can't treat you, you need to find another provider because you refused to allow to..." Become intimidation?
When dealing with matters such as healthcare should not there be a higher threshold?
Is "my way or the highway" ever intimidation? What is helping find another provider; handing the patient a phone book? A list of other providers that will not take the patient's modesty issues in to consideration either?
Then the patient is coerced into consenting and the provider thinks that nothing is wrong.
I think that half of the problems providers have they did to themselves. I am not saying ALL providers did it, I am saying that they did not police themselves. I would also fault the system that discourages dissent.
I think that it is more a bad system good providers are stuck in.
HIPAA was enacted because there was a need. People are refusing to vaccinate due to the responses they have (not) received over their concerns.
Providers have to make certain disclosures about "financial interests" that may affect care. Gifts from pharmaceutical companies have been limited.
I do not agree with these reforms the way they were enacted, BUT there was (and still is) a need for (correct) reform.
What do you
Banterings, when I wrote ?Medicine absolutely does not recognize "PTSD, emotional trauma, psychological trauma, etc" are possible side effects of professionally performed "exams, treatments and procedures due to modesty issues" to the frequency extent as described on this blog", I have no documentation including Bates and the other resources. It's all based on my own experience both as a physician and as a medical school teacher: I have never heard of all these effects caused by professionally performed treatments and procedures and was never told by my medical school superiors to warn students that these conditions arise in the vast majority of patients as suggested here on this blog thread. If this damage was going on for decades and beyond, surely this warning would be heard by all physicians, all medical schools and all teachers. I haven't heard any of this throughout my medical practice and teaching until 9 years ago and continuing to the present and where from? This blog thread! That is my only reference. ..Maurice.
Maurice,
And we did not know about the heartland virus 9 years ago either, but it doesn't mean that it don't exist. Some diseases are driven by technology; mesothelioma from asbestos, the phobia of of flying from airplanes; remember thalidomide?
I don't think it is in the vast majority of patients, unless you meant the majority on THIS blog.
I also think that most of the people who have issues are not from professionally performed exams, at least by today's standards. Just as your example with swim class being in the nude.
There is a reason they don't do that today. I am sure that there are some of your classmates that have modesty issues today.
It use to be commonplace for pediatricians to just have the child in their underwear (panties/briefs), if not naked for the whole exam with the parent in the room for the entire exam. Why is this not acceptable today?
The use of chaperones is also relatively new. Why do that now?
Obviously healthcare has recognized that there WAS something wrong with the way things were done.
Going back to "performed professionally," I think that there was "unspoken" intimidation. The parent forcing the child to comply, if not "you deal with your father when he gets home from work." The parents assumed it was acceptable due to a blind obedience.
This "blind obedience" also permitted many other abuses to continue: spousal, alcohol, sexual, etc. the victims rarely spoke out because they were not believed or upsetting the way things "should be." Collateral damage to people was their own fault due to weakness.
Nurses wearing scrubs today (as opposed to the traditional uniform) was just as much to infection control as gender (male nurses), as nurses feeling sexualized and objectified.
I remember reading something that discussed the power imbalance with physicians in suits and ties.
Even today, consultation and history occur with the patient dressed an desperate from the exam.
I am sure that there is no disputing the following 2 facts:
1.) Mental trauma, PTSD, etc. can occur from exams/procedures performed in an unprofessional manner.
2.) What was considered appropriate and professional 10, 20, etc. years ago, would be UNACCEPTABLE today.
You do the math from there....
--Banterings
Thank God for the internet and the instant sharing of information. It's very hard for someone to keep things quiet anywhere in the world now. They used to be able to bully you into silence but not anymore. Most businesses will send you a email and ask how did we do. Why doesn't the medical field do the same ? I think things started changing about the time people got connected and started to share information. Take care. AL
Dr, Bernstein, when I asked, are you saying that providers are so oblivious to patients being uncomfortable it isn't even worth asking...I was referring to providers asking, not patients. When a male and a female tech are available to do a scrotal ultra sound, is it really reasonable to say they they are so oblivious that it MAY be uncomfortable for the patient that they don't even need to ask the patient if they care or have a preferance. Would they be so oblivious if a woman was having a pelvic exam, would they even pause to have a male nurse assist a male gyn? If they are so...why ask about medical students attending? My point was, I do not think the patients whom are uncomfortable with exposure to opposite gender providers are outliers, yet there is an effort to include us with those who avoid care at all costs when defining outliers. I was one of those who covered their discomfort and I think that is the rule rather than the outlier. That was what I was asking. If you are saying providers are so oblivious to this discomfort that they don't even think to ask, why do we accomodate the woman by loosing her bra for the leads instead of having her remove it? And if it can be done by loosing it instead of removing and exposing...why isn't that offered ny the provider. I think many providers wear provider blinders so they can interpet what they see in a way that makes them comfortable. They don't want to see the damage or the danger so they accept the
SOP. Why haven't providers recognized this in the past, good question. I think partly because patient focused care is relatively new replacing patriarcial medicine. Patients are just now realizing we are more important than providers in the equation. We should no longer blindly accept what is offered, First is was second opinion, now it is our opinion. If providers are so oblivious why are there so many inconsistancies? Why is was there an lawsuit that said providers could discriminate against hiring males in the ob for the comfort of female patients? Why are there accomodations for females getting pelvic exams? Mamographers are female, why? I think providers are more in denial than ignorant. Why do providers come up with their own version of how to handle this what you say, what words, etc if they are unaware that patients are uncomfortable? That is my point, I do not believe patients being uncomfortable with opposite gender exposure is a minority, nor do I believe providers are completely oblivious to it, I do however believe they live in a state of denial, concious and subconciously....don
don,
I think I can answer this as why providers are oblivious:
Note: I do not say this in a derogatory way, but as a matter of observation...
Lack of common sense. The more intelligent and educated you are, the less common sense seems to exist.
My brother is a brilliant accountant and a gifted woodworker ( his hobby), but lacks common sense.
I was at an inlaw's house, he (electrical engineer) and his father (pressure vessel mechanical engineer) were attempting to install a new front door on his house. A total cluster.....
A computer engineer classmate was planning to replace the serpentine (fan) belt on his car. He and another classmate (an accountant) had planned on doing it on a Saturday at the accountant's house. They figured 4 hours should be enough time. I popped it on in the parking lot in 2 minutes.
Teaching is part of what I do now. I have grappled with trying to figure out how to teach common sense. I have found that the best example of common sense are farmers. You look how a farmer solves a problem, it may look half-assed! but it is done fast! it works! and is fixed with the materials on hand.
One other possibility (again I say this with no disrespect) is that physicians are not necessarily "people" persons. I am sure that we have all heard the comment that "he learned to deal with people from his med school cadaver."
That works in paternalistic medicine, but not patient centered medicine.
Patient centered medicine is an oxymoron. Physicians are created in a system where knowledge and experience is what creates the profession. A profession that uses "consults" to increase the amount of knowledge an experience in difficult cases.
Now the physician must share decision making with the "average Joe." (Remember, half of all people are below average.) this is a contradiction to everything that the physician has been taught an creates (at some level) conflict within the physician.
I am curious, what training have the other providers here received in "shared decision making" with the patient. I don't mean there is this new thing called "shared decision making" and this is what it is...
I mean "how to implement shared decision making" strategy." Was this in your formal training? Was it by your practice, hospital system, provider network, by your malpractice carrier or legal defense firm, a course for (licensing) continuing education credits, OR none at all?
Was it formal or informal training? Did you just read about it, or was there lecture too? Did you do role play as part of your training? What was the tone of the training (I.e. " pretend to listen to the patient and his choices to make them feel involved, but you are ultimately making the decision)?
I am going to let everyone in on a secret: as a physician you know the human body better than anyone else, but I know MY body better than anyone else, even you.
It all boils down to this. What is the past experience and expectation of the patient?
If a patient has seen both genders all their life for intimate care, it's normal and accepted and...expected. So, those patient wouldn't have a problem with it.
My mother, an RN was a trusted advisor of mine and I was quite comfortable with the normalcy of medical exams and never felt the least bit embarrassed or uncomfortable exposing myself in a private exam a male provider.
PTSD will not occur unless what happens is unexpected. Again, going into the past experience of the patient.
Standard of care practices sometimes violate social norms and violate patient expectations.
When that happens PTSD can and does occur.
That's why I've been preaching on this blog for a very long time that protocols need to be explained in writing. A patient can feel humiliated, embarrassed but they won't feel traumatized if they know what's going to happen to them.
That happens when the unexpected occurs. So something that seems innocent like leaving a door open can traumatize an exposed patient when they realize they are on display and looking at the people who are looking at them.
It's unexpected, humiliating, degrading, but no one could say that any abuse occurred because most likely it didn't.
Sometimes, however, this kind of treatment is used to punish patients into submission or for not cooperating and like the general population, some practitioners, physicians and others, are not of the admirable ilk that some providers deserve.
There is abuse in all institutions and sometimes those abuses are psychological torture as defined by Amnesty International.
So, while modesty is important for those who need it, the real problem is in the way patients are treated, that they do not know what to expect regarding protocols both physically and medically.
Once a violation has occurred, the patient needs change. They no longer feel safe, nor comfortable and do not want to have any repetition of an action that would make the patient feel the way they did when they had their negative experience.
I would think that every doctor would want to create an environment that protects one's feeling of safety and support protocols that support states of undress and who will be present for any test, operation or exam to prevent PTSD from occurring due to lack of the expected.
It would be interesting to see what objections our medical professional friends on this blog to doing so, and if there are objections, let's hear what they are for progressive dialogue. The only objection that is unacceptable is that they are afraid to tell consumers what to expect because use they know the patient will object. All of this should be part of informed consent, and leaving it out is simply unethical and dangerous to mental health.
Additionally, the psychological community should be the ones writing protocols for treatments that don't fit into social norms that create stress.
Lastly, previous victims of mistreatment at the hands of medical professionals, abuse victims and victims of sexual abuse, should have protocols designed especially for them. These people are not outliers
based on statistics and need support.
belinda
As an add on to Banterings last post
"I am going to let everyone in on a secret: as a physician you know the human body better than anyone else, but I know MY body better than anyone else, even you. "
I also know better than you what my comfort level is, what level of exposure I'm ok with, and who I'm willing to have in the room. (Other doctors, nurses, chaperones, students, scribes... I'm looking at all of you...)
Jason k
Belinda, no (not a single) patient deserves or should accept punishment from a physician or other healthcare provider for whatever reason in the relationship. A common issue that every doctor experiences with their patients is non-compliance. Patients should not be punished for this but educated. To punish the patient for personal or inter-personal issues is totally against what the goal and duties of the medical profession is all about and should not be tolerated. Licensing boards should be promptly notified of any behavior,in the eyes of the patient, which cannot be adequately explained by the doctor, that appears to be punishment. If a doctor-patient relationship is not working to the benefit of the patient, as with the patient moving on to another doctor, the doctor can also direct the patient to another doctor but has to do so properly so as not to demonstrate abandonment of the patient. One bad behavior of a physician is, as punishment to the patient, blacklisting the patient to the next doctor the patient has decided to see. Again, this, when discovered, is something that a medical licensing board should investigate. ..Maurice.
To PT:
I strongly suspect you are still monitoring this thread and so I wanted to invite you to continue posting. I know you disagree with some of views expressed by me but also some of the other writers here and feel that the direction of the discussion is often missing important points particularly in relation to men, their feelings and their rights. And this subject does warrant further discussion since female modesty issues have dominated discussion both here and elsewhere.
Further, though your experience, you have educated the thread visitors on the intricacies of hospital life, function and policies.
So, if you return, welcome back. ..Maurice.
belinda,
I disagree with you when you stated:
A patient can feel humiliated, embarrassed but they won't feel traumatized if they know what's going to happen to them.
Yes, the unexpected can cause PTSD, but the expected CAN cause this too. In our society "prison rape" is (disgustingly) the subject of comedy due to its prevalence and the correctional system's lack of dealing with the issue.
Based on your logic, anyone who is going to prison "knows that they will most likely be raped," therefore as a rape victim they should not experience any mental trauma.
I guess we can say the same for women in combat. (You just solved one of the biggest PR issue for the military.)
Telling a survivor of sexual assault what to expect during a pelvic exam will prevent her from having flashbacks?
My whole point is that what may be acceptable and legal protocol for a procedure, may not be traumatic for most patients, but some may experience trauma from it.
If you look at the protocols, they all say give the patient privacy to undress, put on a gown, drape, expose area being examined, etc. There is NO requirement to build trust, to question the patient's comfort level with exposure, AND resolve the issues.
It just assumes that everybody consents to the same level of exposure. This is why some providers requite the patient completely undressed for a hand procedure lasting less than 2 hours.
Humiliation is defined as a painful state of the loss of pride, self-respect, or dignity;
Humiliation is not the result of the unexpected, it is a feeling of loss of dignity. No protocol is going to negate how I feel in the jack knife position, naked from the waste down, in a room full of people.
It is how those situations are dealt with that determine if a mental/emotional trauma occurs. The mental trauma is a direct result of adding insult to the situation.
There are the issues of "power imbalance" and "loss of control" that also increase the likelihood of a mental/emotional trauma. Lowering those also lowers the chance of mental/emotional trauma.
