Patient Modesty: Volume 68
As I have previously noted on this long running thread, there
appears to be a metamorphosis from repeated descriptions in various details of
personal physical modesty experiences and injuries to more generalized conversations with a philosophical, ethical or legal point of discussion. It is these latter postings which will be
more directed toward discussing ways to actually change the medical system,
either piecemeal or overall, to prevent or mitigate the possibilities that such
personal experiences as noted in previous Volumes will happen. It is my opinion now, whether or not the
experiences written here are statistical outliers, the problems previously
described on this thread and the potential consequences are of sufficient
importance that changes in the medical system should be made. ..Maurice.
ADDENDUM 8-9-2014
The following Comments by Doug Capra and followed by myself, I think are important and pertinent in setting the goals of this blog thread after 9 years of presentations here.
At Saturday, August 09, 2014 12:39:00 PM, 
Doug Capra said...
At Saturday, August 09, 2014 1:48:00 PM, Maurice Bernstein, M.D.said...
ADDENDUM 8-9-2014
The following Comments by Doug Capra and followed by myself, I think are important and pertinent in setting the goals of this blog thread after 9 years of presentations here.
Doug Capra said...
"P.S.- I just thought of an explanation why many of our writers here over the past 9 years have stopped writing or have stopped visiting here. Could it be that all they have seen here is personal experiences and argument with me but absolutely no constructive approaches or attempts to make the necessary changes. Can't you all do more? ..Maurice."
That's precisely it, Maurice. For me, most of this thread is same old, same old, same old. Occasionally, someone provides the URL for an interesting article. Sometimes there's an interesting insight. I know there are some on this thread who are really doing things. I applaud them. I check this thread every once in a while, but I just don't have time to go through the repetitions to get to the new.
I'm on two hospital boards, one a governing board, and I'm on a standing committee for another hospital. I'm trying to work on the inside as a patient advocate. Working with doctors and nurses and with the crisis issues most hospital are dealing with these days, has given me insight into what's discussed here. I've gained great respect for most doctors and nurses. I make no excuses for blatant medical abuse and modesty violations. But more people on this thread need to get into the trenches and work from there.
We talk about trust and good relationships with doctors, nurses, mid-levels, cna's and patient techs. If we really mean that, we need to understand that it's about the relationship, not about any one individual. Frankly, it's not all about the patient. It's about the relationship.
That doesn't mean the patient must tolerate abuse or blatant violations of modesty. But, like everything else in life, if you don't speak up and fight, you'll occasional be taken advantage of.
I hesitated to even post this -- because I know some here will want to debate with me. I don't have time for that. I'm too busy with other projects. But I will always work to defend a patient dignity. You can be sure of that.
That's precisely it, Maurice. For me, most of this thread is same old, same old, same old. Occasionally, someone provides the URL for an interesting article. Sometimes there's an interesting insight. I know there are some on this thread who are really doing things. I applaud them. I check this thread every once in a while, but I just don't have time to go through the repetitions to get to the new.
I'm on two hospital boards, one a governing board, and I'm on a standing committee for another hospital. I'm trying to work on the inside as a patient advocate. Working with doctors and nurses and with the crisis issues most hospital are dealing with these days, has given me insight into what's discussed here. I've gained great respect for most doctors and nurses. I make no excuses for blatant medical abuse and modesty violations. But more people on this thread need to get into the trenches and work from there.
We talk about trust and good relationships with doctors, nurses, mid-levels, cna's and patient techs. If we really mean that, we need to understand that it's about the relationship, not about any one individual. Frankly, it's not all about the patient. It's about the relationship.
That doesn't mean the patient must tolerate abuse or blatant violations of modesty. But, like everything else in life, if you don't speak up and fight, you'll occasional be taken advantage of.
I hesitated to even post this -- because I know some here will want to debate with me. I don't have time for that. I'm too busy with other projects. But I will always work to defend a patient dignity. You can be sure of that.
Maurice Bernstein, M.D.said...
And following up with Doug Capra's "we need to understand that it's about the relationship, not about any one individual. Frankly, it's not all about the patient. It's about the relationship", how can the relationship be improved from both sides, the patient and the medical system and its providers? Education. Education to and for both sides which is still missing. What education?
The System needs to be educated about all of these concerns based on experiences which have been written here over the years and what have been the limitations both practical and psychologic limiting communication and to what degree the System's responses have been inappropriate and inadequate (or even surprisingly the opposite).
The patients, on the other hand, need to be educated by the System as to the current realities, practicalities and limitations of the System. (One reality is the unprofessional or "criminal" physician that can "pop up".) But both patients and the System need to be aware of the facts in order for the trust on both sides be strengthened and maintained.
With the education to both sides, then there can be a real chance for some creative cooperation to mitigate or even fully resolve the issues and problems related to each of the parties.
That is why, the next step here is to formulate ways to educate the System from the individual healthcare provider to the institutions. And, hopefully, with the help of Doug in his institutional relationship and position and mine in medical education can, in our ways, encourage the System to provide better education about their "current realities, practicalities and limitations" of the System.
You know, knowledge can be potentially therapeutic, as with all "therapy" if properly applied. ..Maurice.
The System needs to be educated about all of these concerns based on experiences which have been written here over the years and what have been the limitations both practical and psychologic limiting communication and to what degree the System's responses have been inappropriate and inadequate (or even surprisingly the opposite).
The patients, on the other hand, need to be educated by the System as to the current realities, practicalities and limitations of the System. (One reality is the unprofessional or "criminal" physician that can "pop up".) But both patients and the System need to be aware of the facts in order for the trust on both sides be strengthened and maintained.
With the education to both sides, then there can be a real chance for some creative cooperation to mitigate or even fully resolve the issues and problems related to each of the parties.
That is why, the next step here is to formulate ways to educate the System from the individual healthcare provider to the institutions. And, hopefully, with the help of Doug in his institutional relationship and position and mine in medical education can, in our ways, encourage the System to provide better education about their "current realities, practicalities and limitations" of the System.
You know, knowledge can be potentially therapeutic, as with all "therapy" if properly applied. ..Maurice.
NOTICE: AS OF
TODAY AUGUST 24, 2014 "PATIENT MODESTY: VOLUME 68 WILL BE CLOSED FOR
FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 69
Graphic: "Changing Course" (my title) From Google Images
posted by Maurice Bernstein, M.D. @ 11:40:00 AM
169 comments
169 Comments:
Maurice,
Appropriate graphic. I don't know what exactly role you play here, I suspect that of Socrates in the Socratic method. I was not even sure of your exact position on this issue either.
I am not sure how many people here know of the different philosophical styles of debate and the roles each plays.
No offense by this, but it may also be the scientist in you needing to see a study that says to what extent the sky is blue because you can only see the sky above you.
It heartens us to hear you recognize that a problem exists (although the extent seems to be in question). It only took 9 years.
For us it is some acknowledgment of what we have endured and what we deal with daily in our lives. This is because (I'm sure I speak for everybody) the respect we have for you in keeping this conversation going, and treating everyone (despite differing views) with respect.
I try to keep a respectful tone as I see everyone else doing also. Sometimes though, many of us hit the wall of "why can't you see it?" That is our Achilles Heel.
I think a more important question is one that you can provide insight into; why did it take so long for you to get here?
Again, no one but you know exactly what your views were before or how you got to here.
This I think has implications for all of healthcare in that what is preventing the m from seeing the issue or perhaps what is causing them to ignore it. You have a stake in this too, in are you seeing the extent.
Banterings, as I have written to this blog thread numerous times, I was totally unaware of the physical modesty complaints laid upon the medical profession prior to reading the comments from visitors to the first couple Volumes of this thread. I was never, never complained to by my patients and I hadn't heard of any complaints by those colleagues I knew. As I have said previously, I was aware of the professional standards for patient modesty and followed them (and taught them to my first and second year medical student classes) but no complaints from the patients.
So, I have been listening and thinking about the stories written here virtually from the beginning and found merit in what was being written and found value to all to continue the threads and, as many of my visitors know, I have been encouraging my visitors to "speak up" and for them to make an effort to awaken the medical system as I have been awakened. And, in my modest way, I have tried too (including with Doug Capra) in writing articles to doctors and even tried (futile attempt by myself) to get an internet petition going. I hope this truthful and virtual repetition of what I have written in the past here answers your questions. ..Maurice.
***** @ Sunday, August 03, 2014 3:17:00 PM Maurice wrote
"I was never, never complained to by my patients and I hadn't heard of any complaints by those colleagues I knew."
***** Written By Maurice on Sunday, August 03, 2014 3:17:00 PM
Ever have a patient simply stop coming after a visit that involved exposure, or the presence of a chaperone / opposite gender nurse assistant?
That, and the truly modest of us simply don't go to the doctor for something that would likely lead to exposure, hence the billboard campaign for prostate exams saying "don't die of embarrassment".
Jason K
In view of the many years of practice up to the present, I have never been informed by a patient regarding a modesty issue and though I am not aware of a patient not returning because of a modesty issue , I suppose it is possible.
No patient should arbitrarily reject an important examination or procedure because of concern about exposure. What the patient should do first is to talk to the doctor about the issue, obtain the facts and obtain the approach which can be taken to mitigate or minimize the exposure. ..Maurice.
***** written by Maurice on Sunday, August 03, 2014 9:25:00 PM,
“No patient should arbitrarily reject an important examination or procedure because of concern about exposure. What the patient should do first is to talk to the doctor about the issue, obtain the facts and obtain the approach which can be taken to mitigate or minimize the exposure. “
***** written by Maurice on Sunday, August 03, 2014 9:25:00 PM,
And yet we do all the time, as evidenced by the billboards.
Talking to the doctor does little when it’s a 3rd party that performs the exam / procedure such as a surgical team, or the random lab tech doing an ultra sound (Ask Don about that one) . When it is brought up it’s usually dismissed with a “my way or the highway” attitude. Just look at Artigers posts... said he only had a female assistant, and he doesn’t work alone if a knife is involved.
And that’s assuming the doctor isn’t just lying to us, and when we’re laying there or bent over the table, he doesn’t call the assistant to come in, or the assistant just walks in anyways.
Even that guildeline that Banterings linked to a while ago said that if the doctor feels a chaperone is warranted and the patient doesn’t like it, that the patient should be told to go elsewhere.
Some people (mainly nurses in my personal experiences) are just unwilling to compromise (not grasping that modesty is a real thing, or are small people on a power trip, or some other random reason) and I have walked out because of it.
I get that some procedures will require some exposure..... but like I said in my last post, a LOT of people simply won’t get those done.
Jason K
Dr. Bernstein I have 3 questions, (1) Can you honestly say you never had reason to believe ANY of your patients were uncomfortable with exposure?
(2) Can you honestly say you were completely unaware of body language and or other spoken or unspoken cues to lead you to believe that NONE of your patients were made uncomfortable by exposure?
(3) Did it never cross your mind that the expose just by the nature of the procedure, participants, etc. would just naturally be uncomfortable for the patient?
I am not trying to be critical but is seems like we have seen frequent examples of providers coping by deflecting the conversation. There is a tendency to make this about life and death situations in the ER than the routine exams and procedures, to make it seem like it is an either or rather than and....you can have the best provider/care OR respect for modesty, the modesty issue is about patients who refuse to seek medical care and put their lives at risk. There is a difference, my wife can easily express here displeasure with my actions without saying a single word...but believe me I am well aware of what she is thinking....Don
Maurice, I agree and have had great success. However, protocols need to be in place for those who need it in an emergency. That is sound medicine-promoting physical health; protecting mental health.
Belinda
Dr. Bernstein,
Don asked you three very important questions and I’d like to hear your answers. You mentioned before that you did not use any female assistants as chaperones for your male patients when you did genital exams on them. It is very possible that some of those male patients who you did genital exams on would not be comfortable with female chaperones or female doctors doing genital exams on them. If those male patients were only comfortable with male doctors, it is likely they would not complain to you since they got their wishes for a male doctor and no female assistants to be present.
I have one other question in addition to the questions Don asked you. Did you have any female patients who did not come back to you after the first intimate exam you may have done on them? I am well aware that many women feel that they have to give up their modesty for the sake of their health even though they are uncomfortable with male doctors. I have talked to some women who were uncomfortable deep down inside about male doctors doing intimate exams and just did not speak up. Even some women have made a decision to never let a male doctor do intimate exams on them again. 30-40 years ago, there were hardly any female doctors so many women did not have the option of a female doctor.
Misty
Any other physicians, nurses, PAs, etc. feel free to respond to these questions too.
I think I may have some insight as to why you (Maurice) have never heard any issues from patients.
If you practice like most physicians then it is a nurse, technician/med assistant/etc. that takes the patient to the room and gets them prepped.
If this is the case, do you really know what transpires. If the patient shows any apprehension, the nurses may NOT handle this situation ethically, scaring the patient into compliance. At that point, do you think the patient is going to bring up the issue when they are already in a gown?
Have you ever come in to an exam room to a patient who refused to undress? Then the conversation would start. Same goes for the OR, the prep nurse already has the patient ready.
Any nurses here who prep patients for exams or the OR on here: What percentage OR how many patients a day express reservations about undressing who will see them, etc.???
How many patients don't want to take their underwear off for surgery?
Nurses, have you ever told the physician that the patient had these apprehensions?
--Banterings
Maurice,
You said:
...I was totally unaware of the physical modesty complaints laid upon the medical profession prior to reading the comments from visitors to the first couple Volumes of this thread. I was never, never complained to by my patients...
Since you started hearing about the complaints on this blog 9 years ago, have you ever asked your patients?
--Banterings
As I have written here previously, I would inform my patients what I am about to do and if there was an assistant in the room as a chaperone or interpreter to ask if that was satisfactory for the patient. If the patient accepted my information and that question, that would be satisfactory for me to proceed. I have said "tell me if you feel uncomfortable"..but I don't define "uncomfortable". This is what I have always said to my patients and what I teach my students even before the last 9 years.
But despite my education on this blog thread, I would never ask the patient a direct question, based on what I learned here, such as "Will my examination cause you to be emotionally upset or have symptoms or reject further examinations or develop PTSD because of this examination in light of any modesty issues?"
..Maurice.
Maurice - sure, you explain what you're about to do and you say you ask if the patient is ok with the extra eyes in the room... but you seemed to have missed Banterings point.... if you operate like most facilities, by the time you (the doctor) walk in the room, the patient has already been told to strip down and gown up, so you really can't say that there was never any hesitation / apprehension / complaining on the patients part from any patient ever when it was just the patient and the nurse / tech / aid in the room.