I know that everyone is saying PTSD, but be aware there are a number of mental/emotional traumas: Generalized Anxiety Disorder (GAD), panic attacks, phobias, etc.
We train our first responders and military in the proper protocols, yet many of them suffer PTSD either as an accumulation of what they have experienced or from a single intense experience.
Further we do not train patients to survive, we expect that all will be fine and dandy. If we can't meet the level of comfort the patient requires, perhaps we can teach them to survive.
Many survivors of prostate cancer talk about the first biopsy. After multiple treatments and procedures, they have learned to survive. It also helps them reconcile the mental trauma.
Cannot we teach patients hoe "to survive" before the first biopsy?
And what about the patients who have their first biopsy and it was negative? You never hear from them, probably because they never learned to survive and are laying in bed in the fetal position somewhere.
I wonder how they look at healthcare after that?
To show to the visitors here that my motive in this discussion is not to hide facts about unprofessional occurrences but only try to present these facts though with the understanding that these occurrences though present are rare. So here is a current story from Associated Press.
..Maurice.
BALTIMORE (AP) — A gynecologist who secretly used a pen-like camera to record hundreds of videos and photos of his patients' sex organs during pelvic exams will cost one of the world's most prestigious medical centers $190 million in a settlement with more than 8,000 women.
Maurice,
No person can say that you hide anything, have a hidden agenda, etc. Your blog and posts show your transparency.
You are a philosopher in the truest sense of Socrates. You use inquiry and discussion based on inquiry (asking questions) to stimulate critical thinking and to illuminate ideas.
You will ask people posting about ideas that contradict their view only to stimulate thinking and conversation. Anyone who reads this will see that you are neutral as to legally and ethically allowable:
no (not a single) patient deserves or should accept punishment from a physician or other healthcare provider for whatever reason in the relationship.
I am not sure if you take this position for philosophical reasons, as a scholar in the quest for knowledge, for some higher purpose (enlightenment), or because your liability/malpractice carrier won't allow you.
That being said, I assume that you do see a problem with this issue since it appears more than any other on your blog.
You may have just chosen the topic for purely scholarly or philosophical reasons, I suspect that there was some event that brought to light deficiencies of modesty issues in the practice of medicine.
Being trained and educated in the medical system, there was that "ahuh moment." Just as St Paul went from persecuting Christians to being the reason Christianity is so prevalent, he had a "ahuh moment."
I am NOT asking you to confirm or deny it, it is just an observation. I would bet it had something to do with the doctor becoming a patient...
Moving on to another thought:
One way to illustrate the problem with modesty issues today is to ask a provider why they have to offer chaperones, same gender option, assurance of privacy, etc.
If their first response is that the hospital system decided this, malpractice/liability carrier requires this, it is the law, etc., this shows that they do not believe that there is a problem, it is inconvenient to them as providers, or that patients need or deserve it.
Just look at this article on KevinMD by Joel Sherman.
If the provider answers it is the right thing to do, there have been abuses in the past, people feel uncomfortable being exposed, etc., then it shows an understanding of the patient's perspective.
--Banterings
Artiger, if you are still monitoring this thread I would like for you to weigh in here. I am more than a little confused by the statement that providers are totally unaware that exposure, especially to the opposite gender is not uncomfortable. I think it is so obvious just given the situation that it would be assumed this is awkward, uncomfortable, or other. I can live with unaware of the extreme, I can live with unaware people avoid care though the saying dying from embarrassment is well known. BUT, to not realizing a guy laying on a table naked from the waist down might be uncomfortable with a female standing over him, or a woman with her feet in the stirups might feel uncomfortable or vulnerable...I just don't see how that it is possible to not at least question. From your posts it would seem you attempt to deal with this issue first with a consultation with every patient, and later with practices such as draping to minimize exposure that you feel there is at a minimum the possibility it will be uncomfortable for patients. Could you give me some insight as to why you do the things you do to address patient modesty? Not trying to play you against Dr. Bernstein but this has been a topic that has come up again and again.......don
Latest news:
John Hopkins Medical Systems agrees to a $190 million settlement in a case where ONE physician secretly took pictures of between 7000 and 8000 women and GIRLS during pelvic exams. Google John Hopkins settlement for more details.
There will be no "closure" foe the vast majority of these victims. I also wonder how everyone is so sure these images were never shared.
I guess those victims will now be considered outliers my the medical community?
DP
Johns Hopkins probably has a clause in fine print on page 18 in the "Consent to Treatment" form, that is why no charges were filed.
We will also ignore any policies that JH has and assume that the conduct was (technically) LEGALLY permissible since no charges were filed.
Although we don't know the whole story, but let's assume that other than the camera (and that was arguably acceptable), the exams were conducted in a professional manner.
I pose these 2 questions (especially to those with initials after their name):
Do you expect that these victims will suffer NO emotional or mental trauma as a result of this?
Is this acceptable behavior of your profession?
The JH gyno photographer...
Why is this guy in trouble ( I know he's dead now, but you know what I mean) for taking pictures, but others don't get in trouble for molesting sedated patients in groups? (non consensual pelvic exams)
One was "education" the other was for his own "use"? (I'm guessing that would be someones excuse)
So... assuming you were about to say that, then "what if", in addition to the pictures, they also found a thesis of his where he was conducting a study of the changes in female genitalia over race and age?
Would that make it all ok?
If not, why not?
why is it "acceptable" by the medical community to use a patient without their consent for one, but not the other?
a lot of consent forms mention you giving them permission to take pictures.
As far as I can tell, this guy was ONE half-assed "study" away from doing no wrong in the medical communities eyes.
A quote from one of the online copies of this story says..
"Many of the women who joined the suit still feel so unsettled that they stopped seeing their doctors, and no longer feel comfortable taking their children for medical visits, said Jonathan Schochor, an attorney for the plaintiffs.
"These women were, and are, extraordinarily upset, in fear, dismayed, angry and anxious over a breach of faith, a breach of trust, a betrayal on the part of the medical system," he said. The proposed deal "represents the beginning of a long healing process," he added"
Looks like you're right DP... they're now part of us rare outliers. Surely they'd have NO reason to not trust 100% in every other doctor they meet...
Jason K
Washington post is saying that the settlement deal is for 190 million for UP TO 8500 women. (the plantiffs lawyer says the number is closer to 12500 women)
190000000 divided by 8500 is $22352.94 per person
Just over 22 grand.
Ask anyone you know if getting 22 grand would "make it all better" if they found out it happened to them.
They also say it was video clips AND pictures.
And I'm guessing they're just saying they know he didn't share the pictures to try to contain the lawsuits.... all they could really know for sure was that he didn't email them from his own house. If he put them on a laptop and went to a coffee shop with free wifi, used an un-related email account like hotmail, there's no possible way they could tell.
Jason k
What is interesting in the John Hopkins case is that NONE of the pictures of the genitalia were identifiable to any specific woman. Apparently no need to black out any faces or eyes!
Though in this case, at least from what we were told in the story, the pictures were not distributed to others and/or published on social media. However, I did cover the last issue back in a February 2011 blog thread titled "Should a Non-Identifiable Picture of a Patient's Body or Tissue be Posted on Social Media without Patient Permission?" You might want to go back to that thread, read and write there.
In response to Banterings:
"Do you expect that these victims will suffer NO emotional or mental trauma as a result of this?
Is this acceptable behavior of your profession?"
My response: As far as mental trauma, it depends on how each individual woman would react to such a unique event: a photograph taken of "somebody's" genitalia and unidentifiable to that particular patient by a physician who was given permission to look at genitalia of patients as part of his professional activities at the time of the exam and without knowing the reason the photographs were taken. I would think most women, with the specifics known in this case, would say "I don't care, there is no proof any of the pictures were of me but by golly I'll certainly accept the $22,000." As far as this being acceptable behavior for a member of the profession, it would all have to be related to how the pictures were used. If it was for the doctor's own personal enjoyment then this was not the purpose of society's permission to allow inspection of vaginas. If it was for documented formal medical or anatomic study and not for personal use then that would be another matter and could well be professional and ethical. The purpose of the collection of the unidentified pictures is the critical aspect of evaluating the activity as ethical and professional. We need more facts to answer the question in this specific case. ..Maurice.
Part 1
Maurice,
You said:
photograph taken of "somebody's" genitalia and unidentifiable to that particular patient by a physician who was given permission to look at genitalia of patients as part of his professional activities at the time of the exam and without knowing the reason the photographs were taken…
…I would think most women, with the specifics known in this case, would say "I don't care, there is no proof any of the pictures were of me but by golly I'll certainly accept the $22,000." ...
Let me start with unidentifiable. I will bet most women can identify their own vagina. I know that during my college years, I could identify my girlfriends' vaginas. I am sure that the women on here could pick their's out of a lineup.
If he was taking pictures for scholarly research, then he most likely is picking those with landmarks or deviations from the norm. Even if he had a "normal, control sample," at what point do we say that identifying x of y number of pictures is too many.
By the fact that he was a doctor at Johns Hopkins, that fact IDENTIFIES a specific subset of the population.
I would think most women, with the specifics known in this case, would say "I don't care, but you DON'T KNOW. You are so careful to tread lightly with the number of people who have baggage about modesty issues, but you assume here. I think that this is your own prejudice from being in the medical system.
Is the money about indemnifying these people or about preventing it from happening again? If "documented formal medical or anatomic studies" are so important, why not be totally upfront?
Just say "I am going to take pictures of your vagina for a documented formal medical study, you will not be identifiable, and you cannot really refuse because it furthers education."
Where are you going?
Finally…
This is the self-serving concept of "it is easier to apologize than to ask permission" that business , government, and institutions have adopted.
Part 2 to follow...
Part 2
Maurice,
You said:
...the purpose of society's permission to allow inspection of vaginas. If it was for documented formal medical or anatomic study and not for personal use then that would be another matter and could well be professional and ethical.
It assumes that the practice on medicine's rights trump my own inalienable human rights afforded me by my Creator and my civil rights guaranteed me in the Constitution and the Bill of Rights.
( I mean no disrespect by the following references: )
It was this thinking that permitted Josef Mengele (a physician) to justify and conduct his documented formal medical studies in Auschwitz concentration camp during World War II. Up to his death in February 1979, he never apologized for the atrocities that he committed because he saw nothing wrong with what he did. "Society had the right."
Unit 731: a biological and chemical warfare research and development unit of the Imperial Japanese Army (1937–1945) Note: Dr. Shiro Ishii (head of medicine) was granted immunity from his crimes, in exchange for his documented formal medical studies.
1960's: Injecting Prisoners with Agent Orange: While he received funding from the Agent Orange producing Dow Chemical Company, the US Army, and Johnson & Johnson for a documented formal medical study. Dr. Albert Kligman used prisoners as subjects in what was deemed “dermatological research”. The dermatology aspect was testing out product the effects of Agent Orange on the skin.
During these proceedings, Kligman was reported to have said:
“All I saw before me were acres of skin… It was like a farmer seeing a fertile field for the first time.”
Infecting Puerto Rico With Cancer: In 1931, Dr. Cornelius Rhoads was sponsored by the Rockefeller Institute to conduct a documented formal medical study in Puerto Rico. He infected Puerto Rican citizens with cancer cells, presumably to study the effects. Thirteen of them died.
What’s most striking is that the accusations stem from a note he allegedly wrote:
“The Porto Ricans (sic) are the dirtiest, laziest, most degenerate and thievish race of men ever to inhabit this sphere… I have done my best to further the process of extermination by killing off eight and transplanting cancer into several more… All physicians take delight in the abuse and torture of the unfortunate subjects.”
If research is so important, why are physicians and medical students compelled to participate? By the nature of visiting a provider, patients are compelled to participate.
--Banterings
Maurice... Within your post you said 3 key things....
"What is interesting in the John Hopkins case is that NONE of the pictures of the genitalia were identifiable to any specific woman. Apparently no need to black out any faces or eyes!
a photograph taken of "somebody's" genitalia and unidentifiable to that particular patient by a physician who was given permission to look at genitalia of patients as part of his professional activities at the time of the exam and without knowing the reason the photographs were taken.
As far as this being acceptable behavior for a member of the profession, it would all have to be related to how the pictures were used. "
Are you ****ing kidding me?
What world do you live in where it's ok to take pictures of someone naked without their permission???
And sure... you seem like a nice enough guy... and sure I disagree with some of the things you say, as they come off as dismissive or as making excuses for the medical community doing what they want for their own convenience .... but if you honestly think it's cool to take pics of someones body without their permission... if it shows the face or not.... tells me you honestly DON'T get the modesty thing.
If you... one of the **champions of patient modesty amungst your associates** is saying there's a context where this is fine, then I'm sorry... but I really hope you were trying to be funny with that post.
Jason K
There is no aspect, no justification, no reasonable excuse can be made for what this man did. Dr. either you are just trying to stimulate conversation or this is an example of how medical arrogance can explain a larger portion of what we see as a problem than I first thought. For anyone to even suggest this is in anyway ethical is ridiculous. By golly I think i will stick some cameras in some public bathrooms and as long as i don't film faces no harm no foul. So if this can be justified, is it any big surprise our modesty is routinely ignored? don
Jason, calm down. I was considering the case from an ethics theory point of view and not a final conclusion since we do not have all the facts of the case.