If you really want to see "non-outliers" opinions on some of the things we've been discussing, when you're with a patient, hold up a syringe, and explain that you'd like to sedate the patient... and while they're out you may or may not bring in groups of med students to practice intimate exams on them, and you may or may not start taking pictures of their naked body, and while they're laying there uncovered, naked and unconscious, the windows and door just might be left open for anyone who happens to wander past to see in, and none of these will benefit the patient in any way shape or form.
See how ok a "non-outlier" is with those ideas.
Jason K
Dr. Bernstein, Not trying to badger you and maybe it is just language differences. Do you mean to say then that you asked, they responded, so you never had moments where you observed the patient being uncomfortable or had reason to believe they were because of this? I am just trying to clarify as I would have been one of those saying it is OK and dying inside. So, trying to drill down here, you never had any moments where you observed or felt the patient was uncomfortable with this regardless of what they said? I know from my personal experience I was fighting the anxiety at times bordering on a panic attack though I am not sure I really know the clinical definition of what constitutes a panic attack. I know for me my actions, the speed of talking & actions were out of my norm but doesn't mean someone who didn't know me would recognize this. My bp has shown the anxiety numerous times, but that is internal. Then there is the just the nature of what is going on, we all understand this is routine for the provider but on this side of the gown we just struggle to understand how providers could not know a woman with her feet in the stirrups is not comfortable and having additional males in the room would only increase that feeling. Our minds work differently and point of perspective is huge in these things so not saying BS. Just a key part of the argument we are trying to understand...don
Maurice,
You said:
"Will my examination cause you to be emotionally upset or have symptoms or reject further examinations or develop PTSD because of this examination in light of any modesty issues?"
Nobody knows what will give them PTSD. I know that the concept of this may be hard for you to grasp...
You also said:
"....would be satisfactory for me to proceed. I have said "tell me if you feel uncomfortable"
Sounds like they are already in a gown on the table.
Very diplomatic. Almost sounds like you don't want to know.
Have you ever said in a consultation (not an exam) when the patient was fully dressed:
I have read that some patients may have issues with having their body exposed, especially to many people. I am not aware of patients having problems from procedures performed professionally. This procedure will involve significant exposure. There will also be medical students examining you. Is there anything in your past that may make you more sensitive to this procedure (such as sexual abuse or a previous bad experience in a hospital)?
It seems that the "system" doesn't want to know.
That is like physicians hearing about Middle East Respiratory Syndrome (MERS) and merely asking patients "are you breathing OK?"
You know that patients potentially may have problems, yet you do NOT specifically ask?
What about "for the pursuit of knowledge:
I know that we are checking your arm only, but I have heard that people may have had a bad experience at the doctor's as a child that has affected them and how they seek healthcare as adults, have you...
I can't believe that you never had a patient refuse an intimate exam. I can only think that you are dealing with a population of patients that are somehow stratified. It very well may be due to "liberal" attitudes of the Cali major metropolitan areas.
My point is that "do no harm" means specifically asking.
Patients’ expectations of private osteopathic care in the UK: a national survey of patients This study shows that patient's expectations of modesty were high, and borderline in being acceptably met. This is the UK, their standards are higher to begin with.
Have you ever asked yourself why you take such a passive attitude in regards to this? You say "patients never informed you there was a problem" yet you did NOT specifically ask.
I ask you, WHY?
--Banterings
*** Said by Banterings @ Wednesday, August 06, 2014 5:43:00 AM
Have you ever said in a consultation (not an exam) when the patient was fully dressed:
I have read that some patients may have issues with having their body exposed, especially to many people. I am not aware of patients having problems from procedures performed professionally. This procedure will involve significant exposure. There will also be medical students examining you. Is there anything in your past that may make you more sensitive to this procedure (such as sexual abuse or a previous bad experience in a hospital)?
*** Said by Banterings @ Wednesday, August 06, 2014 5:43:00 AM
Even that question isn't really a fair question... people don't need to have a reason / past bad experience to not be ok with exposure / extra eyes.
The question should be ...
"I have read that some patients may have issues with having their body exposed, especially to many people. I am not aware of patients having problems from procedures performed professionally. This procedure will involve significant exposure. There will also be medical students examining you, so I'm just curious if you'd have any kind of hesitation or problem at all with exposure in the pressence of other liscenced medical people such as a nurse, or people with no medical liscence, such as students, the scrbe who's taking notes or the secretary who has no medical training and was hired for her typing skills, but I might call in to act as chaperone?"
I'm almost half curious if Dr. Bernstein might just work in a nudist colony... that would certainly explain going for YEARS without coming across a single person who has a problem exposing themselves to strangers.
Jason K
In response to all: What I am writing here is based on my own experience in internal medicine and I am not aware of what other physicians in this or other areas of medical practice are experiencing or how they are anticipating or reacting.
The reason a patient goes to a doctor is for help in treating symptoms of disease with relief of symptoms, diagnosis of the disease and the specific treatment and hopefully eradication of the disease. And this is exactly what a doctor has in mind also as to the duty toward his or her patient. The doctor is aware that these goals must be attempted and carried out under the limits of established professional motivation and behavior. Hopefully, the patient comes with similar awareness. If there is any uncertainty on the part of the patient in this regard, the patient should make that uncertainly clear to the physician at the outset. I tell the patient what is expected in terms of history, examination and later regarding the most likely diagnoses and workup. I will not tell them and detail to them all the horrific personal consequences of the interaction between the patient and healthcare provider as described on this thread, as I also would not tell the patient every unlikely diagnosis which could be made from a differential diagnosis list If I did tell, these announcements would in no way be acts of beneficence to the patient.
Yes, I do recognize during the exam if the patient is in discomfort and immediately stop ask the patient to explain the discomfort and I listen but I don't first run off a list of physical and emotional possibilities. I listen and then will respond appropriately to the patient.
Informed consent requires that I inform the patient what I intend to do, why I am doing it, how it will be done and who, if anyone else, will be present. And then I await to answer the patient's questions. This is informed consent. I rarely have had "shadowing" by others but it was always with the patient's understanding the background and role of the other leading to acceptance or rejection of that individual. When I am about to go into a patient's room with a group of 6 medical students, one of the students who had already developed a relationship with the patient will first get the patient's permission for the other students to enter to observe a specific physical finding and then I come into the room and verify that acceptance before I have the other 5 students to enter. Rarely, the patient would say "no" but if the patient did say "no", I would never argue "but this is a 'teaching hospital'" We just thank the patient for his or her prior acceptance of the one student and leave.
As I have written previously, my first year students watching surgery at a children's hospital, as long established program at our school, and which I have had no personal contact with the family is based on my assumption that the hospital has obtained permission since I am in no position, at the time, to verify whether such informed consent was actually given in each case or permission implied or not given. There is a difference between this activity and a medical student examining a patient under anesthesia without specific informed consent previously given.
No nudist colony or porn actors as my entire patient population existed in the past or present. If the patient didn't speak up regarding a modesty issue, it was only because they just didn't speak up. ..Maurice.
Re: the paragraph Dr. Bernstein wrote about surgeries at a children's hospital...
*****" based on my assumption that the hospital has obtained permission since I am in no position, at the time, to verify whether such informed consent was actually given in each case or permission implied or not given. There is a difference between this activity and a medical student examining a patient under anesthesia without specific informed consent previously given."*****
1) Why wouldn't you be in a position to take a quick look at the signed paperwork to make sure they didn't cross out the observer / student involvement parts? it's a scheduled surgery, not a life or death in the ER emergency surgery...
2) I'm not seeing a whole lot of a difference between "this activity and a medical student examining a patient under anesthesia without specific informed consent previously given".... both cases involve the use of a patient without their permission and at no benefit to the patient, not to mention the loss of control for the patient for who gets to be involved in their care / see them exposed... assuming they had the chance to request something like an all same gender team and that wish was "granted".
And you say patients rarely said no to students... in what context are you counting? I'm fairly confident I can speak for most of us when I say there's a difference between us patients wearing our street clothes and a group of med students coming in to look at our elbow ... even palpitating an abdomen Vs someone being bent over a table and the doc asking if it's cool if some students come in to check out his prostate condition. I know you're in internal medicine, but I can imagine a gynecologist, urologist, or proctologist might have a higher rejection of extra eyes rate than a rheumatologist or a neurologist would.
Jason K
Before the advent of the HMOs in the early 80's medical procedures were different. I was at board meeting of a local hospital when the question of whether or not to join an HMO network was being discussed. The administrators and board members were quite wary, at this point. Their main concern was how these companies would impact patient care. The hospitals joined the networks, because they saw the writing on the wall and did not see how they could survive without joining.
One of the major changes was the HMOs began limiting the time doctors could spend with patients. I remember the days before the HMOs when a visit to the doctor, especially a visit involving intimate care, such as a gynecologist, or urologist, was divided into three parts. First the patient met with the doctor in his private office. This was an opportunity to discuss the reasons for the visit as well as any specific issues that were of concern to the patient, such as modesty, fears of exposure, or any other sensitivity issues. It was at this time the the doctor/patient relationship was forged.
The next step was the physical examination. After the preliminary discussion, the doctor and patient knew all of the important issues. They had met on level ground. One person was not dressed and the other exposed while they talked.
After the exam. The patient dressed and had a follow up discussion with the doctor back in the doctor's private office. It was during this meeting that the results of the exam were discussed along with future plans for treatment.
All of this took more time than just the one size fits all we have today whereby the doctor walks to the exam room and meets the already prepped patient and everything is done in this room.
The patient's dignity is maintained and respected. The patient is treated like a whole person and not just a body with a problem.
I know many doctors who still practice medicine the old way. The HMOs do not like this. After all time is money. What gets lost is that patients are people and deserve better care. They deserve to be treated like individuals with individual needs. Doctors need to listen to their patients and do what is necessary to insure that each individual is treated with respect and dignity as defined by each person.
Dr. Linda E.
Maurice,
I don't know what your practice speciality is, but let's say its bladder cancer, I doubt that you would be getting complaints.
Again, I believe that you may have a stratified population sample.
Have you never encountered a situation where the patient is getting surgery and you tell him to undress, put on a gown, and he questions why being naked for hand surgery?
Further I am not suggesting that in consultation you tell patients you may suffer PTSD from this exam, what I am saying is that knowing patients may have modesty issues, do you ask them their expectations?
Telling them what will happen and asking if they understand is different than asking their expectations.
You further said:
I have had no personal contact with the family is based on my assumption that the hospital has obtained permission since I am in no position, at the time, to verify whether such informed consent was actually given in each case or permission implied or not given.
I cannot believe that you would expose yourself to such liability. What if there is NO consent and charges are filed? Is your defense simply "I thought the hospital gained consent?"
What about the potential careers of the students that you put at risk? Truly you have just illustrated that it is about the convenience of the provider otherwise you would know for sure that there was consent.
No offense Maurice, but it seems that you are NOT asking a lot of important questions. Please correct me if I am wrong.
--Banterings
Banterings, I am not a surgeon and I do not deal with preps for a surgical procedure except to be attentive to whether the patient is on an anti-coagulant or other significant risk medications prior to a scheduled surgery amongst other pre-op medical considerations.
No, I don't specifically bring up the topic of physical modesty to the patient unless it is inferred regarding permission in having a chaperone or another person during the physical examination
No liability for me or my students simply observing surgical procedures on children. We are the official invited guests of the hospital and in no way do we interact with the patient. The only risk that I have observed with my students is rarely a student develops a vaso-vagal reaction from the experience and has to leave the operating room to sit in the hall on the floor until the faint feeling resolves. ..Maurice.
Banterings, We're usually on the same page but not this time. You are making this personal.
I don't know about everybody else, but in posting, I also take away what people are saying and take time to process it and here's the conclusion that I have come to.
First, Dr. Bernstein is kind enough to have this blog forum for us. He doesn't come from our experience, has heard some horrendous stories and has his own perspective and I rarely agree with him. I've wondered many times just what he thinks about us and what we say. He tries not to say too much for many reasons but sometimes I wish he would say more.
It's a also important to recognize that when terrible things happen to our dignity that shouldn't, we get very anger. If not dealt with, the anger lives on and we express it here. I think our moderator understands that.
A normal examination should be explained to the patient. Once that is accomplished, nobody is going to get PTSD from a normal, explained examination. They may be uncomfortable, embarrassed, etc. but they won't be traumatized because they knew what was going to happen, who will be in attendance and what level of bodily exposure they would be. It's when something abnormal happens (with or without malice), an open door, people coming in without patient knowledge or consent, etc., and of course abuse of any kind that can and does cause emotional trauma.
It is also safe to say that you have to be a moron not to understand that being undressed for an exam makes some people uncomfortable, especially a group as in a surgical situation and there's that gender issue.
I must say that when I have intimate procedures done, I never feel uncomfortable when they are properly executed. And, they always are because I trust my doctors, have those discussions, bring those written requirements so they become part of my record and proceed with whatever. Embarrassment is not on the table for me. That may seem odd to you given my postings. What does bother me is disrespectful behavior and feelings of distrust from misinformation purposefully configured to either attempt to confuse, manipulate or just blatantly lie to patients. I have seen it and I have experienced it...in the past. It is our job when we go into a healthcare institution to lead by example, express your needs and even if they are not properly executed to try to maintain calm. They understand that. Once we go nuts, they think we are, and that we are unstable.
Yelling and screaming and carrying on is not going to help keep the blog going either. There are times where I feel that Dr. B is either fooling us or fooling himself with his sheltered stance at times, but that's for him to decide.
The problems are really about the medical system and what needs change. Some of these are:
Informed consent of psycho social issues and expectations included in the consent form.
A place on admission form to state any special requirements that a patient may need and to add an attachment.
Enforcing patient rights and not try to coerce patient's into participating when they don't want to participate.
Take a picture or ask for a copy of all forms that you signed.
You have the right to accept or refuse any treatment.
What you cannot do is get upset and leave without permission or your insurance won't pay the bill.
However, if you keep refusing treatment, they will gladly discharge you.