Physicians are given the permission by society to inspect genitals, of course, with the patient's permission. Ethically, if a physician takes a photograph with the intent to be used for the medical benefit of that patient that is also acceptable. That is because a photograph can be a part of the process of inspection, evaluating the patient in the patient's absence. So that could part of the initial permission. If the taking of the picture is NOT for the medical benefit of the patient but is for the physician's self-interest, whatever that might be OR the picture was taken without the patient made aware then this is NOT acceptable and the physician is not protected by the patient's previous consent or society's approval and is unethical. The fact that the pictures are unidentifiable now has nothing to do with the ethics of the act since at the time they were identifiable to that doctor.
In this case, we don't have all the facts but we can be highly suspicious that what the doctor did over the years was secretive, and not for the patient's benefit, and not for society's benefit as some sort of medical research of medical value and easily could have been for his own personal sexual benefit. This, then, would be unethical and apparently had legal consequences.
My comments are not about modesty but about the ethical and legal aspects of a physician given permission for the act of clinical inspection as part of the physical examination.
Jason, if you think that taking a photograph for the patient's benefit only and with the patient's awareness that is being taken is not part of permissible act of inspection, then we should debate further. ..Maurice.
Don, as I tried to explain above, my commentary is NOT about taking pictures in public bathrooms but that a physician taking a photograph of a patient's body, with the patient aware, for only the benefit of the patient and for no personal benefit for the doctor, in itself is ethical and represents what is termed within the physical exam as inspection. No permission is given by society or the individual and there is no value to the individual using the toilet to be photographed in the act and is legally impermissible as a intrusion on privacy. ..Maurice.
Maurice,
with respect to the last comments of both you and Jason, that issue is being debated in the public arena with Google Glasses (glasses with a built in web cam).
People have been assaulted for wearing them, even public places. I think that this speaks to the public's acceptance of being recorded.
Then there is the issue of flying drones.
Finally let's look at the Supreme Court's decision about cell phones and personal privacy.
Looking these at a whole show that society as a whole expects privacy and will push for it. The issue of the GG and drones directly affect our modesty and the imaging of our bodies.
I believe in Volume 66, someone mentioned girls posting FaceBook pics of themselves on the toilet:
The key difference is that they are in control of their own image. These very people may oppose to be imaged by drones but post pics naked on FB.
If you have been following this blog it makes perfect sense. It is truly self-determination.
You can't compare the TSA screening, because there is a backlash there too. Anybody who flies regularly knows that everything done after 9/11 was only to make people who don't fly regularly feel safe.
The TSA worries about nail clippers, yet the Ontario CA , airport has a wine store that sells "corkscrews" that have a knife blade for cutting the foil.
I would say society agrees with Jason. Your point of view equates "visualization" (see it and it is gone) with a "permanent record."
Secondly, does you standing in front of a window in your house constitute consent to photograph you?
Is your daughter walking down the street in a miniskirt consent for an "up-skirt" photo?
What about me taking pictures of her naked (walking down the street) using an infrared camera that can film through clothing? (Reference: http://abcnews.go.com/GMA/story?id=126782)
So do we expect more or less privacy in the exam room of our physician than walking down the street.
Maurice,,, go re-read my last post... I emphasized a few times that it's taking pics WITHOUT the patients consent.
The gyno doc was using a hidden camera built into a pen, so of course it was secretive without anyones consent or awareness.
There is no possible way you can honestly justify this is any way shape or form as being ethical and keep a straight face.
IF the patient was aware the pics were being taken, that would be an entire different conversation, and merely akin to the same argument as stripping down for a doc of the opposite gender or being naked for surgery.
but that has nothing to do with THIS case.
Jason K
Jason, you read my post. I said the patient must be aware that a photograph is being taken otherwise to take it secretly would be unethical and not part of the implied or direct permission the patient gave the doctor for bodily inspection (part of a physical examination). ..Maurice.
Maurice...
" how each individual woman would react to such a unique event: a photograph taken of "somebody's" genitalia and unidentifiable to that particular patient by a physician who was given permission to look at genitalia of patients as part of his professional activities at the time of the exam and without knowing the reason the photographs were taken."
How you worded that implies that the doc either whipping out a camera, or wearing a hidden spy camera is a normal part of the every day exam.
If I have a problem with my penis, and go to a doctor, sure... I'm going to have to accept that they'll have to have a look at it... but that does NOT automatically include consent to snap pictures of it, regardless of their reason.
"Physicians are given the permission by society to inspect genitals, of course, with the patient's permission. Ethically, if a physician takes a photograph with the intent to be used for the medical benefit of that patient that is also acceptable.That is because a photograph can be a part of the process of inspection, evaluating the patient in the patient's absence. So that could part of the initial permission."
Absolutely 100 % wrong. I'm sorry, but I whole heartedly disagree with this. IF the doc asks for permission to snap pics, and explains why, then I might say OK. Just because I go in for an exam does NOT give the doc free reign to do whatever they want.
"If the taking of the picture is NOT for the medical benefit of the patient but is for the physician's self-interest, whatever that might be OR the picture was taken without the patient made aware then this is NOT acceptable and the physician is not protected by the patient's previous consent or society's approval and is unethical."
This is the first time you mentioned the patient being aware of the photos... the post previous basically was worded so that just going in for an exam gave the doc permission to take secret pics, as long as there was some medical tie in.
Doesn't matter if it's "for the benefit of the patient" or not... if they don't have SPECIFIC permission to take pictures, they should be considered as breaking the law. It really is no different than the upskirt pics Banterings mentioned.
The ends do not justify the means. Just because it might "benefit the patient" does not make it ok to take pics of them without their permission, any more than trying to justify the non consensual pelvic exams by saying "one of the students might find something their regular doctor missed", or "the student might save this or another patient later, so it's acceptable now".
And I can tell you this... if a doc ever took pictures of me without my consent, I honestly would be paying them a visit at their home, and it would not end well. (and yeah... I know where both my dermatologist and my family doctor live)
Jason K
So you have decided to censor my comments? I stopped posting months ago when my comment went unpublished. There was nothing in that comment that was slanderous, untrue or vulgar
I posted a comment yesterday at around 4:30 AM regarding the John Hopkins settlement and again, no publication. Instead, you comment on it.
Why are you censoring my comments Dr?
DP
Dr,
My apologies on my last comment. I see that I was published but have often wondered why you chose not to publish my experience and comments regarding my surgery at an ambulatory surgery center that was unidentified. I was turned off to further commenting and only recently looked at your blog again
DP
Why are we even debating this? The fact that there were minors included in this doctors photo library indicates that more than vaginas were included. Unless, of course, you can tell the difference between a 17 year olds vagina and an 18 year olds vagina.
The fact that this doctor committed suicide speaks volumes as to his guilt. Finally, there is the little issue of $190 million.
Also, these women will get far less than $22,000, as legal fees (30 to 40%) will be educated first and of course, the women involved will NEVER know or see their personal photographs. Can you imagine? Uh, excuse me, is this your vagina, or is this one yours? HIPPA alone will make sure that.never happens!
Glad this has sparked the conversation it has.
DP
PT - "Why are we even debating this? The fact that there were minors included in this doctors photo library indicates that more than vaginas were included. Unless, of course, you can tell the difference between a 17 year olds vagina and an 18 year olds vagina."
Of course there would have to be faces included in the pics AND VIDEOS (there were vids as well)otherwise the hospitals lawyer would have to make them drop their pants and spread their legs to a court appointed doctor... (or sherrif if you recall when Michael Jackson had to let them take a picture of his penis) to prove they were one of the ones violated and entitled to be part of the lawsuit.
ALSO... like I said earlier... there is absolutely NO way of knowing if they were shared or not. A file does not keep a log in itself of how many times it's been copied.
ALL they can tell is if he sent them out through his own home internet / email or work internet / email.
There is NO possible way of knowing if he put them on a flash drive or dvd and handed it to someone else to upload, or if he used a laptop at starbucks or somewhere with free wifi then just reformated the laptop.
"Finally, there is the little issue of $190 million.... these women will get far less than $22,000, as legal fees (30 to 40%) will be educated first"
$22352.94
40% of that is 8941.176
22352.94 minus 8941.18 means each woman would get a max of $13411.76
Jason K
Again, to remind everyone, inspection is an element in the examination of a patient. Inspection is performed by the physician's eyes, photographs, X-rays, CAT scans, ultrasound visualization, and MRI. Some do not require a written consent but only that the patient is aware and provides implied consent. Whether the inspection is ethical or legal depends on whether the patient is aware and that the inspection was performed for the best interest of the patient and for no other person's interest including self-interest of the physician or the tech doing the imaging. For example, the real case of the resident surgeon who took a picture on his phone of a patient's penis (tattooed, I recall) while the patient was still unconscious and later showed the picture to his colleagues was of no benefit to the patient and was only for the doctor's own self-interest and was definitely unethical and most likely illegal as a civil act.
My postings here were in no way to defend that John Hopkins hospital gynecologist and I agree that based on whatever incomplete facts regarding the case which we had read, a most likely conclusion was the doctor's actions were unethical, unprofessional and obviously illegal from a civil point of view as witnessed the large settlement of the case by the hospital.
..Maurice.
It wasn't so long ago on this blog that both Dr. Bernstein, Don and others made a big deal about my postings adding that abuse is not part of the problem and that this modesty issue was separate.
Clearly, unless these women consented to being photographed at Hopkins, what happened was without informed consent.
Additionally, forgetting about who might be recognized and who isn't from the photographs is irrelevant.
What does this experience do to those who experienced it regarding their future experiences, developing a sense of distrust, and avoidance of medical care? They may be traumatized or even if their feelings have changed, 23K wouldn't make a dent in the therapy required to give these patients some semblance of a "new" relationship with the medical community.
So, I ask again, and Maurice, I would appreciate hearing from you, what responsibility does the medical community have to protect patients who have been victimized by the system? What protocols would be helpful?
My colleague, a ph.D. in Health Psychology, talks about how healthcare is becoming more patient centered and that the field has opened up for protocol change, etc. by Health Psychologists. I have encouraged her to post here on a professional basis to advocate for change.
Banterings, I think you misunderstood when I said, "one has to have something unexpected happened to trigger PTSD". Abuse in any way, whether you know it's going to happen, or does not happen, doesn't apply to that statement because abuse is a trigger for PTSD.
What I was referring to is the knowledge of those psycho-social issues that could cause emotional trauma and what to expect. Such as, who will be in the room, the gender, bodily exposure required, etc. You know, the issues that are never now posted on consent forms.
Medical care is in the infantile stages of looking at people as such, instead of objects as part of their work day.
It boggles the mind of non medical personnel how they wouldn't understand being naked in front of a group might be traumatic. It's just common sense. They are trained to ignore it. Part of that training is due to the necessity of de-personalizing patients in order to treat them without burn-out. Imagine, every doctor, getting involved with every patient and their families. Illness and death are part of life and when this is your livelihood, this presuming lack of empathy is a protective mechanism to help them do their jobs.
The Health Psychologists must emphasize the damage, both physical and mental to patients who have been victimized. There is a connection.
This issue of basic human rights of dignity and privacy must be at the foundation of how the healthcare system operates.
Patients have been stymied before the internet and this issue is not as "outlier" as one might think. It's much more common, just like rape or any other kind of institutional abuse, whether it be the church, mental hospital, prison, or the medical establishments. We need a new foundation to promote mental health, while treating physical ailments.
You can't separate the modesty issue from the abuse issue. Whether the door is left open on purpose, or accident, it's the same as friendly fire. The patient has still been humiliated and perhaps traumatized.
Furthermore, some of the medical practices required for treatment just further humiliation such as preps for surgery done in a public forum in front of an audience, lack of proper draping that is seen all the time in healthcare. Unless consequences and strong ones are upheld, this behavior will continue at the patient's detriment.
Never a victim, always a protector of myself and others on this issue is the way I choose to live my life. Once, was once too many and I will fight and withhold medical care if it doesn't treat me the way I command. It is highly unlikely I will die due to this, and much more likely that I will survive in a healthy way on my own terms.
belinda
I understand Dr. Bernstein but my point was this is an example of how providers expand consent to meet their wants. I related how I was laying on a table, naked other than gowned, waiting to be sedated for a very personal surgery and the nurse walks in with a clip board and starts whipping through the consent forms, this gives us permission to share with the insurance company, this permission to treat, this permission to do these mundane and related items, and very matter of factly tossed in this one gives permission to film the procedure...at which point I froze pen in mid air and looked at her with I assume a horrified look because she said oh it is really nothing, rarely ever happens we might use it to refer back if there was a complication. Should I in the future assume then that this permission would include the members of the medical community to take a copy of that tape home with them? To add it to a collection? Ignore the how obvious it is what happened here, what reasonable expectations should we have that our providers will communicate fully and honestly with us what exactly they intend to do with images. You are correct we do not know the specifics of this case but I think it is so obvious I don't see how anyone could possibly see a scenario where if not illegal it did not violate patient trust by taking these pictures in this manner. The fact that providers would attempt to come up with a scenario that might be possible justification shows the problem. Would a provider taking pictures to a cocktail party and sitting down having drinks and showing the pictures to other MD's and nurses and saying what do you think of this vagina? ethical? The issue of consent by patients and the expansion of what it means by providers is to me the root of the problem. You gave consent to treat so you gave consent to expose you to whom ever we see fit, even if it might cause you embarrassment and there are options that would reduce that. You gave consent to be exposed to the MD so you gave consent to be exposed to their receptionist if the MD wants to use her as a chaperone.