Last, everything should be done to make a patient stay as comfortable as possible. Psychological needs are just as important as pain medication. The pain from surgery will go away. The pain from poor emotional treatment will not. It will be there every time you need medical attention. Maurice, I think this last paragraph is the most important thing I've ever said here.
belinda
Ed I understand and agree I feel a little bit like part of a wolf pack circling the prey but there is a very important aspect of this issue in play. Dr. Berstein made the comment "Yes I do recognize when the patient is in discomfort.... One of the main explainations for this issue existing unaddressed is ignornance of the issue in the first place. If one reviews the blog it has been put forth by providers, including Dr. Bernstein that the medical community is largely unaware there is a problem. That problem is that exposure in the medical setting is a concern or problem for patients, that it makes them uncomfortable. My problem is and has been that I do not see how this is possible. Not the extent, not that people avoid care because of it, but that it exists. I have been challenged by Dr. Bernstein and and other providers on numerous issues that have made me reflect on my thoughts and concerns and I have changed some of my thoughts and approaches. That is what I have been driving, providers have to know there is an issue, whether it is spoken or not. Admitting that they are aware of the issue whether a patient told them or not changes the whole discussion. The discussion of I had no idea and I was aware but....are two completely different discussion. That doesn't mean i do not respect or appreciate what Dr, Bernstein has done here for us and me personally. I have made huge progress directly related to this blog. There is a book called 5 dysfunctions of a Team dealing with the harm of not recognizing and dealing with issues causes. I have still never heard a provider say "I know this causes discomfort for some patients", Look back. Artiger came close.
Belinda, you stated ....you would have to be a moron not to understand that being undressed for an exam makes some people uncomfortable...yet that is basically what providers would have you believe, they had no idea. That is why I persist...don
I just thought of a way or analogy of how to express better what I am trying to say in answer to those who are concerned here about the view of physician toward their patient's modesty issues.
All doctors (and nurses) I am sure recognize that each of their patients have various degrees of physical modesty just as they do themselves. What I think is the common belief by the healthcare providers is that the expression of physical modesty is situation-directed and that all patients are aware of this similar to the professionals. What is situation-directed? Take the example of a nude artist model standing in front of an artist or a group of art students. I am certain that all nude models are not naturists and wouldn't walk around nude in public. But, as a essential part of their occupation and paycheck, they suppress their feelings about their nudity to be a participant in their job. In this case, their modesty suppression is situation-directed.
My suspicion of what all physicians (as myself) have assumed (and obviously for some patients assumed incorrectly) that every patient who comes to a doctor for examination and treatment has set aside their modesty for this particular situation. This temporary reduction of modesty during the examination or treatment is necessary to accomplish the self-benefit for the patient's own benefit and thus is situationally directed. The doctors, I think, assume that in this therapeutic situation, if the healthcare provider sticks to careful only professional behavior, all patients will accept this "letting down" of their prior modesty.
Obviously, from reading this thread over the years, it appears that this physician belief about their patients is wrong. There are some patients who cannot accept whatever degrees of loss of modesty is required as set by the professional methods of care. And that is why, to me and I suspect to most doctors, some of the requests about change in practice and behavior would be totally unexpected. But that misunderstanding (assuming that every patient understands about situation-specific loss) does NOT mean that all doctors don't believe that the concept of modesty is irrelevant in the examination and treatment of a patient.
I hope I explained this error in doctor-patient understanding adequately. ..Maurice.
Maurice - you said " if the healthcare provider sticks to careful only professional behavior,"
They repeatedly proven they haven't, won't, or can't ... and frankly, it's too late for the medical profession to get that trust back without MASSIVE changes.
I'm still thinking patients personal chaperones (as opposed to the doctors employees who will NEVER speak up against their paycheck acting as chaperone) with video cameras and CRIMINAL charges for misdeeds... not this internal investigation / disciplinary warning / suspend or revoke the license garbage.
If you took your car to a mechanic, you saw some other person driving it past you on the street, and it came back with an extra 1,000 miles on the odometer, and missing the stereo, would you be happy with the garage owner saying "We'll look into it, and if the mechanics notes say he did anything wrong we'll deal with it internally"?
Jason K
Belinda,
On Wed. Aug 6th you wrote:
"What you cannot do is get upset and leave without permission or your insurance won't pay the bill."
This is not true - it is an urban myth.
Hex
I believe that medical practitioners are slowly becoming more aware of patient issues such as modesty and dignity. A review of the literature reveals that these issues are being studied. However, not all doctors are up to date on the latest research.
Given that, since this is my specialty, Health Psychology, I can tell you the latest. The official sub-specialty is Psychoneuroimmunology. It is the effect of stress on long and short term health outcomes.
Just as there are doctors who still believe that pain is just something that is annoying and that patients complain about, there are doctors who still believe that issues like modesty, dignity, and other psychological stress have no real long term effects.
The reality of the situation is that these factors activate the HPA Axis (Hippocampus, Pituitary Gland and Adrenal Gland. This causes the release of cortisol, a stress hormone into the blood stream, shutting down the immune system and activating the inflammatory system. If the stress is ongoing this will lead to stress related diseases such as cardio-vascular disorders, such as heart attack, angina, stroke; diabetes, cancer and other potentially fatal conditions.
The mind and the body are connected. They are one entity and need to be treated as such. While my actual doctoral study was on the doctor/patient relationship and the effect of encounters with support staff, there is a wealth of information in the literature review on this subject.
You can access it, free of charge at Pro Quest. Just google my name (Linda P. Erlich, PhD)and you will get the link. I believe that anyone with issues with modesty and/or dignity in medical settings will find my study and results to be very interesting.
Dr. Linda E.
Belinda & Maurice,
I apologize for not being more clear. I AGREE with both of you that a procedure that is explained, understood, ALL parties agreed to what, how, etc. will happen, AND stick to that course should not produce any mental trauma.
As Belinda stated so eloquently;
It's when something abnormal happens (with or without malice), an open door, people coming in without patient knowledge or consent, etc., and of course abuse of any kind that can and does cause emotional trauma.
This also includes coercion, of any kind. Unfortunately the "abnormal" has become the norm. The procedures/ laws include the phrase "when practicable" make normal what is convenient for the provider.
I also believe that most of the trauma patients suffer are at the hands of nurses more than physicians. Like you Belinda, I have a good physician that I work with and he works with me. That being said, my pants do NOT come off.
I am NOT angry, and I am sure that Dr B will tell you that I try to keep my discourse respectful. If you look at the way I pose my questions, they are based on my experience doing research.
I cannot believe that Dr B has only ever experienced these issues first hand, as some others here feel too.
Maurice, if I have offended you, or anyone else on this forum, I apologize. That is not my intention. I, just as much as everyone else here respect and appreciate this blog.
I would hope that Dr B can also see the questions that I pose to him are how any researcher would approach a perceived anomaly.
I also am wondering, that if not for other reason than knowledge for the sake of knowledge, has Dr B not asked about this of a person in front of him if given the chance? Why solely rely on this and other blogs?
"There are those who seek knowledge for the sake of knowledge; that is Curiosity. There are those who seek knowledge to be known by others; that is Vanity. There are those who seek knowledge in order to serve; that is Love." (Bernard of Clairvaux)
Belinda, you said:
"...but they won't be traumatized because they knew what was going to happen..."
Again I refer to the expression, "if you go to prison, you will get raped." Does that mean you will not be traumatized if you know what is going to happen?
This could actually lead to Stockholm Syndrome. I don't want to go into the mechanics of it, but some traumatized patients who don't object may be victims of Stockholm Syndrome.
Do we as patients not have the right to choose the level of healthcare we wish to receive? Why is it all or nothing?
Maurice,
I think a better example is that nude artist model standing in front of an artist for a painting. When she is finally posed, 6 photographic art students come in with cameras.
There are some patients who cannot accept whatever degrees of loss of modesty is required as set by the professional methods of care.
Set by the professional methods means set by the provider. I am sure that you are aware of policies of the patient naked in a gown for every surgery. Is this truly necessary for outpatient hand surgery???
Consider the the standard procedure for prepping a patient for all surgery, including outpatient: naked wearing only a gown, wheeled into the OR on a gurney. Consider what LDS Hospital in Salt Lake City, Utah did as part of their overhaul of healthcare delivery in 1998:
SOME PATIENTS were especially bothered to spend half the day without underwear -- for shoulder surgery, say. Ms. Lelis was convinced this longstanding practice was meaningless as a guard against infection, persisting only as the legacy of a culture that deprived patients of control. "If you're practically naked on a stretcher on your back," she says, "you're pretty subservient." The nurses persuaded an infection-control committee to scrap the no-underwear policy unless the data exposed a problem; they have not. Source: The Wall Street Journal
So if as a patient I object to removing my underwear in a Philadelphia hospital for outpatient hand surgery my expectation is unreasonable because the professional methods of care says so???
The professional methods of care is wrong. LDS Hospital has demonstrated this. The situation calls for me to "let down" my modesty modesty, but not to the point that I have to undress completely.
The 8th edition of ATLS limited the indications for the DRE when in the 7th edition it was for ALL trauma patients. I argue that the professional methods of care are being proven incorrect, modified, and rewritten.
Why would we not question the professional methods of care and demand improvement when we have been correct so far?
On a sad note, see the link: Virginia Doctors Sued After Patient’s Cellphone Records Them Mocking His Unconscious Body
--Banterings
Dr. Linda,
In response to your comments below:
You can access it, free of charge at Pro Quest. Just google my name (Linda P. Erlich, PhD)and you will get the link. I tried finding it on Google, but I could not find your article. Can you please give the exact link?
Misty
Banterings et al: Go ahead and plan and act to change the medical system to be fair to all patients and to meet your goals for standards of practice. Write about it here, what you want to do and get folks together to actually work for the change. As I have written, I along with Doug Capra have attempted our little contribution via AMA news and my futile attempt at a internet petition and my introduction of this blog thread to my group of medical students. Now let's see, instead of simply "moaning and groaning" here or complaining that Dr. Bernstein doesn't understand, etc., what you all intend to actively do to make the changes. Start now and write here exactly what you are doing and what help from others you might need to make the changes. Be activists!! and not just whiners. ..Maurice.
Maurice,
I have written letters, I have started my own blog, and I attempt to draw attention to the issue on other blogs. I have also invited many physicians to participate here.
I have been trying to figure out what the answer is.
I only know how to change the world one person at a time.
--Banterings
Misty - I think this is the article
From Dr L
http://pqdtopen.proquest.com/pqdtopen/doc/250897797.html?FMT=ABS
Jason k
some good stuff here. Dr. Bernstein I am still trying to digest your comments. It does shed light on how/why providers can justify what they are doing. I am still of the opinion that providers have to know the discomfort they are causing but it does perhaps explain how they rationalize what they are doing. The difference between the art student to me is obvious and shows a bit of the self delusional behavior providers may be practicing. On one hand patients are chided for not putting aside their feelings of modesty to get treatment, but on the other hand providers say they just assume patients are comfortable with what they are doing given the context. I find providers to be hypocritical in that context doesn't seem to matter when they are on the other side i.e. nursing students being asked to participate but it does for patients. But your explaination does perhaps help me understand WHY and how providers can justify their behavior to themselves. I need a little more time to think about this....good conversation...don
Misty,
Thank you for trying to locate my dissertation. I have not attempted to do so for a while. Here is the link.
http://gradworks.umi.com/33/97/3397607.html
I have also discovered that it is available from Barns and Noble and Amazon!! as well as some other venders. I did not know this and I need to investigate this.
Dr. Linda E.
Just a random thought and along lines of the anology of you know rape happens in prison so that should not be a trauma when it happens. Providers know that pain is part of some procedures, the fact that patients are there to be treated for a problem that requires that procedure would indicate the patient has accepted the pain for self benefit...yet we all, provider and patient expect the provider to do everything possible to minimize the pain. Yet that same mentality is not applied to modesty. The fact that the patient understands an accepts the uncomfortable feelings compromising their modesty for care may require does not relieve providers of the duty to minimize that "pain" anymore than it relieves them of the duty to do everything they can relief the discomfort caused by physical pain..still need to think this through and the implications of it....don
Banterings,
You mention "a Philadelphia hospital". I would like to talk to you about this off line and Dr. Bernstein can refer you to my personal e mail address. I would appreciate it. Thanks.
belinda
Linda, What a great commentary on the medical connection to stress.
Maurice, do you believe that this issue should be the navigating piece to illicit the change that is so badly needed.
Also, Maurice, does it seem any more understandable to you how one might forego future medical treatment if previously subjected to cruel or degrading care?
belinda
Maurice,
Some time back in Patient Modesty: Volume 67 we discussed people who avoided necessary care out of fear. I believe (correct me if I am wrong) that you (possibly someone else too) may have disputed that this actually happened.
You can read here an article about a 2009 study titled: "Tomophobia, the phobic fear caused by an invasive medical procedure - an emerging anxiety disorder: a case report physiological arousal covert feelings and thoughts and overt behavioral reactions."
The study is posted on "The National Institutes for Health" website (www.nih.gov). The conclusion that this study reached was :
Due to the rising number of surgical interventions in modern medicine, as well as the high number of unrecognized cases of tomophobia, this common but underdiagnosed anxiety disorder should be highlighted.
Granted it does not say what was the basis of the phobia. The study further concludes:
Above all, surgeons and general physicians may be increasingly confronted with patients who refuse medically urgent procedures due to tomophobic fears.
Both Belinda and Banterings bring very important points. I know of several people who have decided to forego future medical treatment if they had bad experience or heard of family members' bad experiences.
For example, I know of a lady who was so traumatized by her birthing experience that she decided to not have any more children. She was supposed to have her baby with a midwife, but she ended up having a C-Section because he was breech. She got her wishes for a female gynecologist, but this doctor ignored her request that no medical students be present. Also, some people have decided to not have any more surgeries because they were stripped unnecessarily.
I looked at Banterings’ article about Tomophobia. Many people avoid surgeries for other reasons besides of patient modesty.
We will never be able to change the whole medical system, but we definitely can speak up and educate medical professionals about patient modesty and how to be more sensitive to patient modesty. There are certainly some great medical professionals who are sensitive to patient modesty.
Misty
I tried to go to the site but it says page missing. Dr. Key's comments are very telling of the arrogance of some provides. The issue is about THEM not the patient whom is paying the tab. Where else in the business-service world would providers of service think it is about them, not the patient. Disturbing yes, a surprise no. It has been demonstrated over and over providers often have the mentality of what they choose to provide, what they think is right for you, makes it not only acceptable but right for patients. Is it any reason there is a issue, what an arrogant self rightous attitude. What was right for me is right for you....how similar is the concept to many of the great atrocities imposed on mankind by others. My religion is right for me so it is right for you....i have no respect for someone like that at all....don
It has been demonstrated over and over providers often have the mentality of what they choose to provide, what they think is right for you, makes it not only acceptable but right for patients. Is it any reason there is a issue, what an arrogant self rightous attitude. What was right for me is right for you....how similar is the concept to many of the great atrocities imposed on mankind by others. My religion is right for me so it is right for you....i have no respect for someone like that at all....don
Totally agree! Well said. These are are the actions of a dictatorship. Not a democracy.
Paul
Don,
I love that analogy!!! That is great.
Let's expand it to the Romans: You can worship YOUR God how you see fit. If you want us to save your life (by not invading and pillaging your lands), you will worship Caesar as a god by paying tribute....
--Banterings
Maurice... your nude model comment got me thinking, and a thought did occur...
**** Said by Maurice, Wednesday, August 06, 2014 6:09:00 PM
All doctors (and nurses) I am sure recognize that each of their patients have various degrees of physical modesty just as they do themselves. What I think is the common belief by the healthcare providers is that the expression of physical modesty is situation-directed and that all patients are aware of this similar to the professionals. What is situation-directed? Take the example of a nude artist model standing in front of an artist or a group of art students. I am certain that all nude models are not naturists and wouldn't walk around nude in public. But, as a essential part of their occupation and paycheck, they suppress their feelings about their nudity to be a participant in their job. In this case, their modesty suppression is situation-directed.
My suspicion of what all physicians (as myself) have assumed (and obviously for some patients assumed incorrectly) that every patient who comes to a doctor for examination and treatment has set aside their modesty for this particular situation. This temporary reduction of modesty during the examination or treatment is necessary to accomplish the self-benefit for the patient's own benefit and thus is situationally directed. The doctors, I think, assume that in this therapeutic situation, if the healthcare provider sticks to careful only professional behavior, all patients will accept this "letting down" of their prior modesty.
**** Said by Maurice, Wednesday, August 06, 2014 6:09:00 PM
By the same logic, shouldn’t you assume that everyone who has worked hard to be accepted to med school is there for their own “self benefit”, and knows they’re going to be a participant in their education / upcoming job. In this case, their modesty suppression should be situation-directed.
When practicing intimate exams on each other, it shouldn’t be a problem for them as this temporary reduction of modesty during the examination or lesson is necessary to accomplish the self-benefit for the students own benefit and thus is situationally directed.
The doctors / Teachers, I think, could assume that in this educational situation, if the teacher and the students who preform the exam sticks to careful only professional behavior, all students will accept this "letting down" of their prior modesty.
Jason K
The nude model scenario is quite different from a patient situation. The difference? The nude model made a conscience decision to stand posed for money. It was something that they chose to do and not something they had to do.
I was a professional model as a young girl required to wear body makeup everywhere and changing in a small tent with lots of other women. All there was, was a curtain with all the photographers who were male on the other side of it, and I had no qualms about it. I knew I'd be photographed wearing bikini's (and they weren't anything like the bikini's today).
I was paid, enjoyed the work and helped pay for college.
Patients are put into a situation where they have to make a decision about what state of undress they are willing to tolerate. Models don't tolerate their jobs. They may enjoy it, or are comfortable.
There's always another way to make a living. This is different and once you've had a bad experience, it's really different.
belinda
There are a lot of holes being poked in your concept of "situational context" Dr. Bernstein, but I still get your point. Because it is in play does not mean it is right. My father talked of his dismay of being in the south right after the war witnessing the blatant racism and how he argued with a army buddy from Mississippi. Both were looking at the same issue, with vastly different views of it. I do not accept the concept of situational as eliminating the issue in the minds of the providers. I do however believe that it does provide the ability to cover or justify. Just as Dr. Key felt his position of "we are professionals" justified his position...and most of us find it ridiculous if not offensive...it does help me understand how providers can be part of this process when they are other wise good compassionate people. The recent discussions also highlight that we sometimes seem to be search for THE reason, when actually there are numerous reasons this occurs and therefore the answer to fixing it is one a single silver bullet. And while I think we beat the concept up sufficiently, I can't resist one more jab...I had a spot taken off my chest. My dermotolgist gave me the choice cut or burn. I chose burn so I wouldn't have to come back to have the stitches removed. So I intentionally chose to let him take an laser and burn me, he did great. I trusted that he would only burn what was absolutely needed and would numb me up to the best of his ability to minimize the pain. When it comes to modesty, providers don't seem obligated to do the last part "...to the best of their ability to minimize pain", but rather see it as permission to do what works for them and fits their need. And thus, I have less anxiety about my MD taking a hot laser to my chest than getting a ultrasound, because when it comes to modesty, there is no effort to go that "to the best of their ability for my comfort"....don
I have previously discussed here the issue of modesty on the part of first and second year medical students learning how to perform a physical examination. Though both they and patients have their own physical modesty to cope with, the requirements and goals of exposure of ones body is different between the two. For the patient, there is only one goal and that is to allow proper diagnosis and treatment for a disease or screening for a disease. There is no other reason. For the students, the goal is to learn the technique of performing a physical exam. Whereas for the patient, despite technology in medicine, degrees of exposure of one's body to the physician or nurse is still necessary. For the student, their goal is being met by the use of standardized teacher-subjects for female breast exam, pelvic and male genital exams. And the remainder of the body examination is performed by the students examining each other in the bodily areas of chest. abdomen including inguinal and extremities. All shirts and blouses are taken off and the women wear sports bras. Despite their own various degrees of modesty, virtually 100 percent of the students accept examining each other and exposing their body for the goal of learning and not for any medical diagnosis or treatment. And the students learn the basic details of patient modesty regarding the "sensitive" areas as they work with the standardized teacher-subjects. And if you are aware of what goes on in these sessions, as I am, you would certainly see the students engrossed in the issue of patient modesty and required professional behavior. Unlike whatever "need" there is for a patient to be subjected to nudity (and there is rarely, if ever, that is necessary or standard procedure including derm exams, as I have written previously), there is no need for education for the student either to be subjected to nudity as some have recommended on this blog thread.
Whatever, the students must additionally learn about patient physical modesty is taught to them by supervision ny their instructors as they examine real patients. But the students all know that bodily exposure of a patient is established first by patient consent either direct or implied after educating the patient about what is to be done and why. I personally have no control on any "hidden curricula" they are given beyond year 2 and on into their careers.
I hope this repeat commentary explains again the facts regarding why there is no rational basis for medical students to learn about modesty or to learn examination as nude participants except for the testy argument "if you are going to do this to us, you should try it on yourselves first!" ..Maurice.
Maurice –
Standardized teacher subjects may be used at some schools, but you will never convince me that non-consensual exams still don’t take place.
****“But the students all know that bodily exposure of a patient is established first by patient consent either direct or implied after educating the patient about what is to be done and why”****
Earlier on this page you said you took a group of students in to watch surgery, and had just “assumed” there was consent.
And again, it’s the semantics game of naked vs exposed... anyone in an honest conversation would not claim that someone on a table with only socks and a t-shirt on, but their genitals exposed, isn’t naked.
If you want a rational basis why students SHOULD practice intimate exams on each other, how about.... it will save the institutions money hiring the standardized teaching models, they guarantee that they won’t “come up short” finding models, and the places that do practice non-consensual exams can stop (basically) forcing their students to commit what should be considered sexual assault (and would be in any other setting on the planet).
I’d be interested in hearing a rational argument why they shouldn’t. (so far the closest one I’ve heard is that it would be embarrassing for the students, as they’d all be in the same class for long after the exam... but that doesn’t fly, simply because they should “simply” apply situational direction to their modesty, and then it wouldn’t be a problem... right?
Jason K
In my opinion it does show the difference we are trying to convey from our side Dr. Bernstein. There are many more stringent examples of this from allnurses but we will use your example. Providers still draw different lines, and more rigid lines for patients vs providers. I would also argue that there often is no need for patients to be subject to exposure to the opposite gender under the guise of "situational context" and yet it is routinely applied with little or no thought. A patient could often be accommodated but is not because in your explaination the situation has dictated compromise. Yet when it comes to providers, particularly students the rationale is they don't HAVE to be exposed to learn. They comply to a point but then are not asked to step over that line that might make them really uncomfortable because other options are offered. Why then do we say that since the patient has submitted to this, providers are blind to the need to provide the accommodation that would accommodate that especially uncomfortable part like students doing pelvic, genitals, breasts, etc. The fact that providers see the need to do that for their own, but fell the same concept of situational relieves them of doing so for patients is a look into the mind of the provider that causes this problem...don
After reading over my shoulder, my girlfriend suggested a list might be a better way to compare sedated patients vs med students for practice victims for a “rational comparison” .... so why not. I’d love to see Maurices point of view on the 4 basic categories .
Patients Vs Students in context of students practicing pelvic / rectal exams on sedated patients vs practicing on each other.
Why they’re there
Patient: They’re at a hospital for a surgery, likely a life saving / medically necessary one.
Student: They’ve made the choice to pursue that career path, and could just as easily be informed during the application process that a requirement would be to allow other students to violate their bodies.
What happens if they don’t subject themselves to the possibility of violations by (other) students?
Patient: If they chose not to be there, they could literally die.
Student: if they’re not OK with it, could simply pursue a different career.
Effect on mental well being / aftermath
Patient: If they find out it happened to them or are suspicious it has, they would have the same emotional trauma as a rape victim, as their bodies were literally penetrated without their consent, and their most personal areas were exposed to who-knows how many people. Their relationship / trust with their doctor/ medical community in general is beyond gone. The doctor / medical society as a whole effectively allowed them to be raped. Not just allowed, but arranged for it to happen.
Students: None. They can simply turn on their “situationally directed modesty suppression”, and will be completely ok with anything done to them and any kind of exposure under the context of their education, and can consider it "part of their job".
Benefits
Patient: None what so ever. Inexperienced students could even cause physical damage to the patient.
Student: Furthers their education, and the education of their fellow students which furthers them on their career path.
Jason K
Jason, first I am against any teaching program in which students perform pelvic exams on anesthetized or sedated patients without the patient's specific approval of that exam by that student. And I think that this practice of such exams without specific permission is fading away from medical education.
Second, I see no need to compare medical students modesty experiences of one sort or another with that of patients. Medical students become patients themselves either for routine exams or illnesses themselves and are exposed to the examination and management of their own physicians and the medical system. They are exposed to similar experiences as most non-medical student patients. Remember, medical students are humans as we all are with just as private bodily parts.
..Maurice.
Instead of tabulating lists here for me as your now only physician respondent for me to answer as Jason and others have done, why not starting now, create a more significant and possibly more effective list: A list of potentially productive efforts each visitor should consider and possibly actively participate to change the medical system and meet the goals of change that have been repeatedly documented and detailed here? Let's make that list and add to the list. And then, instead of being isolated, anonymous visitors to this blog thread come together, communicate directly by e-mail to each other to work together to achieve the goals. Wouldn't that be more productive to achieve a goal then what has been the activity here all these years.
I have a beginning suggestion: Let's see our visitors, with their skills of communication, to start petitions on multiple internet petition sites. I am sure many of you can do a better job than what I tried a few years ago on one site.
So let's start a list of realistic things to start and make an attempt to carry out to make a change.
We can start with my suggestion:
1. Begin internet petitions.
OK, now which of our visitors is going to make up a list of all the internet sites which publish petitions? And then let's assign a visitor to put up an argument for that site.
But this is only number 1. on the list. Start adding other approaches that we can do as a group to achieve the goal.
Think of 9 years of complaints here and the complainers are really doing nothing (except those who have spoken up to their individual healthcare provider) to attempt to make any change in their care or the attention the healthcare system provides.
..Maurice.
P.S.- I just thought of an explanation why many of our writers here over the past 9 years have stopped writing or have stopped visiting here. Could it be that all they have seen here is personal experiences and argument with me but absolutely no constructive approaches or attempts to make the necessary changes. Can't you all do more? ..Maurice.
Maurice,
The turnover of posters here is (probably) because "life happens," if that makes sense.
You stated:
I am against any teaching program in which students perform pelvic exams on anesthetized or sedated patients without the patient's specific approval of that exam by that student. And I think that this practice of such exams without specific permission is fading away from medical education.
Could you clarify something for me in regards to this.
What is professionally considered consent?
What is ethnically considered consent?
What is (in general) legally considered consent? I know this varies by state.
What do you consider consent? The law requires the minimum, morals require the maximum. For example when I do research I have to disclose that what I am doing is research and it's purpose. I go one step farther, I offer all participants a copy of results (not the conclusions).
It also shows that I am concerned with the metadata (tabulation) and not the "individual identifying data."
--Banterings
Maurice - Sure med students may eventually become patients themselves.... but I sincerely doubt they're treated the same as non-medical people when they're in there... would you lead a group of students to watch surgery on a doctor? Do you really think they'd perform a non-consensual genital exam repeatedly on a sedated doctor? Do you really think a doctor is stripped naked in the OR for outpatient hand surgery?
Why don't we do more?
Pretty much the same reason that if you had a house rule where your kids (say 10 years old) couldn't have friends over after 7, your kids couldn't do a whole lot to make you change the rule, even if all your kids agreed it should be changed.
We pretty much have no sway over rule makers, either local doctor offices or governing bodies.
At least you're a doctor with the ears of other doctors through your listserv, and are able to at the very least put a bug in their ear and maybe get them to think about it, see things from the victims side, and just possible change their ways and pass it on from there. Additionally, you're a teacher, so you have the chance to at influence groups of new doctors. not saying you don't... but you've admitted that before this blog you had no clue there was a problem, so I'm guessing / hoping your teaching method / lessons have adapted in pairing with the awareness that this issue does exist.
Internet petitions really don't do squat... I've tried googling "success rates of online petitions", and have really only found a few "successes" that are more PR stunts. Not industry changing victories.
So I guess when we boil it down, I know complaining on this blog doesn't do squat either.... but venting is better than nothing.
As for why there's a turnover... Like Banterings said... :life happens"...
But you also do sometimes come off as .... well.... a little arrogant, intended or not.
Take this chunk of a post of yours....
***Friday, July 18, 2014 8:08:00 AM, Blogger Maurice Bernstein, M.D. said...
"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. "
***Friday, July 18, 2014 8:08:00 AM, Blogger Maurice Bernstein, M.D.*
It comes off like you're saying unnecessary exposure, unnecessary extra eyes in the room, and all the other negative things we talk about here are only negative to us, and a "normal" person wouldn't have an issue with that behavior from the medical folks. it might not be exactly what you meant, but a lot of your comments do come off like that.
Jason K
Like most of the contributors to this blog, I grew up in the United States; a country that by law and custom forbids intimate bodily exposure between members of the opposite sex who are not intimate. We have single gender rest rooms, lockers rooms, and bathhouses at the beach. In addition, we have laws against “indecent exposure” so particularly in the case of a male, if he publicly exposes his genitals he can be arrested, jailed and added to the sex offender list.
As a result, I was, from an early age, taught by my parents and society to be physically modest in the presence of females. I internalized these teachings and they have become part of who I am. So to ask me to give up my modesty because of the situational context of a medical setting is asking me to stop being myself for a period of time, and to behave as though I suffered from a psychological illness called dissociative disorder in which aspects of an individual’s waking consciousness such as identity are interrupted and they become mentally separated from some part of themselves.