What this says is bigger than the issue. The medical blinders providers apply to practice to expand the meaning of consent and justify THEIR opinion or right and wrong to the point where almost anything can be justified is THE problem.
Maurice - other than keeping track of skin lesion / moles, or for before / after pics for cosmetic procedures, what procedures would benefit from plain old camera photography?
And have you ever just pulled out a camera and started taking pictures of a patient without telling them first, since them being there in the first place is apparently implied consent?
Belinda - "Furthermore, some of the medical practices required for treatment just further humiliation such as preps for surgery done in a public forum in front of an audience, lack of proper draping that is seen all the time in healthcare."
Just imagine if you were able to bring a trusted loved one with a camcorder with you who never left your side, and violations of this sort made not only the hospital, but the doctor / nurse / orderly / tech responsible for the "accidental" violation legally & criminally liable....
As far as i'm concerned, exposing a patients uncovered body to any POSSIBLE viewing by non-necessary people should have the same criminal penalty as if some random guy was walking down the street pulling womens tops ups / pants down.
If the entire procedure was filmed by the patient, then the patient would know the tape would never be "accidentally" leaked online, and they'd have an unedited copy for their lawyer, and the hospital wouldn't need to worry about keeping thousands and thousands of tapes. It would also eliminate the "one patients word vs the team of staffs word", and the "oh, they were just hallucinating from the sedatives" line.
The sterile environment excuse doesn't hold up either... the friend can be scrubbed up just like any other person going in, and the camera can be encased in a thin clear plastic bag.
Jason K
Jason you wrote "other than keeping track of skin lesion / moles, or for before / after pics for cosmetic procedures, what procedures would benefit from plain old camera photography?
And have you ever just pulled out a camera and started taking pictures of a patient without telling them first, since them being there in the first place is apparently implied consent?"
Off hand, I really don't know other than documenting surgical findings for the patient's record or for later publication (the latter, of course, with the patient's permission.)
The only photograph which I took of a patient was a skin rash on arms which I was unsure of the diagnosis and which I wanted to review with a dermatologist. I explained to the patient the basis for the photography and he agreed.
Otherwise, I don't recall any other incidents.
..Maurice.
"The only photograph which I took of a patient was a skin rash on arms which I was unsure of the diagnosis and which I wanted to review with a dermatologist. I explained to the patient the basis for the photography and he agreed.
Otherwise, I don't recall any other incidents."
And did you hide the camera and take covert pictures, or just pull it out and start snapping away...... or did you explain what you were doing before hand and why?
Jason K
Jason, this was just within the past couple years and I used my smartphone to take the photos. And as I wrote I explained to the patient why I want to take the pictures and how I would use them for consultation and he agreed. I even showed him the pictures I took.
We should remember that not all picture taking in medicine is devious, sexually oriented and any harm to the patient, physically or emotionally. And the description of my use of photography is a good example. ..Maurice.
Maurice,
Bravo on generating discussion.
I did a post on my blog that is a satyrical look at the process of an insurance broker providing a medical practice med mal/liability insurance. I believe that this is an issue that many providers will understand.
The practice partner is treated the way that many patients feel they were treated on this and other blogs in regards to modesty. I even address the photograph issue.
So I indulge you Socrates Bernstein and your contemplators of ethics, to look at Aesop Bantering's fable: A Broker Addressing Malpractice As Medicine Addresses Modesty
Hello, I am new to this blog. I am a licensed psychologist with a Ph.D. in Health Psychology so I believe I have expertize in this area. My doctoral dissertation was on the doctor/patients relationship, specifically the effect of front office personnel on this relationship. I have however done lots of research on the doctor/patient relationship and treated many people with PTSD.
As Dr. Bernstien stated, the AMA does not recognize that a medical procedure may cause PTSD, however, the American Psychological Association does not rule this out. The trauma leading to the PTSD is defined by the effect it has on the recipient. At one time, PTSD was a diagnosis restricted to those who were subjected to the trauma of war. It has been expanded to any situation where a person feels their psychological integrity and well being is severely threatened. Therefore it is not the event itself, per se, but the effect on the person.
If a person, because of their history or mental state feels psychologically traumatized to a point where they begin to destabalize they may suffer a Post or a Traumatic Stress illness. This is a condition requiring treatment. This is an ongoing condition that requires accommodation by the medical community and needs to be recognized as such.
The problem is that the medical community, by in large, fails to recognize this need. They need to be more in tune with their patients and do less talking and more listening. There is no one set of rules that fits everyone. Practitioners need to be cognizant of the needs of their patients. They need to be open to accommodating to those patient's needs and listen, listen, listen.
As far as practitioners who misuse their power and abuse their patients, they need to be delicensed and prosecuted. Caring for an individual's modesty and privacy needs to be a priority in medical practice.
Dr. Linda E.
Don't say that I am hiding "bad doctors". Here is an example of an anesthesiologist who behaved worse than simply collecting a bunch of unidentified genital photographs.
What I am saying is that all doctors, if they are not aware, should be aware of these criminal doctors who pop up here and there and so to understand why patients reading and hearing the news about these doctors can look with some fear of the medical profession. This is all about the fear by patients of criminality in medicine, however I am not sure this really has to do with natural ,common physical modesty issues. You want to debate my last statement? ..Maurice.
By the way, you can thank the anesthesiologist that I am communicating with on Medscape as the one who provided me with the above link. He noted to me on Medscape Forum: "Oh ,, there are much Much MUCH worse things that happen that should keep your blog participants awake at night." I think he was referring to that anesthesiologist in the above link compared to the eye doctor or also Dr. Sparks behavior
... remember Dr.Sparks? ..Maurice.
p.s- thanks to Dr. Linda E. for her contribution above to the discussion here on PTSD in the doctor-patient relationship.
Dr. Linda E.,
Thank you, thank you, thank you!
Please stay around and comment some more.
Can you cite where the APA recognizes this?
A couple other points (feel free to comment on):
PTSD (use to call it "shell shock") is not the only potential trauma, there is a whole possible spectrum: specific phobia, GAD, trust issues, body issues, avoidance (of care), etc.
Would you consider issues of trust of providers a "Traumatic Stress illness?"
I really cannot speak to the gender preference issue since I don't want anybody touching me.
What frustrates us is that the medical community refuse to see this, yet live by a double standard.
It is unethical for med students to perform intimate exams on each other, but expect patients to be OK bearing all to a room full of students then justify intimate exams on anesthetized patients.
It is self serving and unethical for them to fail to recognize this, especially with the evidence staring them in the face.
You very diplomatically say:
If a person, because of their history or mental state feels psychologically traumatized to a point where they begin to destabalize they may suffer a Post or a Traumatic Stress illness. This is a condition requiring treatment.
Agoraphobia is obvious for the need of treatment. Would you say that someone demanding same gender care needs treatment due to a past "traumatic" event involving modesty issues?
What about the patient refusing to take his underwear off for outpatient hand surgery? Just because healthcare does not think it is necessary, is this a trigger for treatment?
Since you have some expertise on the doctor-patient relationship, any insights on why they refuse to recognize this?
Is this not contrary to the purpose of the AMA?
I guess that is what the APA is for...
--Banterings
I personally know at least 17 people that own pitbulls. They're all gorgeous animals with responsible pet owners. (ok... a couple of the dogs are dumb as posts... one hasn't grasped the concept of glass and keeps walking into the patio door...but still friendly as hell)
Every time there's a mauling, the media reports it "without all the details".... but these attacking dogs are in a vast minority of the overall pitbull population.
Some of them are only bad due to the training they've received.
Quite a few non-pitbull owners are afraid of pitbulls or simply doesn't trust them due to the few bad apples they hear about.
The average non-pitbull owner likely hasn't been attacked by one, nor knows anyone who had been.
I wonder if they should be labeled as being in need of psychiatric treatment?
I wonder if Dr Linda E is aware that most of u here have indeed been "bitten" by bad doctors / nurses / medical personnel of some sort... maybe not to the extent of national story, but enough that if it were a dog that scarred us, nobody would say we needed treatment for not trusting ANY dog afterwards.
Jason K
"
What I am saying is that all doctors, if they are not aware, should be aware of these criminal doctors who pop up here and there and so to understand why patients reading and hearing the news about these doctors can look with some fear of the medical profession. This is all about the fear by patients of criminality in medicine, however I am not sure this really has to do with natural ,common physical modesty issues. You want to debate my last statement? ..Maurice."
It's two separate but intertwining issues.
I don't trust "Dr A" to protect my modesty at the sacrifice of his / her convenience or sheer stupidity (closing a door really that hard to figure out?) ...convenience or stupidity being the least "bad intent" reason for the violation....
Just think... you're butt naked except for a gown that doesn't actually close, sitting on a table...
IF the doctor wanted to fill the room with "justifiable bodies", there would be...
1 - the doctor
2 - the chaperone
3 - the scribe
4 - the nurse to assist
5 - Another doctor for a consult
6 - a med student
7 - another med student
8 - yet another med student
9 - hey look... another med student
10 - some sort of med student
11 - the 6th med student
(my second appointment with my dermatologist, I was asked if he could bring in some students... I said I was keeping my pants on but otherwise I was cool with it... he brought in 6 students, so I know it's a valid number of med students)
So... in theory, if the doctor knows best, do what we tell you because it's for your own good, you could be exposed infront of 11 (or more) people. only 3 of which would have any kind of license.
And then they start taking photos....
And that's just the modesty side.
And why wouldn't I assume the worst for the criminal side of it? when these docs get busted... the gyno photographer, the butt slapping doc, etc.... they have ALL done their crimes for years.
Like I said before... 1 bad doc has worked with how many people in the OR / chaperones in exam rooms?
Not one of those people spoke up.
That indicates a culture of abuse and acceptance from the medical side of it.
WHY on earth would I trust anyone from that world?
Jason K
All of this is very dynamic and analog.
analog is defined as relating to or using signals or information represented by a continuously variable physical quantity such as spatial position or voltage.
(The opposite is digital, either TRUE or FALSE.)
The thresholds, triggers, and trauma are constantly in flux. The mental trauma is not discreet, it is not like an infection that is infected or it is not infected.
It is diagnosed by observation of actions: is it interfering with daily living?
A provider and patient both having stressful weeks and the frustrated provider saying "we are professionals, seen it all" is the difference between traumatizing the patient or not.
All protocols followed, but that phrase makes the patient feel marginalized. Now this patient is not traumatized to the point he avoids care (yet), but his next experience can either reinforce the trauma or "reverse" it.
You may say the protocol says "make the patient comfortable," but what is that? How many providers would say that means give the patient a gown and privacy to change.
Think back to the days of the "strip-as-you-go" exams: can anybody here say they were DIGNIFIED?
Just because we made improvements doesn't mean we have done all that we can. We need to continuously question ourselves. Blogs like this point to more can still be done.
I know that you may argue this is impractical, unprofessional, etc. BUT assume that the same congressmen who came up with the ACA enact this:
How different would the procedures be if the provider had to be in the same state of exposure as the patient?
The motives of the Johns Hopkins case is probably very clear. The doctor committed suicide.
If he had any medical reason for taking, keeping and having those photos on his home computer (joke),
he likely would have defended his
position, not kill himself.
Many were minors.
What practical purpose would taking photographs of genitalia do to enhance medical education.
Can you see cervical cancer.
Chances are, externally all these photographs were within normal limits of healthy tissue. And...if it were for a medical purpose, what's with the secret camera?
How many cases are reported. This doctor just created 8500 more people who will forever question the integrity of medicine. Had this doctor been tried, I'm sure the punishment wouldn't have fit the crime based on the continuing suffering of 85000 people who trusted the medical system.
Furthermore, I do not believe that this activity was such a "secret". Anybody who knew is just as culpable.
What a shame for all the good, decent medical professionals of whom there are many.
belinda
The fallacy of "non-identifiable" is:
If the original picture identifies the patient (whole body pic), and is blurred out, cropped, pixelated, etc., there is no guarantee that the original is deleted. A good researcher will keep all "raw data" incase the data, methods, or results are called into question.
If the picture is already non-identifiable, then it is "referenced" so the researcher can identify where it came from, date, notes, etc. Again, incase the data, methods, or results are called into question.
Some people can identify their own and other people's body parts. Consider tattoos and other body modifications. Finally there are generally 2 distinct groups in research; the control and the deviation. The control is usually the "average" (depending on the study). The deviation may be unique enough as it will always be identifiable.
Consider the following, can you guess who it is?
--Banterings
Dr. Linda E
Glad to have you with us. I have a couple of questions over and over on this blog. The first is around the role gender plays, paticularly opposite gender providers doing intimate care/procedures. A good number of posters here find this uncomfortable, embarassing, or even traumatic.. Providers down play this with such justification as the context, being professionals, etc, make it alright not only to them, but to the patient. Providers claim those who have concerns are rare and outliers. Do you have any thoughts or data on the issue and the prevelance or lack there of?
The 2nd is around providers themselves who say they have/had no idea being exposed to a member of the opposite gender created anxiety or made patients uncomfortable. I find this hard to believe.