While I am not implying that those who are able to give up their modesty fairly easily in the situational context of a medical exam or procedure are mentally ill, I am emphasizing the fact that those of us who cannot do so without feelings of terrible embarrassment and humiliation should in no way be considered odd or unreasonable given the cultural context in which we were raised.
MG
Hello Everyone. I came across a interesting site the other day. Google ( Hospital closings for 2014 ). Read some of the different reasons for the closings. Most blame it on the lack of government subsidies. Medicare and Medicaid along with a declining, paying customer base.
Maybe us outliers are making a difference. The medical profession likes to pretend that they don't hear us. Maybe the unemployment line will help with their hearing. I think the time has finally come where the medical profession has to compete for your business. A nameless Doctor said on this blog , If you don't like what we offer go someplace else. I have enough business as it is. What if he worked for one of the closing hospitals. Would the administrators see things the same way? To tell your customer to go someplace else is bad business and will only work in a noncompetitive environment. That is why you need to send your complaints to the administrators. Take care. AL
Another suggestion to the list:
2. Several thousand comments from this Patient Modesty blog thread over the years should be collected and sent to the Joint Commission, the organization that sets the standards for physicians and hospitals who receive Medicare funding in how they care for and attend the needs of all patients. The Commission has a lot of clout and routinely investigates medical facilities to be assured that the Commission's orders are followed. By the way, the Commission encourages patient feedback.
Anyone here willing to take on that task of reproducing and submitting? ..Maurice.
p.s.- I am awaiting further suggestions for signs of beginning activism here on the issue of changing the system.
And, by the way, I am not sure there are any statistics regarding how the issue of patient modesty would reflect in terms of numbers of responses to a internet petition.
"P.S.- I just thought of an explanation why many of our writers here over the past 9 years have stopped writing or have stopped visiting here. Could it be that all they have seen here is personal experiences and argument with me but absolutely no constructive approaches or attempts to make the necessary changes. Can't you all do more? ..Maurice."
That's precisely it, Maurice. For me, most of this thread is same old, same old, same old. Occasionally, someone provides the URL for an interesting article. Sometimes there's an interesting insight. I know there are some on this thread who are really doing things. I applaud them. I check this thread every once in a while, but I just don't have time to go through the repetitions to get to the new.
I'm on two hospital boards, one a governing board, and I'm on a standing committee for another hospital. I'm trying to work on the inside as a patient advocate. Working with doctors and nurses and with the crisis issues most hospital are dealing with these days, has given me insight into what's discussed here. I've gained great respect for most doctors and nurses. I make no excuses for blatant medical abuse and modesty violations. But more people on this thread need to get into the trenches and work from there.
We talk about trust and good relationships with doctors, nurses, mid-levels, cna's and patient techs. If we really mean that, we need to understand that it's about the relationship, not about any one individual. Frankly, it's not all about the patient. It's about the relationship.
That doesn't mean the patient must tolerate abuse or blatant violations of modesty. But, like everything else in life, if you don't speak up and fight, you'll occasional be taken advantage of.
I hesitated to even post this -- because I know some here will want to debate with me. I don't have time for that. I'm too busy with other projects. But I will always work to defend a patient dignity. You can be sure of that.
I just want to make sure that I have all the issues:
1.) gender choice
2.) modesty, unecessary exposure (carelessness)
3.) not recognizing our feeling
4.) unnecessary exams
5.) specific informed consent (anesthetized patients)
6.) true patient participation
7.) choosing our level of healthcare (self determination)
8.) no reprisal for self-determination
9.) lack of empathy
10.) paternalism
The first step is a complete list of the issues we are addressing. Am I missing anything?
Can anything here be combined?
We first need a statement of what changes need made. That includes listing specific problems.
Simply saying "modesty" (alone) is too vague. This can include gender choice, exposure, etc.
--Banterings
And following up with Doug Capra's "we need to understand that it's about the relationship, not about any one individual. Frankly, it's not all about the patient. It's about the relationship", how can the relationship be improved from both sides, the patient and the medical system and its providers? Education. Education to and for both sides which is still missing. What education?
The System needs to be educated about all of these concerns based on experiences which have been written here over the years and what have been the limitations both practical and psychologic limiting communication and to what degree the System's responses have been inappropriate and inadequate (or even surprisingly the opposite).
The patients, on the other hand, need to be educated by the System as to the current realities, practicalities and limitations of the System. (One reality is the unprofessional or "criminal" physician that can "pop up".) But both patients and the System need to be aware of the facts in order for the trust on both sides be strengthened and maintained.
With the education to both sides, then there can be a real chance for some creative cooperation to mitigate or even fully resolve the issues and problems related to each of the parties.
That is why, the next step here is to formulate ways to educate the System from the individual healthcare provider to the institutions. And, hopefully, with the help of Doug in his institutional relationship and position and mine in medical education can, in our ways, encourage the System to provide better education about their "current realities, practicalities and limitations" of the System.
You know, knowledge can be potentially therapeutic, as with all "therapy" if properly applied. ..Maurice.
I put onto the introduction to this Volume the Comment above by Doug Capra followed by my response since I think this fits the needed attention to changing of course both of the medical system but also about the content of this Patient Modesty thread. ..Maurice.
Thanks to Banterings for an excellent beginning tabulation of concerns which can be part of the education of the medical system. ..Maurice.
To Banterings
"2.) modesty, unecessary exposure (carelessness)"
It's not just carelessness, some of it is powertipping from the staff, or potentially (and this has been proven by that gyno photographer lastly) for their own personal amusement.
To Doug Capra - debate it or not, but just to reply... as a patient, I honestly couldn't care less how bad the medical side has it, or how much they have on their plate... when I go to the hospital, and MY body gets exposed against MY wishes or without MY consent, then it's about ME and MY opinions and wishes, not theirs.
It's a bit like saying that if someone breaks into your house and robs you that's bad... but if they're hard up for money and just wanted to steal stuff to sell, it should make it somehow less bad to the victim. Sorry... ain't buying it.
Jason K
Doug,
I agree that it is about the physician-patient relationship & the problem is in the system.
We have a GP or specialist that we can work with, if not we are gone.
It is the hospitals that present the problem. If you go to the ED or for a one time surgery, there is no relationship. Chances are, other than the surgeon, you may never see the other people (support staff) again. This is where you get the prep nurses that insist on being totally naked for any surgery. This is where the medical students come in who you don't not know.
When you work with the GP or a specialist you get to know them, their students, their staff. If you are not comfortable with them or if they do not respect your expectations then you are onto the next one, no matter how good they are.
Most hospitals today are run by healthcare corporations. The only thing that these companies he is the bottom line. If we are to change the system, then it has to come from their bottom line.
I was contacted by somebody today who has a plan that can change everything. I am going to talk to them more about how it will work.
I know his plan will work, I know it is legal, but I question the ethics of it. That is something I have to wrestle with.
--Banterings
Jason, all patients despite their mild or serious symptoms and illnesses, when entering a doctor's office or entering a hospital have to realize that medical care is not only directed to YOU but, unfortunately these days must be directed to a host of other patients with limited time and certain resources available to each. So, in a number of respects as documented on this thread, patients may find that they are not given without specific communication ("speaking up") all the behaviors by the healthcare providers and the system which the patients expect.
Again, whether it is in a doctor's office or in a hospital, you do not represent an isolated doctor-patient event but are part of a pool of patients and a pool of patient interactions. That is an important point of education that patients should receive. Since not every patient in that pool have exactly the same concerns about how they are attended then this is where the doctor and system must be educated regarding that individual patient's separate concerns. When selecting a doctor or hospital, despite their professional responsibility toward each patient, they are not looking at you as their single Master. You are a patient and for the best outcome you have to work with them and they have to work with you.
To think otherwise, you are only fooling yourself and opening yourself to more unrealistic emotional turmoil. ..Maurice.
Banterings, professionalism both in the case of a doctor and in the case of a hospital and its healthcare providers accepts that there is established a relationship with each patient even if this is a first time interaction. In fact, the relationship has ethical and legal consequences when the relationship is terminated by the act of the doctor or the hospital and this is called abandonment. Beyond abandonment, the relationship involves many other factors including attention to every patient's needs and attention to every patient's safety. It doesn't require multiple visits for these standards to be met.
Yes, trust requires time for both the patient and healthcare provider but professionalism and its responsibilities begin with the first interaction. ..Maurice.
Maurice – I never once for a single second assumed I was the center of the medical staffs world while I was there. Wait times, being called out of the room for an hour or more... it’s whatever, it’s all good, and I’m aware other people with serious things would take priority over less serious things.... that’s fine. (unless I’m bleeding severely and they walk away or some other life threatening thing...)
That is still no excuse for unnecessary exposures, unnecessary extra eyes in the room, or refusing same gender care. (Imagine the uproar if a “leading” feminist activist who was also a rape victim was refused a female gynecologist when one was available...)
So again I say that when it comes to MY body, I really don’t care how bad the medical staff has it, I do not and will not tolerate privacy and modesty violations for THEIR convenience regardless of what kind of justification / excuse anyone tries to make for it. ( and “limited time and certain resources available to each.” does not justify any kind of violation... it’s an excuse for them doing things to make their job easier with no regard for the patient.)
You also put in your reply ot Banterings “Yes, trust requires time for both the patient and healthcare provider but professionalism and its responsibilities begin with the first interaction. ..Maurice. “
I’d say it begins before that. In my opinion, the providers professionalisms responsibilities begin as soon as they’re accepted to med school. People, especially in a small town, know they’re a doctor / nurse / whatever, and see how they act away from the hospital setting, and that reflects on their opinion of them as a representative of the medical profession as a whole.... And by that I’m referring to all the people I knew personally who are nurses and a doctor... as I’ve said before, I’ve heard each and every one of them gossiping about patients out in public, and sharing intimate details about the patient where I, who wasn’t part of the group, was able to clearly hear without trying, so who knows who else can hear their conversations, and if they do that the few times I’m around then it’s pretty obvious they do it all the time.
Jason K
Great post MG, exactly right.
Or there could be another reason people quit coming here. They see little recognition by the few providers who do stray here that they would accept much less change what they are doing in treating the patient. Artiger was compassionate in his own way, but found the suggestion of offering colonoscopy shorts it seemed ridiculous. Or Dr. Key still throwing out the age old "we are all professionals" even thous ALL seems a stretch given what is sometimes posted. Maybe being told they are outliers makes them think they ARE the problem. I do get your point of people need to do something rather than post. I quit going to allnurses other han a rare visit once in awhile because it bacame so obvious they had their minds made up, providers were right, patients were wrong, and nothing was going to change that...I think that may explain why provider quit coming here but I would suggest there could be a lot of other reasons posters quit coming here. Doesn't change the fact that if no one ever converts what is discussed here to actions...we gain nothing but venting...don
Sometime ago, I posted a list of protocols to illicit change. Perhaps Maurice, you can do a search by blogger name to find it? It wasn't that long ago.
One of the things listed was accountability, responsibility of the medical community and an action plan for remedies for those who commit infractions and stiff penalties for both the person(s) responsible and those knew and kept quiet. These penalties must be strong enough to deter further
infractions.
Mandatory training programs designed by psychologists for every employee so there are no excuses for "making a mistake" once too often.
The fact that they are already trained in this area is proof of why new training programs must be instituted by those who understand how emotional damage occurs.
Everyone in healthcare could use a course called "Put Yourself In Our Position".
belinda
Maybe what is missing from the medical profession is:
etiquette
Compassion, empathy and skill are important but maybe what has been taken as "usual" or "the norm" actually to some patients represents "lack of etiquette".
Etiquette-Based Medicine is the title of a Perspective article in the May 8 2008 issue of the New England Journal of Medicine
Click here to read the full free article in the New England Journal of Medicine. ..Maurice.
Here is the California Business and Professional Code 2281 regarding pelvic examinations. How do you interpret the law? ..Maurice.
2281. A physician and surgeon or a student undertaking a course of
professional instruction or a clinical training program, may not
perform a pelvic examination on an anesthetized or unconscious female
patient unless the patient gave informed consent to the pelvic
examination, or the performance of a pelvic examination is within the
scope of care for the surgical procedure or diagnostic examination
to be performed on the patient or, in the case of an unconscious
patient, the pelvic examination is required for diagnostic purposes.
re: the etiquette checklist ... I'd add #7
7- ask if the patient has any concerns about exposure or presences. (gives them a chance to ask the DOCTOR, not some prep nurse why they want them naked in a gown to look in their ear, or the chance to express concerns about the docs gender and a chance to complain about the lack of, or presence of a chaperone / scribe/ whoever.
Jason K
Re: the pelvic exam question
That looks like it doesn't change a thing.
"informed consent" is a small blurb hidden in a wall of text on the standard admission form, or something they get you to sign after you've been versed / drugged and are an obedient little drone.
"or the performance of a pelvic examination is within the
scope of care for the surgical procedure" gives them free reign to run a parade of students for any procedure involving a womans genitals.
"or, in the case of an unconscious
patient, the pelvic examination is required for diagnostic purposes." is a very broad spectrum that can be used as a fall back... "we don't know unless we check"... same rational as shoving their finger up someones bum and calling it a DRE for every trauma.
Also notice it only applies to pelvic exams for women, not rectal / genital exams on men.
Jason K
Maurice,
The NEJM article: excellent reference. It hits the nail on the head:
Furthermore, it's simpler to change behavior than attitudes.
Etiquette: Patients have a choice of the gender of their healthcare providers...
Attitude: ...where practicable.
CBPC 2281 is just like TSA screening; it just makes the average person (one who does not know the REAL internal workings) feel better, safer, etc.
2281. A physician and surgeon or a student undertaking a course of professional instruction or a clinical training program, may not perform a pelvic examination on an anesthetized or unconscious female patient unless the patient gave informed consent to the pelvic examination, or the performance of a pelvic examination is within the scope of care for the surgical procedure or diagnostic examination to be performed on the patient or, in the case of an unconscious patient, the pelvic examination is required for diagnostic purposes.
What is informed consent LEGALLY? Is it paragraph 49 on page 3 in fine print in the "Consent to Treatment" form. Is it implied by simply coming to a teaching hospital for care?
Or is it having the students meet the patient personally before the procedure, introduce themselves, explain what they will do, and ask the patient for consent?
On men, do what ever you want. Again, ignoring men's modesty and feelings.
Rectal exams for everybody!
Breast exams for everybody!
2281 only covers pelvic exams, whatever they are, because they are not defined here
...OR the performance of a pelvic examination is within the scope of care for the surgical procedure or diagnostic examination... No consent needed here, even if you refuse!!!