Do you have anything you could add to this discussion?....don
Pertinent to the discussions here (genital "studies") at this time is my blog thread from July 2010 "Clitoral Sensitivity Study in Children: A Question of Ethics".
Hexanchus wrote the first response there at the time. You are welcome to continue the primary discussion there. ..Maurice.
I had an experience last night that reinforces my opinion that a lot of the issue here is for the benefit...particular ease for providers. I was visiting a family member (female) from my wife's side in the hospital. She is fully mobile, not attached IV's, etc. but was wearing those lovely hospital gowns. She leaned forward and it was a whoa look away look away moment. I found myself at risk because I was intently focusing on the TV so as not to see what I wasn't supposed to. Earlier she entered the room accompanied by a female nurse who we holding the back of her gown together. Really, in this day and age we can't come up with clothing that does a better job protecting the patients modesty? Even providers have to understand exposure to random visitors and family is uncomfortable and yet the old "I See You" gowns are still prevalent even for patients who are fully mobile, able to move clothes around, and do not have special access needs. Even when there are special needs there are garments that overlap, provide coverage and access so what possible explaination could they be for requiring patients to wear something everyone knows they hate...because it is easier and cheaper for providers. I still believe that is the driving factor that providers try to ignore and it plays out in same gender as well....don
Anyone want to complain what Google intends to do? ..Maurice.
Don,
Nobody has to wear a hospital gown. I never do, and when needed to hold a heart monitor, I cover it up with a bathrobe.
Once feeling just a little better, I graduate to flexible bottoms with elastic waist and top with sports bra for comfort and that is my hospital "get up". Never once have I heard any medical professional complain.
Additionally, when going for MRI or CT Scan, I wear no metal and don't have to change.
Any intimate test, I request same gender care (and so does my husband and gets it) and that takes care of that.
Maurice, Hurray for what Google is doing. As long as there is patient consent (and I would be one of those) anything that can catch disease before it happens it a great thing. Patient compliance and full consent must be obtained. Why would anyone inhibit medical science from moving forward. The larger issue is once they start doing this without patient consent, that's where the problems are created.
The outcome would be negative as some would simply "opt out" by not going to the doctor.
Having an extremely complex medical history and so does my family, I would do anything with consent to dissect me any which way to get at the root cause of the disease process that is making everyone sick.
belinda
Misty
Don’s experience with visiting a lady in the hospital is interesting. My mom and I walked through the hallway at a hospital last year after visiting my grandfather in the hospital and we were shocked to see a woman who looked almost naked in a room. She was wearing a hospital gown that did not protect her modesty. I personally think it is best for patients to wear their own clothes and gowns as much as possible. Many patients think that they have to submit to wearing hospital gowns at all times, but that is not true. I cannot help, but wonder if that lady really knew how exposed she was and that people who walk in the hallway could see at least part of her breasts. Hospitals do need to work on providing gowns that protect your modesty better, but at the same time, I wish that patients knew that they can refuse to wear gowns and wear their own clothes.
Misty
"Anyone want to complain what Google intends to do? ..Maurice."
The project itself I see as kinda cool... a more detailed map of the overall human DNA basically.
(and before anyone tried to draw a correlation between this and photographs etc... a blood / tissue sample is nothing like a photograph, no matter how cropped / framed when it comes to modesty issues.)
IF the study goes well / better than expected, then we can get a simple blood test when we're kids, and be fore warned of upcoming likely problems, and given advice how to avoid it. It could even give pharma companies a "specific target" to aim for to come up with cures and treatments for conditions. (as in if they find out that bio marker azk91773-g is what's responsible for male pattern baldness, they can focus specifically on that particular biomarker)
BUT... like the fears that came when they first started mapping DNA, IF it is capable of showing who's prone for what, insurance companies and employers could make it a prerequisite to get screened for ... well... everything, and could lead to discrimination.
But I still think mapping out the biomarkers is a cool idea.
Jason K
Part 2
What do the researchers, ethics committee, hospitals where the procedures were performed, providers, etc. owe these girls?
Clitoroplasty is not life saving. Don't even try to say the mental aspect of growing up normal. (See part 1)
This was totally self serving. I think that the institutions and individuals are liable for their actions to these girls in the future. At the very least, to sit with them face to face, hear how the experience has affected their lives and explain their reasoning to do this.
This only reinforces that medical students should conduct intimate exams on each other. The quest for scientific knowledge is THAT important.
How many physicians or providers here would subject your own daughter to this???
I'm sure that I know the answer.
--Banterings
Check out this article:
Pelvis-photo victims must recount trauma to share $190M. This article revealed that not all patients of Dr. Levy will get actual money. Victims have to convince a panel of psychiatrists that they were in
fact victims.
Look at some important parts of this article:
Thousands of women whose genitals might have been photographed during gynecological exams can share a $190 million settlement from Johns Hopkins Health System. But they’ll have to describe their trauma before seeing any money.
That might be painful for some women who feel profoundly violated by Dr. Nikita Levy, who committed suicide in February 2013 after being caught with hundreds of pelvis pictures. Others who have gotten over their shock in the year and a half since then might wonder if it’s worth their trouble.
No amount of money can reverse the pain and damage a woman may have endured. I know this is controversial with some of the readers here. But this is exactly why Medical Patient Modesty encourages women to avoid male doctors for intimate examinations. Dr. Levy was a very popular doctor who helped so many women.
Misty
Misty - "No amount of money can reverse the pain and damage a woman may have endured. I know this is controversial with some of the readers here. But this is exactly why Medical Patient Modesty encourages women to avoid male doctors for intimate examinations. Dr. Levy was a very popular doctor who helped so many women."
I get that, and I'm not disagreeing or arguing with you, but it's not just women.... the fact that a doctor did this at all is one more point of proof for me I shouldn't trust a doctor.
But if this is part of the reason ladies shouldn't trust men doctors, shouldn't they also be encouraged to not see lesbian doctors? (or if you wanted to be really paranoid, doctors having financial troubles as well, since a hetero lady doc could be snapping pics / taking vids to sell to fetish sites or something)
And making the victims explain their trauma is kind of pathetic on their part... a rape victim doesn't have to justify "why" she's a victim....
Jason K
Jason, I was thinking along the same lines as you are with regard to this issue.
The gender of the abuser is irrelevant. What is relevant, is what is the medical community doing to prevent this kind of thing from happening?
Right now, practically nothing. They don't report each other, nor do they discipline workers in a way that is so punitive that it acts as a deterrent.
You are right that the burden should not be on the victim, but on the system.
This doctor was so humiliated, what did he do? He killed himself. If he can do that to get away from his humiliation, why is it a stretch for people to reject medical care for the same reason.
Humiliation studies show people will do anything, including, death to avoid feeling humiliation.
This case just proves the point.
It's also impossible to believe that nobody knew about this. Somebody did and they should be as responsible.
Finally, NEVER join into a class action suit with a situation like this one. File your own. You will benefit at least financially instead of the insulting settlement that these women are entitled to.
It would be worth giving up the small sum of money in return for avoiding further trauma of being quizzed, possibly be forced to look at photographs to find their own, etc.
Maurice, any other proof of where the "outliers" come from and the future of medicine when violations occur every day, all the time, by both genders?
What does this say about the system, the way it operates, it's refusal to mitigate damage by working with health psychologists and patients to find protocols to
help alleviate the damage from previous experiences.
Any professional should be fired when they behave in this manner, and any professional that knows about the behavior should be fired if they don't speak up. I've said this before on this very blog.
Frankly, I'd rather be dead than to be abused in this way again. If you don't participate, then you won't be abused. That's where the outliers are coming from.
The real outliers are the medical professionals that have caused patients to feel this way.
While some patients may have some modesty issues and preferences, there is a difference between that and someone who has been traumatized previously by being lied to, manipulated, coerced. Personally, I have been given consent papers after anesthesia has been administered and didn't have the capacity to refuse. It happens, it's real, all the time, at every institution. Just take that walk down to the assigned risk department and the proof will be waiting for you.
belinda
Belinda "What is relevant, is what is the medical community doing to prevent this kind of thing from happening?
Right now, practically nothing. They don't report each other, nor do they discipline workers in a way that is so punitive that it acts as a deterrent."
A LOT of high schools have metal detectors and check students that set it off as they come into the building... perhaps it's time medical staff was subject to the same level of security to help prevent recording devices from being brought in again.
Patients are expected to put up with and accept a lot for cost reasons (how often was it brought up that altigers and other small clinics can't afford adequate staff to cover gender requests? ) Now this ONE doctor cost that hospital 190 million. Perhaps the other staff should be put out for it, and other hospitals should follow suit to prevent their own expenses.
If doctors and nurses don't like it, they'd be free to seek employment elsewhere. (has a familiar ring to it, doesn't it?)
I don't think a doctor who acts in this manner should be fired... they should be criminally charged.
Doctors, police, judges, and teachers should all be held to an insanely high standard due to no other reason than the trust we're expected to place in them, and the authority they're granted.
As for the consent for after you've been drugged... .that should be a criminal act also, and (as I've said MANY times) if we were allowed our own chaperone with a video camera, that practice would also end pretty quickly.
Now that I think of it, if you could prove you were drugged before you signed, it WOULD constitute a criminal act... you wouldn't be of sound mind, so the "contract" would be null & void, and anything done to you would be done without consent. Assault & battery, assault with a weapon... could even tag on attempted murder, since they literally cut you open.... plus everyone else in the room would legally be an accomplice to the crimes.
Jason K
At Saturday, July 26, 2014 5:07:00 PM, Jason K said...
Belinda "What is relevant, is what is the medical community doing to prevent this kind of thing from happening?
Right now, practically nothing. They don't report each other, nor do they discipline workers in a way that is so punitive that it acts as a deterrent."
Jason,that says so much.I totally agree. MDs resort to "lack of time and costs money" when they need an excuse and don't have a reason. Do MDs deserve to be called a profession, other than the dictionary definition? Is there any other profession that uses "time and money" as a "reason"? BJTNT
BJTNT - the part you quoted was the piece of Belindas post I was quoting / responding to. ( I generally add what I'm refering to for the reference of reply, and because I don't know how many posts will be between it and my post by the time it gets put up.
Jason k
To avoid confusion, write xxx stated on (date) "yyyyyyyyyyyyyyy" with quotation marks before but also remember to put them after the quotation. ..Maurice.
While gender choice may make on more comfortable, demanding same gender for all will not solve the problem. Remember Dr. Sparks, female ENT MD in New Mexico that was abusing male patients? And I just read an article where a female employee of a hospital was fired for taking pictures of a nude female patient. We can say men on see men and women only see women....but that really doesn't solve the problem does it. nor does it really address the concerns of many here, which is not abuse, it is modesty...don
Hi Everyone,
Thank you for your gracious welcome to the blog. I want to thank my colleague Belinda for making me aware of this blog. Sorry for the long time it has taken me to re-post, but life just got in the way.
Jason, Sorry I cannot give you a citation for my statement that the APA supports PTSD caused by medical procedures at this time. I do not have the time to do the research right now. I can tell you that my colleagues and I diagnose, treat, and bill third party payers for services based on these criteria. We have never been question, including during clinical reviews and discuss this during staff meetings. We are client centered and not guideline centered.
Jason, I am also aware that people posting on this blog have been abused by medical professionals. Unfortunately, there are too many abusive practitioners out there. By too many I mean more than 0. I am in a position where I have had clients who have been abused and one client who was a nurse who was an abuser. Interestingly, she did not realize she was abusive until she became a patient and was on the receiving end of the abuse.
I am mildly disabled due to several serious injuries. Let's just say I have had more than my share of encounters with the medical profession. While I would not call my encounters abusive, I have been maltreated and that is what sparked my interest in my dissertation topic and Health Psychology in general. I did have one experience post-doctorate that I would classify as severely abusive involving a rehab center following a skull fracture and brain hemorrhage. I was continuously abused for 10 days and I have PTSD from that experience. I confronted the rehab center, doctors and administrators. I even billed them for the consultation. I continue to have flashbacks. My neurosurgeon/pain management specialist has confirmed that they may have damaged me physically and definitely damaged me psychologically. I was endangered and humiliated. They were able to get away with it because I was brain damaged and could convince my family that everything I said was a delusion. I got a copy of my medical records and it was all there. When I told the doctor that I thought I had injured my back because I was in pain, he told me not to worry about it because it was the bed that was causing my pain. I could go on and on.
Jason, why trust anyone from that world? I have built relationships with medical professionals. They have saved my life. My team is built on referrals. The trust goes to people I know who tell me who to trust. I am fortunate. I can tell who is trustworthy. When I was in the rehab, I begged my family to get me out of there. My neurosurgeon was on vacation. He was in contact with my family, but they did not ask him about getting me out of there and I had a damaged brain. They made a mistake. They will not do it again.
Yes, providers are human. They have stressful times. If they cannot be sensitive and compassionate they need to take some time off. That is what I did.
I will post again. Thank you for listening.
Dr. Linda E.
*** At Sunday, July 27, 2014 7:14:00 PM, Blogger Dr. Linda Erlich said...***
Jason, why trust anyone from that world? I have built relationships with medical professionals. They have saved my life. My team is built on referrals. The trust goes to people I know who tell me who to trust. I am fortunate.
***Said by Blogger Dr. Linda Erlich At Sunday, July 27, 2014 7:14:00 PM, ***
That's all well and good if you see the same practitioners often enough and long enough to actually build a relationship.
That doesn't account for random ER docs, random rotation nurses, and other docs you'll meet once if at all like surgical teams.
I've had more trouble from nurses who I've never seen before or since who didn't even bother to say who they were than from any kind of doctor.
*** July 27, 2014 5:00:00 PM - Don Said ***
We can say men only see men and women only see women....but that really doesn't solve the problem does it. nor does it really address the concerns of many here, which is not abuse, it is modesty...don
*** Said by Don @ *** July 27, 2014 5:00:00 PM ***
Agreed 100 %.
If I'm going to have to expose myself to a doctor, it's going to be someone who's earned my trust, not someone who just happens to have the same plumbing... and an audience isn't going to happen. A nurse (male or female), chaperone, scribe, or camera will end the conversation right then and there.
Jason K
Medicine basis it's principals on "do no harm."
The complete quote being "Make a habit of two things: to help; or at least to do no harm."
I would argue that it is a "Machiavellian help or do no harm," where the helping justifies the means. Modern medicine is just beginning to realize the Machiavellianism of their ways with issues like DNR, chemo Vs. quality of life, and hospice.
I would say that the concept of medical beneficence AND the exception to informed consent ( allowing the physician to act on the patient's behalf) could be unified under the "Golden Rule" (do unto others as you would have done to you).
Yet medicine ignores the "Golden Rule" and reverts to Machiavellianism by not requiring students to perform "intimate" exams on each other but on anesthetized patients.
To the providers here; after all these years, you must be faced with the situation of "what you THOUGHT you knew." Any insights from you now?
I wanted to encourage everyone to check out some disturbing comments by an anonymous lady who was forced to have an urinary catheter who commented on June 24, 2014 on the article I wrote about urinary catheters on Dr. Sherman’s blog:
Anonymous said...
Thank you for your article & your many other helpful blog write ups. I suffer from ptsd as a result of being forcibly catheterized, held down by a room full of men & women as I screamed "NO" repeatedly. I was very sick- septic, pneumonia, & a near fatal infection in my heart- but at that point I had control of my bladder & was making it clear that I wanted to go to the bathroom. Their reason for forcing this on me- my iv wasn't long enough for me to go to the restroom...? There was no medical need whatsoever for the cath and I made my refusal to consent loud and clear yet I was held down as I kicked, screamed, pleaded. Not that it wouldve been ok otherwise, but to top it off I had been previously sexually assaulted so to wake up in an ICU not knowing where I was completely naked and uncovered from the waist down and then having a room full of people hold me down and spread my legs open was particularly traumatizing and sexually violating. Meanwhile my husband and friend who had brought me to the hospital did nothing to try to stop them from doing this to me despite my refusal- I won't let my husband touch me as a result of this, & I'm sure in time it will ultimately lead to the end of our marriage. The hospital and NYSDOH complaint processes will just make me relive it more than I already do and force me to talk out loud about what I can't verbalize without sobbing &/or becoming violently ill, & I know those complaints almost always lead to absolutely nothing. I don't have the "perfect" case or history so legal recourse isn't feasible, & even if it was it would do nothing to undo the trauma that's been done. To top it all off, as a result of this experience I am going without necessary follow up care because I can't bring myself to go to a doctor & talk about it (I have a hard enough time conveying the basic emotional info related to my ptsd to my psychiatrist). What is left of my life is shattered- flashbacks, nightmares, inability to function, panic attacks, dissociation, etc etc. My family misses me, hell I miss who I used to be, but I feel dead already, hopeless, ashamed, disgusted, worthless. I have "I do not consent _____" written in sharpie on my body should I ever become sick & be brought to the hospital unbeknownst to me again. I really wish my friend had never brought me to the hospital, I was just a day or 2 from being dead, I never would have needed to go through all of this. I've already explained to my kids that if I got sick again I wouldn't be coming back alive, I love them more than anything but my heart mind & body are not strong enough to go through that medical rape again, & if kicking and screaming that no i do not consent isnt enough protection for me then obviously there isnt any way to guarantee that it wouldnt happen again. All of this because it was just basically more convenient for the staff. If only they had been respectful of patient rights & treating people humanely as you seem to advocate through your blog, who knows how many less people would be traumatized, harmed physically & mentally, & how many more people wouldn't hesitate to get the help they medically need but are too afraid of what they'll be subjected to. Education & prevention are key, but where do those of us who've already been wronged, raped, & spat out of the machine that goes "ping!" go?
This case is horrible. They should have never forced the lady to have an urinary catheter. If they felt her IV was not long enough, they could have provided a bedside toilet for her to use. I have seen special beside toilets in ICU before. It’s so sad that this lady is so traumatized by medical professionals that she does not want to seek future medical care. I wish that the medical facility had been sued.
Misty
What I'm really hoping to read one day is a news story, where someone like this forced catheter victim is either a little bit psycho, or friends with some "less than law abiding" people... and through their medical records are able to find out who these people are, and we get to read a story where these medical rapists are raped themselves, preferably gang raped by the psychotic patient and their friends. (I know if I was held down and cathetered while screaming for them not to, they'd better pray damn hard I can't find out who any of them are or where they live.)
Lets face facts... anything done without consent is assault. Sure, an argument could be made that if a person isn't conscious when they come in - from a car accident for example - , then a doctor should do what's best.... but this catheter victim was fully aware and actively refusing consent.
The "special privilege" medical people get is, frankly, a joke.
Imagine the freedom doctors have in other professions...
You're a little drunk with your friends (unable to make decisions for yourself), when your friends think it'd be a good idea to take you to a tattoo shop, where you're held down and have a giant dragon tattood on your face, while you're screaming for them to stop... and after the fact there's nothing you can do about it, the only way of proving anything was done to you against your will or out of the ordinary would be the tattoo shops own records, and everyone tells you that lots of people have tattoo's so grow up and get over it.
Or you take your car in to a mechanic you know and trust for a $50 oil & fluid change... you go to pick your car up, you find out that the competent mechanic you know and trust didn't actually do anything to your car, this other mechanic who you've never met before tells you he was the one who worked on your car... and he mentions it's his first day on the job (so you have no idea how competent this guy is) and he presents you with a $80,000 bill because he felt the other work might have needed to be done, and you have to pay it before you get your car back.... and when you try to call the police about it, they don't grasp what the big deal is... everyone cars need repaired ya' know...
Or imagine you're a parent, and you found out your teenage daughter was slipped some sleeping pills by the school, so they could strip her naked and let a class full of males and females see and touch her unconscious naked body for sex ed class... it's for education after all so that makes it ok... right?
All 3 of these scenarios would involve you calling the police, right?
So why is it ok for hospitals to get away with the exact same behavior?
Jason K
Let me tell you why lawsuits occur to healthcare providers. (For the record, I have never litigated against a provider.) So many people are wronged in the system so often, providers refuse to recognize (let alone apologize for) their infractions, that once there is a legitimate reason to litigate, they go full bore.
I have read many, many court filings, depositions, suits, etc., and it is always brought up that the claimant has filed past grievances against providers. There are attempts to paint these people as mentally unstable, serial litigators, all to tarnish their credibility.
If you read their past complaints, it is for issues of not respecting their personal choices. Many also cite the failure to acknowledge their pain.
There are feeble attempts at apologies, such as "I'm sorry you feel that way," as if they are wrong for feeling violated after such an event like the one above.
Then when they have a legitimate cause of action, they want their pound of flesh. Most lawsuits can be avoided by 3 things:
1.) Look at the situation from the patient's perspective. What is legal is NOT always moral. That is why it is called "ETHICS" and NOT called the "LAW."
2.) Sincerely apologize. Humanity goes a long way. To sincerely apologize, you need to recognize your failings. You don't need to do it in a letter that can be used as evidence, but say it.
Meet with the person. The other thing that angers victims is not meeting with them. You know that this person is threatening to sue, so you don't meet with them.
3.) Change the system so it never happens again. If you read all stories of the people who have had their dignity, modesty, or right of self determination disregarded, almost all of them do not want "the money they deserve" (as lawyers put it, they want acknowledgement and change so that no one else ever has to endure what they did.
I would argue that not seeing the patient's point of view, admitting you (may have) injured the person further is an issue of academic dishonesty (student providers) or professional integrity (licensed providers).
You want our trust, earn it!
Misty. As bad as that story sounds my question would be, WHAT THE HELL IS WRONG WITH HER HUSBAND. When things started going wrong he could have asked everyone to leave for a minute so he could talk to her about her concerns. He could then have walked into the hall and addressed her concerns with the staff. There was no need to force it on her. Something could have been worked out peacefully. Anyone see a need for a advocate here. AL
AL,
I agree with you that her husband should have asked everyone to leave and helped to fight for her wishes. I do not know why he stayed silent. A spouse should always advocate for their spouse and it’s so sad that he just stood there and did nothing.
Misty
If the husband had tried to get involved, Security would have forcibly taken him away if he persisted. We patients mistakenly think the deliver of medicine is about us. The medical community is a bureaucracy with a culture committed to them.
BJTNT
BJTNT said:
"We patients mistakenly think the deliver of medicine is about us. The medical community is a bureaucracy with a culture committed to them.
Again wit the "I am a professional, I've seen it all before...
When are you going to understand, IT IS NOT ABOUT YOU?!?!?!
This is why the push for patient-centered healthcare.
The above situation could have been fixed with a longer IV line. If you truly believe "do no harm," then physically restraining her caused way more mental and physical harm than a longer IV line, plus it allowed her to keep her dignity.
Physicians are like mechanics: the dinasaurs only knew the mechanical (body). The modern professional knows the mechanics (body) are computer controlled (mind).
The mechanical can damage the computer and the computer can cause the mechanical not to run correctly. How many times has a mechanic who doesn't understand the computer aspect only repaired the symptoms.
Even worse is when they short something out in the computer through their ignorance. Then it is up to the next guy to clean up the mess.
How can people who sacrafice so much, are so educated, so intelligent, be so ignorant to the concept of basic human dignity?
Based on the point of view of physicians, people like John the Baptist, Mahatma Gandhi, Maximilian Kolbe, etc. all died for some irrational belief (like patient modesty or human dignity).
BJNT, What do you think would have happened if the patient or her husband said, "You are breaking the law. You do not have informed consent. You are committing sexual battery. You will be sued to the fullest extent and every attempt will be made to lose your license and criminally prosecute.
They would have stopped dead cold.
Security would not have been called and if they were, the patient repeats what's happening.
Physically the husband and the family could have pushed them all away. They might have gotten temporarily arrested, however, the patient would not have been traumatized if it were stopped before it happened.
Comments like...You will not touch my wife. She is refusing your procedure and it's her legal right to do so. I would have started taping on my cell phone avoiding the exposure of my family member but focusing on lack of consent.
Then I would call all the news agencies, provide the video, name the persons involved, file a complaint in Superior Court requiring a court trial.
BJNT and others, you don't have to give away your power and assume you have no option. What would have happened if the family called the police and said their family member was being assaulted against their will. Would they have come and arrested everyone?
Those are the kinds of questions and information one needs when they go to the hospital.
Know your rights. Tell them when they are being violated. Tell them that the procedure is being done against your will. Tell them to stop touching your body at once. Tell them their behavior is criminal and they will go to jail.
Go directly to a criminal attorney's office, file a complaint. With the video declining treatment, your statements that this is being done against your will, will guarantee a quick and speedy settlement...in the millions.
Personally, I would donate most of the award to an organization that protects patients.
This behavior is never right and it does happen and it's not as "outlier" as one would imagine.
What motivates the medical staff to ignore you is their liability of being sued if something happens when you don't follow their protocols that they will be sued.
What they must understand either way they lose.
When you reverse the power role, let them know you know your rights and they are violating them, see how fast they walk away.
belinda
Since I'm guessing my last reply didn't get posted because it was a rant that crossed a line or two, I'll rephrase it and try again....
One of these days the medical community are going to treat a patient badly... like the catheter lady... but the patient is either going to...
A) be a little unstable with violent tendencies and track down those involved at their homes
or B) Be a judge or district attorney (or related to one) and then they're going to do everything in their considerable power to absolutely bury those involved.
"medical authority" needs to be drastically scaled back... imagine of other professions took the same liberties that doctors / nurses do...
Your teenage daughter goes to the school nurse for a headache, the nurse gives her sedation instead... then when she's out they wheel her into the sex ed class, strip her naked and let the other students look and touch... "for education". (and if any of the providers here disagree with that analogy, by all means, point out the differences to me.)
Jason K
Jason K _ I really like that last analogy.
That also lead me to a question for the physicians on here:
If you knew that a spouse or child was going to have a procedure done at a teaching hospital, the surgeon is a teacher, and there is a very good chance that there will be video taping, students coming in to do an intimate exam: what would you do?
Note your child or spouse signed consent to treat that says there may be students and video taping involved. Would you inform your spouse, request a "professional courtesy" of no students or video, have spouse/child mark that on the consent form?
Why would you treat (or allow to be treated) any differently your spouse/child mark than a regular patient?