Unconscious, this is for diagnostic purposes. Does not say how many times or who performs it.
Besides, CBPC 2282 lets US (the providers) write the rules and procedures.
--Banterings
Jason, I agree with your addition to the checklist. How about the doctor or nurse using a specific question after a specific introduction as they say "Remove your bra for the examination. I am giving you a cape to put on. Do you have any concerns about that?"
Jason and Banterings: With regard to 2281
I agree. It seems like the legislature who created this law should be educated also.
..Maurice.
Maurice, Doug, et al,
About people leaving the blog, I had another thought:
Perhaps some folks were just frustrated and left. It seems to us so obvious, yet providers "just don't get it."
With this new thread marks a "turning point."
I bet there are some still "lurking" here. We have made progress, finally. To put it bluntly, if we could not convince the 4-7 providers that are active here there is a problem, how would we convince a whole industry?
At the beginning of this threat I was exploring the "reasons" for his change, hoping to find the source of his enlightenment.
I suspect that Maurice is still grappling with why something that seems to make sense to him (as a provider) is such an issue for us, especially why in a serious situation that someone may refuse care.
This also alludes to Doug's comment about him seeing the inside workings of the hospital.
Jason K and A. Banterings,
Thanks. You stated my sentiments re: 2281 much better than I could.
I remember in 1996/7 reading HIPAA while waiting to see the MD. I could only smile because it codified the status quo and provided legal cover for what the medical community was doing. Read HIPAA from a legal standpoint and not what you want it to say.
BJTNT
Maurice - you said "How about the doctor or nurse using a specific question after a specific introduction as they say "Remove your bra for the examination. I am giving you a cape to put on. Do you have any concerns about that?" "
That wording would work great, assuming they kept to it / weren't just trying to go for expediency ... and the nurses quit using some wording of "that's our S.O.P." for an answer. (it's hard to resist the urge to slap them when I hear the generic answers / insults from them)
I'd say a good 90% of my issues have been with the prep nurses rather than doctors.
They'd still have to ask about concerns about extra people in the room...
Jason K
You all should be interested, as I have been, in the declaration of the American Congress of Obstetricians and Gynecologists regarding the professional and legal standard of informed consent. After reading the extensive declaration, do you all feel a bit more comfortable?? ..Maurice.
I feel that Dr. Bernstein, Don, and Banterings are right about reasons that people may have stopped commenting or coming to this blog. There are other reasons that many people may have stopped coming here. One man shared that this blog made him emotional and that he rarely comments here and that his wife encouraged him to not look here too much. Some people probably have been traumatized by this blog and just cannot handle it. I am sure that some of the comments here have brought flashbacks for some people who had bad experiences. Some people may have decided to avoid medical care and it’s not worth their time to read this blog anymore.
I want to respond to each person’s comments about reasons people may have stopped coming to this blog:
Dr. Bernstein- I just thought of an explanation why many of our writers here over the past 9 years have stopped writing or have stopped visiting here. Could it be that all they have seen here is personal experiences and argument with me but absolutely no constructive approaches or attempts to make the necessary changes. Can't you all do more?
Don - Or there could be another reason people quit coming here. They see little recognition by the few providers who do stray here that they would accept much less change what they are doing in treating the patient. Artiger was compassionate in his own way, but found the suggestion of offering colonoscopy shorts it seemed ridiculous. Or Dr. Key still throwing out the age old "we are all professionals" even thous ALL seems a stretch given what is sometimes posted. Maybe being told they are outliers makes them think they ARE the problem.
Banterings - Perhaps some folks were just frustrated and left. It seems to us so obvious, yet providers "just don't get it."
I agree that we need to take actions to improve patient modest. For example, maybe Don could meet with the administrator of several urology clinics and encourage them to hire male nurses / assistants.
I really appreciated Banterings’ points: To put it bluntly, if we could not convince the 4-7 providers that are active here there is a problem, how would we convince a whole industry? The truth is we will never be able to change the whole medical system. But we can certainly play a role in educating medical professionals about patient modesty and encourage patients to stand up for their rights. I personally only see hope with patient advocacy / education. There are times patients will have to drive farther to a medical facility that is more sensitive to their needs.
Misty
Doug Capra,
I hope you will continue to contribute here from time to time. I have really appreciated the articles you have written about patient modesty on Dr. Sherman’s blog.
Yes, I agree that people need to volunteer their time to improve patient modesty. It is important for patients to speak up.
I see that you are from Alaska. I know there are many rural areas in Alaska. Do any of the urology clinics in your area have male nurses? Have you played a role in encouraging hospitals and medical facilities to hire enough medical professionals of both genders so patients who desire to have same gender intimate care can be accommodated?
I’d love to hear about some of the ways you have educated medical professionals about patient modesty. Have you showed them your articles and other articles about patient modesty?
Misty
Re: declaration of the ACOG
First thought before reading any of it is that the gossipers I’ve personally heard, the gyno photographer, the butt slapping doc and all those others... I’m fairly certain all of them were violating laws and regulations already, so re-worded ones won’t do a thing unless this is about to introduce CRIMINAL penalties not just for the offending person, but all those medical people in the general area as well.
But, I’m off to read it now.
#1 – again, “informed consent” being a small blurb in the middle of a wall of text on the back of page 7 of 12 sheets (yes, I know that’s an exaggeration) of admission papers, or papers you’ve been coerced into signing by pressure or while drugged....
#2 – “ it particularly respects a patient's moral right to bodily integrity, to self-determination regarding sexuality and reproductive capacities”
So they can’t sterilize you or “cure your gayness” (???) without your consent. Is that what they’re trying to say?
#3 - see #1, and again, once you’re under, they generally do whatever they want anyways.
#4 talks a lot, but doesn’t say anything. (especially considering it says “can and should”, not “MUST” )
#5 again, worded as “should be”, so we know it will be ignored whenever it’s not convenient to the staffs schedule / workload
#6 “ physicians should make every effort to incorporate a commitment to informed consent within a commitment to provide medical benefit to patients” – that right there is the loophole that would let doctors / staff do whatever they want without consent.
#8 is just reminding staff to cover their asses to not get sued.
That’s my take on that, so no.... it changes nothing in my opinion, and that would be assuming any new regulations would be followed at all... and as they say... seeing is believing.
Jason K
This does nothing. It is not binding, there are no ramifications if a physician does not follow it.
It fails to address certain issues, such as observers.
It sets forth that treatments (procedures) are take it of leave it.
That is one thing seriously lacking, treatments are not take it or leave it.
You can leave your underwear on for hand surgery...
It also states:
In rare circumstances, what is known as therapeutic privilege can override an obligation to disclose information and hence to obtain informed consent.
Another way to make excuses.
You ask if this makes us feel better? You stated:
...my first year students watching surgery at a children's hospital, as long established program at our school, and which I have had no personal contact with the family is based on my assumption that the hospital has obtained permission...
I guess that ACOG Committee Opinion and all the other "committee opinions" work.
They make the patients feel better, safer, because the providers can say here, read this, look what informed consent is...
...where practible...
I received the following e-mail from John who permitted me to publish it. ..Maurice.
The other side of patient modesty isn't mentioned here at all.
I am a middle-aged male. At my recent "physical" with a female
health provider, she never even lifted my shirt to check heart
sounds. When it came to putting on the gown, I kept my underwear
on at all times. During the skin cancer "check", I never removed
the gown and she never examined my buttocks or genitals. The only
prostate "check" was a couple questions about my urinary habits. I
didn't ask her to check my intimate parts because I didn't want to
sound like a pervert!
What about a law requiring practitioners to ask before each exam
how much nudity would be acceptable and which genders can be present?
The patient then signs a waiver acknowledging that the practitioner
is not responsible if any nudity restrictions compromise their care.
Wouldn't that have prevented all of the stories posted here?
John
OK.. tomorrow at noon till 5pm, I am going to be teaching 2 groups of 6 students how to perform a cardio-vascular examination on patients, their first teaching on this subject. I want to present my visitors now with some factual information and then I want to see how my visitors suggest I teach a patient modesty consideration, in this case, specifically regarding if the exam is to be carried out on a female patient.
FACTS:
1. INSPECTION for the apical impulse (a visible pulsation of the chest from the heart) and PALPATION for the apical impulse is laying the hand on the skin of the chest to feel the location of the impulse. The value of identifying the anatomic location of the apical impulse is that the finding suggests the size of the heart particularly the left ventricle. The apex impulse will be located on the left lateral anterior chest often in an area hidden by a bra or beneath the breast itself. This important finding can be hidden by a bra.
2. PERCUSSION of the left border of the heart is another method to confirm the size of the heart. It is a tapping with a finger of the chest by the physician and recognizing the sensation reflected back to the finger after the tap. If the tapping is performed through most bras, the response will be damped by the material of the bra and not easily sensed by the physician.
3. AUSCULTATION of the heart is to listen to the heart sounds in various but standard locations of the upper and lower chest including areas hidden by the bra or located beneath a breast. Again, the damping effect of clothing diminishes the intensity of the sound and for some faint sounds such as mitral valve stenosis which is low pitched may hide the sound entirely.
Now, here is where I want help from my visitors for tomorrow's session. How should I teach my students how to teach my students to perform a thorough, complete physical examination of the heart in a female patient and be aware of and attend to patient modesty issues? What should I tell them about the issue of the presence of a bra and what to do about it? Remember, this is the students' first learning of examination of the heart and I certainly don't intend to teach them some sloppy technique with the great potential of missing important abnormalities of the heart.
Do you realize, your responses may be contributing to medical education (at least with my 2 groups)? And what they learn tomorrow is something they will, hopefully, carry on as they get more and more practice and then later be responsible, as MDs, for the value of their examination. ..Maurice.
Just to clarify something you all know but under AUSCULTATION, the listening is obviously in these days since the invention of the stethoscope by the placement of the bell or diaphragm of the stethoscope onto the chest and NOT as in times before that instrument, the placing of the doctor's ear on the chest. ..Maurice.
Maurice - I know from time to time exposure to the doc is necessary... but it's the extra eyes and UNnecessary exposure that's the issue.
Personally, I'd ask the students to imagine they were the patient, and the examination was being conducted in the middle of times square... they'd want exposure to be as brief and minimalized as possible, right?
In the case of tomorrows procedure where lifting the shirt to expose the bottom edge of the breast / area under the breast but not the entire breast, then pulling down the neckline to check the upper part of the chest is apparently not an option (or is it?) I'd ask them to imagine that there's the patient and the doctor... and to imagine EVERYONE else who comes into the room is wearing google glasses that live stream to the world... would they as the patient want extra eyes in there for no reason? (chaparone, scribe, etc)
Then ask them to imagine they're not the doctor or the patient... but they're trying to find a doctor for their friend who was a rape victim. Maybe the friend is a female who was gang raped by men... they certainly wouldn't want to have a male doctor, right? perhaps the friend was raped by a group of other women, and would be just as "not ok" with being vulnerable and exposed to a woman. They'd do their best to accommodate what their friend would be most comfortable with, right?
With that in mind, they have NO idea what the patient has gone through in life, so regardless if the patient is male or female, and the doc is the same or opposite gender, the patient might just want someone else Odds are it's not because "that male patient doesn't think a woman can be a doctor"... it's just a gender preference. it takes just a second to ask. (granted, gender preference should be asked by the receptionist booking the appointment, but in a clinical / hospital setting where the doc is random, and even in the ER if it's not a life or death "right now" deal, they should really ask.)
Jason K
Re the letter from John...
The problem with a consent form is that the medical society has a history of trying to intimidate / scare people into signing things, drugging them first then getting them to sign thing, or just outright doing whatever they want and lying about it later.
Then there's the deliberate mistreatment from the scum of the earth who happened to make it through med school...
Here's a quote from the allnurses board
*******
http://allnurses.com/operating-room-nursing/patient-modesty-concerns-196068-page21.html
This teen was injured and was banged up from a skateboarding injury on his legs/knees. Im sure I used the word naked but he did have on a gown the thing is in looking at his injury the nurse lifted his gown to the point wear his genitals were exposed with several others standing around.
The kid was obviously embarrassed and made an effort to cover himself when the nurse made some comment that dismissed his embarrassment and the gown was lifted again by the nurse.(again with several students standing around) I used the word naked.....but even in one of those gowns if my privates are hanging out for everyone to see I consider that "naked"..........."
*********
Jason K
Maurice,
I am assuming that you will have a SP to demonstrate on. The first thing I would do is while the SP dressed announce that I am entering. I would ask (consent) to bring in x number of students.
The students will shake her hand, introduce themselves. Then the "attending" (you) will explain the procedure, what should be exposed and the reasons why.
I would then ask permission for the students to observe, and to participate. Explain what their participation will be.
I would then explain how close they will be to observe, ask if she has any problems with that many people being that close (claustrophobia?).
I would then say something to the effect:
"Some people may have had bad experiences previously in a medical setting, may have been the victim of past sexual or physical, or may be more sensitive than most people, that may make this exam uncomfortable or may even cause a panic attack. Is there anything such as this I should be aware of?"
If so, what can WE do together to make this experience tolerable?
I explained to you how we will be exposing the breasts one at a time (or what ever the procedure), do you have any suggestions how to help make the process easier for you?
Note: My doctor knows about my phobia, early on he tried to ascultatie my heart by putting the stethoscope in the front of my shirt. I just take my shirt off. I am comfortable with that, but my pants stay on.
She may just say she'll just take the gown off.
Ask her if she has any questions for you or of the students. Reassure her that you will tell her everything before you do it, if she is uncomfortable at any time that we can stop, take a break, or change the way you are doing the exam (such as she said no gown, didn't realize this would bother her and wants to use the gown).
Note: Personally and professionally, I tell people, "you can't offend me, but are welcome to try." This is my way of saying you can be open an honest with me.
Thank her and say you are leaving so she can change. Tell her how long until you return. Ask if that is enough time.
Knock before entering, ask if she is ready and if it is still OK for the students to participate. Ask if she is ready to begin.
Do the exam, saying what you are going to do first, then ask permission to proceed. If the breast needs to be moved, ask if she would prefer to do it or you.
Remember she is a human being, not just a living cadaver.
Ask if she has any advice for the students. This is great advice even when dealing with real patients, the students might learn something that makes a good physician a great physician. Ask her if she wants to know anything about the students.
Someone who allows so many different people to touch them may enjoy knowing something about the human being that she is helping. It may validate what she is doing instead of her feeling like "a piece of meat."
When done, give a brief synopsis such as everything sounded normal. Say after you dress, we can discuss the exam OR anything else that you like.
This is an opportunity if she (even a SP) needs to decompress."
Have each student thank her for allowing them to be present. (They may not want to shake her hand unless she is properly covered.)
--Banterings
Seems like it might be logical to give her a gown and have her remove bra, leave pants on, put gown on, and move the gown around to give access while keeping her covered as much as possible. But providers as in Artiger's case feel these extra steps are not their problem, and others feel it takes to much time, and still others claim we are professionals. But given the cost of medical care it would seem to be a simple thing for the nurse to ask if they had a preference. don
Banterings, I left out in my description of tomorrow's activity, that there is no standardized patient but I will demonstrate the exam on one student, usually but not always a male and then the students will examine each other afterwards. No, the sports bras of the women are not removed nevertheless even though this interferes with the best examination, the purpose of the teaching is get the students to understand the sequential protocol of a real exam on a patient which they will shortly be beginning on hospitalized patients who give permission for examination. ..Maurice.
Maurice - might be an idea just for giggles that when the students are gathered to practice the exam, just ask the ladies how many of them would be comfortable enough to remove the sports bra as well infront of the class (not actually ask them to... just ask who WOULD do it) .... then remind those that wouldn't that it's pretty much what they're going to be asking the patients to do.
Might help them keep things in perspective a bit when they first start expecting people to just be exposed for them.
(I'm also just curious what the numbers are for those who would and those who wouldn't)
Jason K
Maurice,
I would. use a female student, and then do everything exactly the same. Ask her to "pretend" she is not wearing a bra.
Then, I would have one student demonstrate examining a male student to see if they "make any assumptions."
I know two men who were the victims of sexual abuse, the fallout is not pretty. One will start to tear up when a situation turns emotional. I will give him a hug, remind him he is my friend, and he is a surviver. Then he will push me away (he is NOT "manning up"), but he begins to feel claustrophobic, (I think having flashbacks) and wants his space. The other has "overly manned up," he sleeps with every girl he can, started using steroids bulking up, gets in fights at the drop of the hat,denies what happened. Touch him, he says "you want that hand broken?"
Obviously this is more ritualized for the new patient, ED, patient, etc. once a physician has an ongoing relationship established, he can say "You know that if there is anything that makes the exam uncomfortable, we address that to make you comfortable."
You can even tell the patient that human beings are social animals. Touch builds trust in the relationship. In some species of monkeys grooming (touch) builds trust and strengthens the relationship of the troop.
You may even ask if any students have a fear of doctors and use that person as the demonstration. Afterwards ask how she/he feels if you were his physician. I would bet that he would feel very comfortable.
Tell them that I (and I am sure everyone on here) hope that they become great practitioners of the healing arts. Despite all that I have been through, we want to see them become good physicians so that no one ever experiences what I did.
It is obvious that you care about your students, I think that genuine caring with doing the exam in a thoughtful and caring manner, that student should feel trust in you. That feeling will be something that you cannot learn in a book.
Maurice, I give you permission to use me as an example to them as someone phobic about providers if they do not believe that this happens.
As for the "ear on the chest ," have you learned nothing? A 12 foot long stethoscope so you can listen from the next room. Sorry, I couldn't resist a bit of humor.
"usually but not always a male..."
Your teaching a cardio-vascular exam to male and female students, which everyone agrees for obvious reasons is more difficult to perform on females for both the physician and patient, and your going to use a male? The irony and hypocrisy is breathtaking! I now know why male patient dignity, modesty, and privacy is ridiculed by self professed professionals; your teaching it!
Ed
100% agree with Ed.
Would it not make more sense to teach them with the most difficult conditions, so the rest is just easier?
Also, you mention that the females leave on their sports bras... are the guys allowed to leave on their t-shirts if they want? if so, are they told they can? If not allowed to, why not?
Jason K
Ed, we let the students volunteer for the demo. This is the 2nd year students first experience to learn the detailed technicalities of a cardio-vascular examination. What I wrote as FACTS was only to give an example of what inspection, palpation, percussion and auscultation require but nothing about the details of how they are performed or what observations need to be derived from the examination. There is a lot of new and detailed learning to accomplish for each group in their allotted 2 hours. To turn this difficult first time learning experience into some sort of a game or psychological rather than an instructional challenge is defeating the brief allotted time I and the other instructors have with the class.
Matters of instilling the need for attention to modesty, though obviously an important value to give the students, has to be, at this time, very simple learning tools to use when they perform these exams on real patients.
Don's "give her a gown and have her remove bra, leave pants on, put gown on, and move the gown around to give access while keeping her covered as much as possible" or what we call "segmental uncovering" is an easy concept to teach and is born out of attention to modesty but also to keep the patient warm and less likely to shiver, complicating the exam. ..Maurice.
Jason, in answer to your last posting, all male students are examined with their shirts off both by males and females and there never has been any objection. Females are usually examined by females but is at the decision of the students themselves. As instructors, we allow the student to select the gender of the examiner. And, by golly, isn't that what you all are proposing and insisting should be the practice of all in the medical system?? ..Maurice.
Maurice,
I think that they are making a good point, I point that I made: Treat the males the males as you would the females. Give the option of the gown. If he says not necessary, that is a good time to point out "never make assumptions."
In LA, offering a male a gown to cover his bear chest should make a statement.
I truly appreciate and respect your participation with us on these issues but the fact that you don't recognize the fallacy in your reasoning just reinforces the depth of this problem!
V/R
Ed
Maurice -
I think you mis-read my post, or missed the point of my question....
The only thing gender wise I asked was why not show them on a female, as the female breast tissue would "get in the way" and thus they would see the proper technique for dealing with it, rather than on a flat chested guy.
You said women get to leave on the sports bras. I asked if guys are allowed to leave on shirts, and are they informed they can leave shirts on? and if they're not allowed, why aren't they?
I'm sure there's over weight male students from time to time, and I'm sure some of them have body image issues and would rather leave a shirt on.... dang nabbit.
Jason K
Jason, it's up to the students who wants to participate as a subject for my demo. For educational purposes, it is better to use a male since there will be no covering of the areas of interest in terms of identifying the apex impulse, left cardiac border or the valve listening sites compared with a girl subject wearing a sports bra. Virtually all male students (I haven't experienced an exception by my recollection) find no problem with being examined with a shirt off. (Maybe tomorrow, I will find an exception!). As I had written previously, all students, male and female, have exposed their abdomen for examination in all my years teaching except one, a male with a colostomy who allowed to be examined in other parts of his body but was uncomfortable for a colleague student to examine his abdomen even my saying that it would be of educational value to the others. But he refused and I felt his decision was his and not mine. He participated in the teaching exercise examining another student's abdomen and that was consistent with his learning responsibilities as a student. ..Maurice.
it's up to the students who wants to participate as a subject for my demo. For educational purposes, it is better to use a male since there will be no covering of the areas of interest in terms of identifying the apex impulse, left cardiac border or the valve listening sites compared with a girl subject wearing a sports bra.
Which is all well and good... but hypothetically, in a perfect world where all your students were cool with being 100% nude infront of each other... wouldn’t a skinny male or a small breasted female first to point out the locations of each part... then a large breasted woman to show them how to deal with the extra tissue when it comes up in the real world exams be more ideal? (kind of like the reasoning why I learned to drive in the winter as opposed to summer... figure out how to do it in the worst conditions, and the rest is easy.)
Virtually all male students (I haven't experienced an exception by my recollection) find no problem with being examined with a shirt off. (Maybe tomorrow, I will find an exception!).
But if they are allowed to keep a t-shirt, are they told they can was my question. For example, yeah, I’m fat... but I also have severe plaque psoriasis, and as a result I haven’t had my shirt off in public in YEARS... I haven’t been to a beach since I was 12 or so. There could be any number of reasons a guy isn’t cool with taking his clothes off infront of others, and every time you’ve spoken of it, you’ve kind of made a point of emphasizing that the ladies get to protect their modesty, but you say the dudes take their shirts off. Just the way you keep wording it the way you do was what sparked my question.
all students, male and female, have exposed their abdomen for examination in all my years teaching except one, a male with a colostomy who allowed to be examined in other parts of his body but was uncomfortable for a colleague student to examine his abdomen even my saying that it would be of educational value to the others. But he refused and I felt his decision was his and not mine.
I know you and I don’t exactly see eye to eye on most topics... but I’m going to try to word this as non-argumentatively as I can, so please don’t take offence if it does come off as argumentative.
1- “even my saying that it would be of educational value to the others”
This isn’t “that bad”, but it’s right up there with nurses trying to say they’ve “seen it all before”... Obviously he’d have known it would be something neat for a student to see for "education" since he was in the class... but if I were him I would have been offended that you had even said that.
2 - “he refused and I felt his decision was his and not mine.”
How could him exposing his body (in the setting of a classroom, and not drugged in an OR or something) possibly be anything other than his decision?
Sure, if “person X” refuses to do something that’s required... be it in school or at work or whatever... there would be ramifications... but they’re still free to refuse to do the thing they don’t want to do.
Jason K
Maurice, why are you allowing the students to choose the gender of the examiner and regardless is there a teacher in the room? If so, does the student choose the gender of the teacher.? This is an important question. It would be most appreciated if you would address it. Thanks
Belinda
Maurice,
You responded to Jason K:
...it's up to the students who wants to participate as a subject for my demo. For educational purposes...But he refused and I felt his decision was his and not mine.
Why wouldn't (shouldn't) patients in a teaching hospital (or any setting) not be afforded the same considerations?
Again, I go back to ...my first year students watching surgery at a children's hospital, as long established program at our school, and which I have had no personal contact with the family is based on my assumption that the hospital has obtained permission...
This is the same as congress exempting themselves from Obamacare.
--Banterings
OK, to a degree I see/understand your reasoning. That said, I strenuously disagree with the following:
"all male students are examined with their shirts off both by males and females and there never has been any objection. Females are usually examined by females but is at the decision of the students themselves. As instructors, we allow the student to select the gender of the examiner."
The message you're sending to future doctors is that it's perfectly acceptable for females to have a gender preference but not males. If one of your students, I would only reciprocate with those who allowed me to exam them. Do your students get to make this decision privately or in a public forum with all the negative ramifications of peer/instructor pressure? What does this say about the quality of training your male students get? And it just reinforces the perception that patients are some lower life form while medical folks are exempt from the same practices!
Ed
Re-read some of the posts from yesterday.
Is it just me, or is Dr B's ...... "refusal" to give a yes or no answer to "are guys allowed to keep in their shirts if they want to" a pretty good indication that no they're not... but he's trying to avoid a gender preference argument or something similar?
No offense Maurice.... and again, I know you and I often butt heads... but generally in my experience when people do everything BUT answer the question, there's often a reason for it...
Jason K
Belinda, yes, the students pick the student or students to examine them, often a couple of students practice on one student subject. And yes, an instructor like myself is in the room to survey the student's performance and give suggestions and point out errors in their practice. As I wrote on a previous Volume, only once did I have two girls to examine each other but wanted to practice in a room away from their colleagues because of modesty concerns in relation to their student colleagues. It was acceptable to me since I was permitted to monitor them in the other room.
Jason, students understand the need to obtain informed permission from the patient throughout the examination.
Yes, if the student can explain an emotionally traumatic result of having an exam of the bare chest (as the student with the colostomy explained it to me), then, of course, it won't matter since there are other male students available for examination. That has never happened. If a student refuses to examine other students then that would be a significant teaching issue in terms of medical education of that student. ..Maurice.
Maurice - "emotionally traumatic" sounds pretty severe... how about if it's just embarrassing?
The ladies don't have to explain an emotionally traumatic result of them being topless....
(and I never mentioned refusing to perform the examination... that's why they're there.)
ANYHOO... my girlfriend just had a pretty good idea that ties in to where you just said "students understand the need to obtain informed permission from the patient throughout the examination." that might really drive it home, especially considering your other post where you took them on a tour of an operation and had just assumed there was consent....
I know it's likely too late for todays class, BUT...
You say that non-consensual exams are fading... but they're still present, and in more likelyhood are just going back underground...
But here's the thought...
Set up a camcorder in the corner of the classroom so it gets the students faces....
Come in with those little clear shotglasses you often see on cough syrup bottles... just have plain old orange juice in it.
Have the students each drink one, and check your watch....
then explain that one "lucky" student just ingested a sedative, and in a few minutes will begin to feel really sleepy and relaxed. When they're out, you're going to undress them so the class can practice a pelvic exam, or rectal exam, and practice cathetering.
Give them a few minutes to start panicking... then tell them you were joking, but that feeling of fear & betrayal is what they should remember from it... then show them the tape of their faces so they can see the universal concern and objections throughout the class ...
Then remind them that every time they're led into a room where the patient is already out, this is potentially what is happening to that patient.
If they're not ok with being drugged then used, then they shouldn't assume the patient is either.
Jason K
Maurice,
I just want to take a second and acknowledge an issue that has been discussed here before, physician suicide. That profession has one of the highest rates.
In light of what happened with Robbin Williams I did a post on my blog here:
It ties in with the issue of physician suicide.
If you are in crisis, call 1-800-273-TALK (8255)
National Suicide Prevention Lifeline
This goes for EVERYONE, not just physicians and providers.
--Banterings
and by golly isn't that that what we are proposing and insisting of the medical system?"pretty funny a little humor is always welcome.
But it only goes to the point we are making, all of the things that have been used to explain & justify why patients should accept compromising their modesty, why providers should be given a pass for their ignorance...is present in these examples but applied completely different to providers. Situational context makes a difference for patients, but not providers, students are OFFERED choice of gender even thoughtno exposure is required, when it comes to patients, not only do these
not matter,the provider whom as a student was offered these considerations is strangely ignorant they exist....the double standard is pretty obvious to us, and it seems impossible for providers to recognize or perhaps admit. Just as we must learn from our providers, we must teach them to see what they do not want to....don
I appreciate the emotions and concerns that lead to the bizarre scenarios being written to this thread by Jason and others all trying to make a point and support that point. And I already know what is the point and points after all these thousands of commentaries, so it is unnecessary to remind me.
With regard to the students I worked with all afternoon, what everyone here must realize that these are medical students learning to perform the specific and detailed technicalities of the physical examinations and in no way these students were simulating true patients or the events which may occur with real patient interactions. They examined each other in various combinations of 1 or 2 students for each of 2 subject and then the subject became an examiner and so on. In the 2 separate groups of 6 students each, as usual, the females subjects were primarily examined by a student of their own gender while the male subjects were examined by both males and females.
The necessity for attention to modesty was brought up by me right from the beginning of each session and continued throughout my examination of a student and when they were examining themselves. The use of a cape for both male and female subjects was followed and the students were instructed how a female patient's breast area should be examined in a way to avoid any unnecessary handling or exposure considering the wishes and consent by the patient in terms of personal modesty. Similarly the potential for male modesty regarding chest area was also mentioned which supported the use of a cape in males.