I know this happens, I have seen it more than once, and recently with my own eyes. I know in recent years that there are more requirements like "a chart on file," but it still goes on. Many have at least given the required immunizations. Do not insult me by saying that it does not, is unethical, etc., or that you are unaware of this.
A relative of a physician (child, brother, sister) needs a medical form signed for school, sports, work, etc. They "sign the form." Again why is your family treated differently? (Saying that you "know" their health is no substitute for an exam.)
I know the answer to this, but I am going to ask anyway:
Would you ever give your adolescent/adult child, brother, sister, close relative a physical exam? Would you require it to be an undressed, thorough exam?
If conducted in a professional manner, there SHOULD be no issues for you or the patient. I would argue that there is more trust here.
Ask yourself, WHY you would treat a relative differently. I think artiger mentioned that he has treated friends' wives, why not family? Is it the patients' "ick factor"> Do you not think that patients unrelated to you have "ick factors" too? Is there a difference if they were 14, 24, or 44 years old?
I want you to explore your own prejudices. You can't deny that you have them, you are human.
--Banterings
All Comments have been published. .Maurice
Since we are on the subject of spouses advocating for you as a patient in the hospital, I wanted to ask the readers who feel strongly about their modesty and having intimate procedures done by same gender medical professionals only here some questions.
1.) Do you feel your spouse is strong enough to stand up to medical professionals to fight for your wishes for procedures and modesty?
2.) Would you be comfortable with your spouse being present for an intimate procedure you may have? If not, why?
3.) Can you trust your spouse to fight for your wishes to not have unnecessary procedures as such as urinary catheters?
4.) How do you feel about your spouse being present for surgeries and sitting against the door of the operating room to make sure that no one who is not supposed to be there comes in?
5.) Do you feel you can advocate well for your spouse for procedures and surgeries? If not, why?
I wanted to share a case where a man refused to let a male surgical technician enter the room where his wife was having C-Section that was submitted to Medical Patient Modesty’s web site a few years ago. I really admire this husband for protecting his wife’s modesty. I believe we would see a big drop in patient modesty violation cases if spouses would advocate and stand up to medical professionals.
Both of my children were born by cesarean. During the last one I was in with my wife while they were prepping her. (My wife had a female gyn and female Anesthesiologist) They asked me to leave the room while they gave her an enema. As I was waiting just outside I observed a male in blue scrubs start to enter into the room where my wife was. I had seen him coming in and out of other or rooms as I was standing outside my wife’s room and I noticed that he was just bringing in supplies and didn't seemed to be of any real medical value. As he started to enter into my wife’s OR room I asked him why he was entering the room and he told me that he was the surgical tech. Well, I stopped him right there and told him that I didn't want him in there. He said ok and stayed outside. A few moments later the OR nurse came out to get me and asked the Tech why he was outside. The Tech told her that at my request he was not going to enter. She just looked at me and said that's weird. I told her I didn't really care if she thought it was strange or not and I asked her if the level of care that my wife and baby were receiving would be any less if he stayed outside. She just said well, I guess not. Please do not assume that everyone who has on scrubs has to be present when these procedures are taking place. The medical community thinks so little of us that we are made to feel like they all have the right to see us and our loved ones exposed. I wonder if it was that nurse that was there having the c- section if the tech would of felt the need to be there during her enema? I think not but then again we are just the little people.
Misty
A Banterings said
"Medicine basis it's principals on "do no harm."
The complete quote being "Make a habit of two things: to help; or at least to do no harm."
I would argue that it is a "Machiavellian help or do no harm," where the helping justifies the means. Modern medicine is just beginning to realize the Machiavellianism of their ways with issues like DNR, chemo Vs. quality of life, and hospice."
First do not harm is a basic tenet of the helping professions. As a psychologist, I can tell you that it is a basic principle of our Code of Ethics and is taught. However, that does not mean it is practiced.
I can tell you, I am always aware that everything I do and say must be for the benefit of my client. When I say everything, I mean everything. Even if I meet my client in the mall, an they choose to acknowledge me (privacy) what I do or say must be in their best interest. Fortunately I have the temperament and personality that in conducive to this so it comes naturally. However I do monitor myself. If I do make a mistake, I acknowledge it and apologize and make amends immediately.
I do not think that most practitioners are Machiavellian. I think they are thoughtless and perhaps arrogant. They get caught up in the power they feel in being "the doctor" or "the nurse". or even the "receptionist". People invest them with this power, too. People have tried to do this with me. I do everything I can to equalize the power between me and my clients. I tell them I work for them. I do not insist on being call Dr., although some people insist on using my title.
Look at the power gradient and use it when you are in a medical situation. I once got tossed out of a hospital into a snow storm after major surgery because a resident lied to me and my doctor. He told me the doctor wanted to discharge me and told the doctor I wanted to go home. This doctor promised me he would not discharge me until my pain was under control. It was not. The resident was fired. Now all students in this program have to watch the movie "The Doctor" as part of their training.
I am telling everyone to take back your power or better yet do not give it away in the first place.
Dr. Linda E.
Misty,
Let me be the first to answer:
1.) Do you feel your spouse is strong enough to stand up to medical professionals to fight for your wishes for procedures and modesty?
Yes!!! (see answer to #3)
2.) Would you be comfortable with your spouse being present for an intimate procedure you may have? If not, why?
First she has seen me at my best and at my worst; we are still together. I have told her everything about me from day one. She knows all the skeletons in my closet, I know hers. We have been together 25 years, in that time people get sick, accidents happen, etc. You overlook the "yuck" many times out of love and commitment. She goes with me to hold my hand if I need a tetanus shots or blood draw.
I don't want to get graphic here, but let's just say we have a healthy relationship and we explore. In the context of our intimacy, I would let her do things to me that I would not let anyone else do to me, even to save my life. This is something that perplexes me and I don't know why.
I avoid healthcare at any cost, the few times I really had to go (like when I had three inch hole in my neck that I was ready to glue shut), she talked me into going and stayed to hold my hand. I would never let anyone put a catheter in me, but if it was her... maybe, but reluctantly.
Believe me there is nothing arousing about a catheter, at all. I have to think that it is the trust and intimacy that we have in our relationship. Where I would refuse to sacrifice my dignity for my self (perhaps save my own life), for her I would give my dignity or my life without a second thought. There are implications here for me dealing with my medical phobia.
3.) Can you trust your spouse to fight for your wishes to not have unnecessary procedures as such as urinary catheters?
Our relationship is built on trust. Some of our earliest dates were climbing ice covered mountains when it was -20 degrees. Many times she was at the other end of the rope as I was losing my grip. I'm still here.
4.) How do you feel about your spouse being present for surgeries and sitting against the door of the operating room to make sure that no one who is not supposed to be there comes in?
I would rather her in the OR as my "second."
5.) Do you feel you can advocate well for your spouse for procedures and surgeries? If not, why?
God has graced my life with her, I would fight to the bitter end to protect her.
To answer Mistys questions
1 - Yes & no... I can't see her arguing with the doctors about them doing or not doing a procedure, but I can see her freaking out for people wandering in and out, doors & curtains left open, exposure when none is needed, and definitely refusing to be kicked out of the room or turning off the camera (so a lawsuit would definitely follow if I was told one thing then they went and did another)
2) absolutely. She's already seen everything there is to see with me, and I trust her with my life.
3) see #1
4) again, see #1, but she knows how I feel, so she'd definitely freak out at people if they tried to bring students in
5) Absolutely. I know her feelings towards needless procedures, modesty, students, spectators and all that... and with my disdain for medical people already and my overall size and demeanor, I'm not one to get pushed around easily.
Jason K
Dr. Erlich,
I'm fascinated with your references to receptionists. I feel this is a big part of the poor impression patients have of the medical community. Despite the saying that you don't have a second chance to make a first impression, this needs some elaboration. Many medical offices have two or three receptionists working at the same time. Every year there seems to be one or two replacements. The point is that there are 2-3 receptionists plus turnover, so how many "first impressions" do patients encounter over several years in the same medical office. Many of these encounters are negative rather than positive.
Several years ago I was a pawn in the riff between a receptionist and the X-ray tech in a different medical office. Long story, but I still can picture the blank expression on my MD's face when I handed him the X-rays that I was told by the receptionist to present to him months later at my next visit. I could have sent a complaint letter to the office and received a form letter that they were sorry and will take measures to prevent future repeats. This outrageous lie would tempt me to never return to this office, but I like my MD too much to consider such action.
Did your research show how receptionists contribute to the negativity in the medical community and make modesty violations just that much more galling? BJTNT
Many thanks to Dr. Linda E. for joining the blog, for her insights and sharing her personal story with her own experiences. She is in a unique position to look at these issues from both a professional and patient experience viewpoint as are MD's who are forced into the healthcare system. We would certainly like to hear their observances of issues they have as well.
Yesterday I went for a routine mammography. There was an error in the script and I was told there would be a co-pay. I told the receptionist that I would re-schedule (as there is none for a routine x ray) and she ran out of her seat in a tizzy without comment to me. During her absence, I asked another receptionist for their fax number, called my ordering physician's office and had another script sent asap.
What was interesting is that I asked for the original prescription back and it was reluctantly given and was noted by the receptionist that it hadn't been scanned into their system. The receptionist then told me that I had to give the original script to the technician doing the films.
I did not listen to her. All that would have resulted is a complicated billing issue and it served no purpose.
This front desk person was surly, poor attitude and all I did was keep smiling, saying thank you.
Maurice, did it ever occur to you that your observations of the medical system are basically an outlier position as there is so much you don't see (not because you're not looking, but because in your job function, you are not privy to such)?
What if....these problems that we express are the norm, not the exception and this "outlier" position of who we are is because we have been abused in one way or another by the system and that the problems not only exist, but exist as the norm rather than the exception.
It's important to differentiate between the experience, the people involved and who reports it and talks about it.
The nature of healthcare is intimate. People's perception of what's being done and why is slanted mainly due to how they are treated during a procedure. They may experience the exact protocols, but because of the way they are treated are traumatized because the healthcare system is insensitive to the psychological needs of people when it comes to humiliation, their dignity, autonomy--the very things that cause trauma when they are ripped away from you.
What if...there are ways to mitigate these problems by latching onto the advice, expertise of the psychological community in a big way. What if...there was a 75% increase in positive experience?
While you try and we thank you for your unbiased positions, perhaps they are clouded by your experiences as seen through your window?
What if...
belinda
I am pleased to read the current stream of commentaries which deal with more a "thinking out" or even philosophizing the conflicts that are occurring in all the phases of the practice of medicine.
Here is another aspect of medical practice and its relation to the patient that is worthy of discussing: the doctors of osteopathy (the D.O>) who is said to be the doctor whose profession sets the importance of contact and attention with the patient ("laying on of hands") and less to prescribing or testing.
Have any of my visitors had professional contact with doctors of osteopathy and whether they were found to be more "patient centered" in every way and they and their offices were more in keeping with the desires of our visitors, in contrast with MDs?
..Maurice.
Just to show you that the medical system is not ignoring potential modesty and privacy issues in the process of understanding the values (benefit and harms) in developing changes within the system, here is a posting on a bioethics listserv requesting opinions. ..Maurice.
I am looking for any insights from facilities that may be using video recording in patient rooms. We are considering a proposal for a pilot program that adds video monitoring options for patients at risk for safety (falls, self-harm, etc.). While there are concerns about privacy and patient rights related to this, the pilot seems to have addressed these relatively adequately by spelling out specific circumstances under which patients would be transferred to monitored rooms, and the policy includes notifying the patient/surrogate of the reasons for transfer to the monitored rooms. There has been a request, though, to incorporate the option for the persons watching the monitored rooms to record a particular incident of concern. The argument is that this will help provide evidence in the event that an incident happens (including non-clinically related things such as violent or inappropriate behavior towards a staff member or by a staff member towards a patient). I am having a hard time believing that this is actually enough of a reason to use recording equipment, and the act of recording seems much more invasive than monitoring (not to mention the subjectivity involved in when to actually record, and the obvious need to have other types of safeguards in place if there are concerns for the behavior examples listed above.) It just doesn’t seem to be the case that the recording would be of enough benefit to justify the additional privacy invasive of patients. My question to the group is if any of you have systems in place that allow for such recording and/or if you have grappled with this in your own facilities? Your insights and references to key articles would be much appreciated.
And here is the first response on the listserv to the issue posed above. Again, these are examples showing that modesty and privacy are NOT being ignored by the profession. ..Maurice.
Our hospital looked at this a few years back, although the question of recording for risk management purposes didn't come up.
I think it's important to recognize that video monitoring is different than other types of clinical monitoring. It involves highly personal information in a context in which, I think, a patient has a reasonable expectation of privacy. The fact that a patient is on hospital property or that the monitoring has therapeutic intent is not sufficient; the burden is on the hospital to show that the monitoring, overall, holds a greater prospect for good than harm. It's also important to remember that different cultures come with very different expectations of privacy. Video monitoring that may be "no big deal" for one patient or family, may be highly offensive to another. Notification would be a minimal condition; I would argue that in most cases, consent should be required.
On the question of recording, perhaps it would come down to intent. Is it for the patient's benefit, or the hospital? If it's not for the patient's benefit, nor necessary for hospital operations, what justifies it? Would it even pass muster with HIPAA? I'm not sure - I'd be interested to hear others' thoughts on this.
Reference: Thursday, July 31, 2014 7:03:00 PM, Blogger Maurice Bernstein, M.D.
If this evinces that the medical community is concerned with patient privacy and modesty because of video monitoring, why doesn't the medical community show the same concern for and punish patient privacy and modesty violations by nurses, aides, and techs? BJTNT
*** From the second posting on a bioethics listserv
"Our hospital looked at this a few years back, although the question of recording for risk management purposes didn't come up."
********************
If they didn't install the cameras for risk management, then what would be the purpose?
Only 3 reasons I could think of for monitoring people in a room would be
1) risk management (keep an eye on the ones who may fall or hurt themselves, but even that isn't ideal since a camera could aggravate a person and cause violence / conflicts, or it means nobody would get there till after the fact)
2) theft management (watch people don't raid the supply drawers.)
3) voyeurism. (which is my default assumption for ALL cameras)
*** From the first post from that listserv
"There has been a request, though, to incorporate the option for the persons watching the monitored rooms to record a particular incident of concern. The argument is that this will help provide evidence in the event that an incident happens (including non-clinically related things such as violent or inappropriate behavior towards a staff member or by a staff member towards a patient)"
*****************************
Wouldn't that mean that cameras would have to be recording ALL the time? otherwise they wouldn't be able to prove the lead up to the incident, they wouldn't have the start of the incident recorded depending on the reaction time of the person hitting the record button.
And just like there's no way I'd believe a chaperone in the room would actively try to stop a doctor acting inappropriately or go to the police about a doctors actions, I don't believe for a second they'd "start recording" when a doctor / nurse started misbehaving.
Jason K
There are many problems with this. First if this was instituted, could someone like Dr. Nikita Levy (Johns Hopkins) is the policy as a defense if the recordings took place in that wing? I'm sure his lawyers would try.
Again I point to US Supreme Court Case about cell phone searches without a warrant. I point this out because decision written by Justice Roberts specifically mentions "videos" (pointing to the fact that a camera is a component of a cell). There is also a mention of networking (the Internet) that shows that the information is not just a single file.
"Cell phones differ in both a quantitative and qualitative sense from other objects that might be kept on arrestee's person," Chief Justice Roberts wrote. "Many of these devices are in fact minicomputers" that "could just as easily be called cameras, video players, rolodexes, calendars, tape recorders, libraries, diaries, albums, televisions, maps, or newspapers."
Moreover, the information a cellphone contains—or can access through the Internet cloud—can "reveal much more in combination than any isolated record" that might have previously been found in a suspect's pocket. "The sum of an individual's private life can be reconstructed" through photos, email, phone records, Internet search histories and other data, the court said.
"It is no exaggeration to say that many of the more than 90% of American adults who own a cell phone keep on their person a digital record of nearly every aspect of their lives," it continued.
That an individual can now carry such a record so casually "does not make the information any less worthy of the protection for which the Founders fought," the chief justice wrote.
This decision's implications are that it describes American's expectations of privacy. It will be used when legal challenges arise (and they will) for privacy in regards to drones with video cameras and Google glasses.
I would argue that patients expect the same privacy in treatment rooms as they would expect using the bathroom.
When did society switch to the "easier to apologize than ask permission" mentality? The only way to guarantee no abuse is to NOT have them.
Cameras and their recording in a room with a patient can be one activity in which invasion of privacy can be considered. How about another act often carried out by physicians: hugging their patients or the patient's family members.
I presented this activity as a thread in November 2007 titled "Being Hugged By Your Doctor: Invasion of Privacy vs Sign of Compassion?" and as of today found 41 comments posted.
My introduction was as follows:
According to the article in Fox News "Affectionate students are feeling the squeeze around the country as their displays of affection land them in trouble with school administrators." Even if the intent is to express, though the act of a hug, a social connection with their peers on the school grounds, this behavior may be considered sexual harassment. I find this news story has directed me to consider something some of us doctors do as part of being a humanistic human being beyond simply a doctor of medicine. Some of us actually hug our patients or patients' family members. We hug, not out of sexual excitement or anticipation, but out of a sense of the need to express directly compassion and support at the time of a patient crisis. Is hugging a patient professional? Does it exceed boundaries of professional behavior? Does it invade the patient's privacy? Should doctors first ask the patient "may I hug you?" and wait for permission? When you are upset and in distress and need the attention and compassion of someone who shows that he or she cares about your feeling, should you or would you accept a hug from your doctor even without them asking?
Have you been hugged by your doctor? And would you consider that act to be a violation of privacy or in fact battery? ..Maurice.
The hug thing....
Depends on context.
- how well do you know this person?
(known them for years / first time meeting them / encounters have been strictly clinical vs joking around while talking to them)
- what's the circumstance?
(Did the doc just tell the person they had stage 4 cancer and are going to die soon, or was it a routine check up and the doc is trying to hug for no reason?)
- how much physical contact?
(There's the "semi-side hug" where basically it's left shoulder to their right shoulder vs a guy hugging a lady and pulling her in until her boobs are pressed flat against him)
- duration of the hug
( a 2 or 3 second hug is a bit different than not letting go for a few minutes)
- hand placement / movement
(one on the shoulder, 1 on the mid back is different than lower back and back rubbing)
Jason K
Maurice, It's great that a couple of doctors voiced their concerns with privacy issues and cameras monitoring patient behavior. They are not enough of a sampling to measure what widespread physicians think about this practice.
As a patient, I find it enough to permanently keep me out of the hospital. It's now added to my list of questions if ever admitted and something to add to the consent form. Additionally, I would want to know where the cameras are in my room and physically put tape over them because I wouldn't trust anyone to confirm they are off--oops! another mistake? Are you kidding me?
If a camera were necessary (like when you're in the ICU), I would opt out and get a private nurse to monitor me.
Most of the time, it's just another ridiculous morphing of what expectations the hospital has for it's benefit with a total disregard of what's good for a patient, their privacy, dignity and autonomy. It's just like prepping patients for surgery in a public forum instead of in the privacy of another area. It wasn't always that way. Years ago, you went into the hospital the night before surgery where prepping, enemas, etc were done in privacy.
There's a famous TV psychologist who says to things that I find so true. One, "You can't change what you don't acknowledge, and, "There are always two sides to a pancake, no matter how flat it is".
The medical community has not acknowledged there's a problem. The only evidence we have of such, are the laws that were developed to protect patients as in the Patient Bill of Rights. While informed consent is another law, it often is broken without consequence.
It's time that the medical community submitted a piece of work that talks about procedures and when privacy evasions occur, the reason and how and why they were handled in a particular manner. You can't avoid every situation but probably can elleviate 99% of them. You can't fix the problems without knowing what they are.
Without the acknowledgement of the medical community, we will never get where we need to go with this blanket issue of dignity, autonomy, privacy and informed consent (that bodily privacy is a part of). The actual problems are much larger than that.
One of the things that galls me is when there is a mistake made, they correct it and then try to bill you for correcting the mistake.
This happens frequently and I wonder how patients handle this issue. This is how I handle it. You can bill me. I will pay you and then I will take you to court and sue you. Or...you can drop the charge and we can be on our way. Is that not fair and equitable? Why should we (and our insurance companies) have to pay when a mistake is made to correct it?
I'm of the ilk that mistakes happen. Most of the time it's ok with minor consequence without going into the area of gross negligence. What's upsetting is the refusal and the attempt to hide the mistake through double talk, medical language that the patient won't understand (unless you're like me and ask them to translate).
There's absolutely no embarrassment to acknowledge that you are not a doctor and don't understand all their terminology.
It would be the same if I were speaking to a doctor in the language of my business and they had no clue.
It's done to intimidate--don't bite. Just ask for an explanation.
Cameras in my room? Never!!!
belinda
*****
Said By Belinda August 02, 2014 8:16:00 AM,
As a patient, I find it enough to permanently keep me out of the hospital. It's now added to my list of questions if ever admitted and something to add to the consent form. Additionally, I would want to know where the cameras are in my room and physically put tape over them because I wouldn't trust anyone to confirm they are off--oops! another mistake? Are you kidding me?
Said By Belinda August 02, 2014 8:16:00 AM,
******
Like I mentioned a few pages back, there are cameras in the exam room of my GP, but they are dome cameras so tape wouldn’t do you any good, unless you mummify the entire dome.
So far, since they’ve put the cameras in, I’ve only talked to the doc, gotten blood pressure, and a couple shots... no mention of even taking my boots off.
If that day comes, I’m going to insist we go to a room without a camera, or they bring a bucket large enough to go over the dome, and duct tape to secure the bucket to the ceiling around the camera ... or I tell them we’re done here and I walk out.
I might even be a smart ass, and take my cell out, point the camera at the doc, and ask if they’re willing to undress infront of my camera.... they have my word the cameras not turned on, so it’s ok.... you can trust me.
Jason K
Jason K,
Did you ever ask about the cameras?
I would bring up the issue of Johns Hopkins with your provider. Even though your GP may feel there is a legit reason that may be the "scientist" reasoning, not a normal person.
It is amazing how hospitals won't let news crews film inside the building (citing HIPAA), yet they have cameras in the treatment rooms.
Now that is a news story!
Banterings - yeah, I asked... I was told some dismissive answer about it's for everyones safety / security, and then the subject was quickly changed
Nobody I know who goes to the same office noticed the camera (they're not small.... about the size of a cantaloupe...) but nowhere from the sidewalk till you're sitting infront of the camera... NOWHERE is there mention / warning you're being filmed.
I don't generally go to the doctors very often, so it's not an issue so far.... we'll see what happens when it does.
In response to Maurice's post on hugging.
This is a sticky and complex issue. I would never condone any unnecessary touching in a therapeutic relationship. The key is unnecessary.
In my profession, the rule is: everything a client does or says has diagnostic value and everything a therapist does or says should have therapeutic value.
Therefore, if hugging is to take place, it must be beneficial and therapeutic to the client and also represent authentic caring feelings.
In my practice, I do hug some of my clients. These are clients for whom the above criteria are met. I would never hug or even shake the hand of a client unless it was beneficial to the client and I had their permission. These actions are always initiated by the client.
As far as my personal experience, I have received and given hugs to a very select few of my own doctors. These are doctors with whom I have an exceptionally close relationship and who have been involved in life saving care. On the other hand I have encountered doctors who have been instrumental in saving my life that I would not want to ever touch me again, even to save my life.
As far as Belinda's comments on video recording medical procedures, unless you have signed a real, valid informed consent, it is wrong. Risk management is not, in my opinion, a valid reason for recording a medical exam or procedure. If someone feels they need to practice medicine defensively, they need to take a long, hard look at what they are doing and why they are doing it. This is not good patient care. Defensive practice is fear based practice and fear kills caring and being a beneficial presence to your patients. This damages the doctor/patient relationship which is vital for healing and health.
One of my surgeries was videotaped, with my permission and full knowledge. The first surgery on my right foot, performed to repair the Lis Franc dislocation and fracture was videoed for teaching purposes. My doctor is a world reknowned podiatric surgeon at the Temple University School of Podiatric Medicine. He was dean of Academic Affairs at the time. He was and still is the doctor who treats professional football players who are injured. He is also a wonderful human being. The video is shown to all future surgeons and is a valuable learning tool.
Yes this is one of my doctors that I hug. This is also one of my doctors that has become a colleague and a friend.
Dr. Linda E.
I would like to notify our visitors to this blog thread of a book signing and question and answer session August 18 2014, 7pm at Seward Alaska library by our long time Patient Modesty thread contributor Doug Capra. The event is regarding the newest book he wrote titled "The Spaces Between: Stories from the Kenai Mountains to the Kenai Fjords"
Best wishes Doug on a swelling readership. ..Maurice.
As for hugging: human beings are social animals. To deny this under the guise of professionalism creates situational conflict (awkward moments) and internal conflicts (stress). Remember that is all in context and where appropriate.
In relationship to the "fist bump," this reminds me of the movie "Demolition Man" where in the future everyone is a germaphobe and a high 5 looks like 2 people cleaning a window (video here video here: When I see my physician, I will shake his hand.
Have you ever dealt with someone from the Middle East or Europe who greets with a kiss? I have and learned the intricate complexities of this custom. On the other end of the spectrum is the correct Japanese bow: must be sincere ("from the heart"), upper body bent 10 degrees, eyes down (big one), and last at least 3 seconds.
Jason K, wire tap laws require that all places that have closed circuit TV (with or without recording) have a conspicuous warning sign posted before one enters from the outside (considered public area).
Several states have laws prohibiting the use of hidden cameras in only certain circumstances, such as in locker rooms or restrooms, or for the purpose of viewing a person in a state of partial or full nudity.
You can find more info on CCTV laws here:
Simply having a policy or approval from the ethics committee or research board does NOT guarantee misuse of the images or video. Take the TSA. See the article One Hundred Naked Citizens: One Hundred Leaked Body Scans.
The abuses were so rampant that the TSA removed all body scanners. If the Federal Government could not guarantee people's dignity, how can healthcare? What do you think the backlash against healthcare will be when people begin realizing what is happening?
The only way to guarantee protecting people's dignity is NOT to install them in the first place.
NOTICE: AS OF TODAY AUGUST 3, 2014 "PATIENT MODESTY: VOLUME 67 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 68
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