Let's now move on to completing a list of necessary procedure and behavioral changes to the medical system and specific approaches to actively attempt to promote and produce those changes. We should now go beyond "moaning and groaning" and writing imaginary and not realistically helpful scenarios and direct this thread's attention to DOING SOMETHING CONSTRUCTIVE towards the goal.
If my visitors don't show that they are interested in doing that, this thread has become virtually worthless. I hate to say that but it is true. ..Maurice.
Maurice,
From your perspective as a physician, is there a place to target (such as an association)?
Where is change driven from in healthcare?
(Don't say government, we saw how that worked.
Also, may I ask how the students responded to the addressing of modesty in your teaching?
--Banterings
Jason,
I am like you, I have been hurt by providers. Do you see where we are at? Maurice sees that there a problem and admits there is.
I agree that students should be patients. What we need is to find studies about, OR physicians (telling their stories) as patients.
Look what lead up to Maurice's change, it has been evidence based.
I challenge everyone on this blog to invite another physician who advocates "doctors as patients" to join this blog.
I want to hear strategies of how we can initiate change. I asked Maurice (as a physician himself) where he thought we should focus our energies.
Does anybody have any industry contacts or MEDIA contacts?
Jason, look at the the YouTube video A Physician Advocating for Physicians on my blog post "Suicide is Painless..."
Look at her web site. Listening to her made me feel better. You need to see the good that is out there just as much as the bad. By studying the good too, we can figure out what is working and WHY these providers see our dignity.
Jason (or anyone here), if you want to know what I am doing to deal with my phobia, you can find my email (on my blog profile) and contact me directly.
I met a psychiatrist (became friends with him) from my work as a research assistant (I actually ran the research). He was on the project. He is one of those "unconventional" therapy types. I worked with him on my issues, and I have made great progress. I discovered that my issue is loss of control of my body.
I am NOT saying to stop (Jason), you keep reminding all of us that physicians should be patients.
Maurice always fell back on "professionally performed procedures," we need to fight them with their own weapons.
For example, I posted here & on my blog about LDS Hospital allowing patients to keep their underwear for things like hand surgeries.
Here is the link to that post.
The full WSJ story is linked there.
BTW Maurice, this is a good modesty reference for your students!
If you read my blog, part of my solution is freeing physicians from forces that interfere with them doing their jobs. This will get physicians on board. It is better if they follow us than having to push them.
I just completed a degree in web development (because much of what I do professionally is delivered via the Internet). I volunteer my services toward this fight. I don't do Wordpress, I do PHP (Linux), HTML, and MySQL (database).
We have a list of the issues we want to address, now let's:
1.) Start brainstorming how to make change (who to target).
2.) Assessing our resources (studies, data, procedures from providers, skills, etc.).
3.) Let's invite advocate (patient modesty, physicians as patients, etc.) to join this blog.
If anyone is aware of funding sources, I have an accountant friend that owes me a favor, I can probably get him to set up a nonprofit.
4.) Who do you know with influence? Prominent physicians/providers/educators/administrators/policy makers, media contacts, celebs, law makers, etc. anyone who can help get the word out.
Let me throw this out there, what do ya'all think about a blog that only links to stories of healthcare abuses (to show the extent of the problem) that are in the news?
Any other ideas to get started?
--Banterings
Some time ago I posted on this blog (probably more than once) issues that needed analysis prior to doing anything.
You can't fix a problem until it's been identified. This modesty issue is just part a systemic culture that needs improvement. What makes the modesty issue different, is the amount of psychological trauma that results when an infraction occurs with or without any medical misconduct for a medical issue.
Until recently, Maurice couldn't understand why one would forego medical care for modesty reasons.
These issues sometimes are and sometimes are not considered improper or abusive. However, the hospital culture is so broken that "standard of care" procedures can and do harm to patients on the psychological level.
The medical industry pretends it doesn't know when 40% of the cases that wind up in the legal department have elements of this modesty, loss of dignity issue.
First, problems need to be identified.
Second, it's up to the medical community, not the patients who use the system, to fix it. They can't change what they don't acknowledge. Ignorance is no excuse.
Third, a team of psychologists, medical professionals must identify what needs to be changed, how it needs to be changed, why it needs to be changed, without compromising medical care.
Fourth, protocols need to be developed
Fifth, appropriate punishments for those you have multiple infractions; tough enough that loss of licensing should occur across the board whether a CNA or a physician.
Sixth, Legal professionals to change consent forms to be in a format approved by the psychological community, identifying those who have required needs that don't fit in "standard of care".
Seventh, a pamphlet on what to expect regarding your privacy in the hospital. It should have the
same level of detail that our pharmaceutical disclosures have on their television commercials.
Eighth, protocols put into place
to handle those who have requirements.
Ninth, in order for an institution to receive funding or licensing must be equipped with the proper staffing requirements.
Tenth: Medical and psychological professionals to meet with congress identifying the damage that can happen, both physically and psychologically.
This seems like a stretch however, Patty Murray identified that female victims of sexual assault should have special needs when hospitalized to alleviate psychological trauma.
Until the medical community collectively recognizes the problem there is nothing we can do except spin your wheels. Good luck with that!
belinda
Ok..let's start with Banterings list of issues to be met and for each present what we think is a practical solution to each.
1.) gender choice
2.) modesty, unecessary exposure (carelessness)
3.) not recognizing our feeling
4.) unnecessary exams
5.) specific informed consent (anesthetized patients)
6.) true patient participation
7.) choosing our level of healthcare (self determination)
8.) no reprisal for self-determination
9.) lack of empathy
10.) paternalism
But let's start. And visitors who haven't yet written to this thread, please start now to contribute your ideas about what solutions the medical system should consider to the above issues. ..Maurice.
RSL, if you are still lurking, please contact me. You can find my email on my blog here:.
Belinda... "Sixth, Legal professionals to change consent forms to be in a format approved by the psychological community, identifying those who have required needs that don't fit in "standard of care"."
You should add laymans to that group, to ensure the average non-lawyer can actually understand what's being put infront of them.
Jason
Banterings,
I do not know if you realized this, but Medical Patient Modesty is a 501c3 non-profit organization. We actually have a separate web site about sexual misconduct by doctors. We do include articles about doctors who have been accused of sexual abuse in the news. I encourage you to check out the web site about sexual misconduct by doctors.
I developed both Medical Patient Modesty and Sexual Misconduct By Doctors’ web sites. I also have a lot of experience with databases. Both web sites are database driven. I used ASP and SQL. There are many articles on MPM’s web site. We have helped many people to avoid unnecessary exposure and intimate procedures. I had the privilege of helping a man to stand up for his wishes for an all-male team and colonoscopy shorts for colonoscopy. He found a clinic that was willing to accommodate his wishes.
I would welcome your research about abuse that we could include on Sexual Misconduct By Doctors’ web site. You can contact me via email.
I like many of your ideas. We will never be able to change the whole medical system, but we can empower patients to protect themselves. We also can help to educate some medical professionals to be more sensitive even though not all medical professionals will be receptive.
Misty
In answering Batterings question from yesterday "
Where is change driven from in healthcare?" One such non-governmental resource but which is involved in the accreditation of healthcare organizations which receive governmental money is, as I had previously noted, the Joint Commission.
From the JC website:
An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
Our Mission: To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.
Vision Statement: All people always experience the safest, highest quality, best-value health care across all settings.
..Maurice.
Just a question. Who does the Joint Commission respond to? I assume insurance companies, the government, & associations of MDs or medical administrators/bean counters in the medical community. Does the Joint Commission even consider inputs from individuals or seriously consider inputs from the organized public?
BJTNT
BJTNT, go to the link to the Joint Commission website which I posted above and you will see that they are independent and it is "to continuously improve health care for the public" which is their mission.
Though complaints coming from visitors here might not be specific, I am sure our visitors will learn how to introduce the general complaints regarding gender and modesty issues by communicating with the Commission. Here is the link for information on how to do that. ..Maurice.
So now, which visitor here is going to be the first of hopefully more than one visitor who will send messages to the Joint Commission regard the rationale and need for a change in the standards of how the medical system handles the matter of provider gender and patient modesty?
You may want to present here what you plan to send or have sent for review or comments. Remember, for your message to be more effective towards a goal, it shouldn't be simply an expression of hate but rather an expression of history, need for action and patient suggestions.
This job now of communicating with a resource who has clout over all medical institutions is one for my visitors-- it should come not from one physician who runs a blog but from the very folks who have been uncovering the professional behaviors and patient needs all these 9 years here. However, if you desire you can refer the Joint Commission to all the 68 volumes of this blog thread for their further understanding of the issues.
I say, "get going" on this first step from here to make the necessary changes to the system. ..Maurice.
And here is the ACOG recommendations from 2012 regarding the age and frequency of pelvic and breast exams.
Surprisingly, in the Toronto Star article, there was absolutely no mention or description of how the doctor explained the reason or need for the frequent exams. The story is totally about a conclusion of the investigative committee but nothing referring to the physician's explanation. Regardless of the case raised by the committee against the doctor, it is poor reporting not to present both sides of the case. If the doctor had given no explanation, that information should have been included in the article. ..Maurice.
I have written the Joint Commission in the past but did not get a response. I don't know if that is standard or not.
Dr. Bernstein I wanted to make sure I was clearly communicating my stance on your students. I was not advocating forcing them to examine or be exposed to each other. I do not think that is something we should force on students. My point was that all of the things that are used to justify exposure and expectations of patients are present in these situations when providers are on the other side, and yet they are discounted. It is providers who are defining and making these decisions. It is much like congress passing laws that do not apply to them. In fact, if we advocated forcing them to go through this, it could just as easily lead them to the conclusion that it is an acceptable practice to force patients. Asking if anyone would feel comfortable or willing to, but making it clear there is no expectation they do and they should feel free to decline might be an interesting exercise and might provide some insight & training to the students but they are not our lab rats for experimentation. The message that the context of this and your learning but the same thing in the context of the medical system make this completely different probably contributes to the problem. The message we are not forcing you to but you can apply your reservations to how your patients feel....might be a positive to addressing the issue. Just wanted to make a difference....don
Found a different article with a bit more of his side / reasoning
http://metronews.ca/news/toronto/648792/toronto-doctor-stanley-bo-shui-chung-denies-performing-exams-for-sexual-reasons/
"He reiterated that performing the examinations was part of the training he received in medical school."
"During the cross-examination, Alice Cranker, counsel for the College, told Chung that Patient A had 18 pelvic and breast examinations in just over two years. The lawyer asked him if he now believes every examination was necessary.
“They were necessary at the time of presentation,” he said, adding that in hindsight, there may have been some that were unneeded, but there was no way of knowing that until the examination was performed."
Jason
@don Well phrased.
@Jason Good reference
This is an instance of "Can't see the forest through the trees."
Let's take him at his word and assume that Dr. Bo-Shui Chung did not do these excessive exams for sexual reasons.
Why couldn't he see that this was excessive???
Why did he not realize that this was a traumatic experience???
According to him, it was because that was what he was taught in medical school.
That is more frightening than the reason that he was sexual predator. That means that all physicians have the capacity to do something as egregious without recognizing the harm that it does.
--Banterings
They do recognize it but hide under the guise of standard of care or medically necessary. I know. I experienced it and had to deal with ridiculous commentary but did succeed in the end. A doctor was disciplined and changes were made to standard of care practices...and this was 35 years ago.
Belinda
Even if it was as non-invasive as... say using that thing they use to look in your ears....
The fact that (according to him) he didn't know WHY he was doing it, he was just always taught to do it that way... added with the indoctrination of his patients from the time they were little (one of the stories said he did these exams on a 12 year old) both aspects of it are a huge reflection of the overall issue. (see the whole underwear during surgery issue)
the real failing comes from the college that warned him A DECADE ago, but never bothered to check up on him to see if he'd actually stopped.
It's garbage like this is why I'm in favor of criminal penalties for ALL "possibly aware" (so they can't claim ignorance and actually HAVE TO do due diligence) parties involved in medical wrongdoing, not just the one actually doing wrong.
It may seem a bit extreme, but if you take it out of the medical setting, you'd likely agree.
Imagine a mechanic who did everything to peoples cars from swapping out high end parts for rebuilt parts likely to fail, took peoples cars for joyrides / used them as his personal vehicle for weekends, let unlicensed people work on cars..... and everyone else in the shop, including the owner was aware.
Then one day the work done by one of his unlicensed friends fails and causes a fatal car accident, or he hit and runs someone while driving your car....
Do you not think the owner of the garage and all his co-workers who knew this was going on should also be to blame?
Jason
Don, can you tell us what you wrote to the Joint Commission and specifically what was the route into the Joint Commission you took with your message? Their interest is primarily in that of the patient and not simply the institution and all their standards set for practice within the institutions is for the benefit and safety of the patient and not the institution.
I am still waiting to the a response from our visitors regarding initiating a constructive attempt to start making changes in the medical system. This periodic presentations of the behavior and consequences of outlier unprofessional or criminal physicians does nothing beyond whining about the need for changes of the medical system to actually begin to DO SOMETHING. ..Maurice.
Maurice,
I have taken your challenge seriously. Perhaps it is the scientist in me that is taking the approach that I am. I am simultaneously composing a letter and trying to figure out who to target.
I am also looking at the Joint Commission. I am researching the different high ranking positions, who filled them, and their background. That way I can figure out who will pay attention to what I say.
Silence does not equal inaction. There are many on here that are trying to change things in a visible manner (Misty, Doug, Linda), there are those who do nothing, and those who do things that no one sees.
I like that you are looking at the joint commission. I am just wondering if there is any other target that may bring change.
--Banterings
Here's an idea. The effect would be much more profound if we all wrote to you, and you submitted the information to The Joint Commission. Clout of an individual (even collectively) doesn't measure up to a physician presenting the material. Perhaps we can add a psychological professional and submit this oroject together with a comprehensive voice?
Belinda
Like banterings said earlier on this page "To put it bluntly, if we could not convince the 4-7 providers that are active here there is a problem, how would we convince a whole industry?"
So, as an industry insider, what would YOU suggest be done to effect an industry wide change from what's effectively a half a dozen people when... frankly... the guy who's been hearing constantly negative experiences from us and those like us for NINE YEARS still refers to as "outliers"?
Jason
It was in regard to my experience with the ultrasound. I relayed my experience and focused on the fact that the nurse who did my ultrasound walked into the waiting room and told a female patient she was going on break and the other tech on duty was make so if she would feel more comfortable with a female and could wait about 15 minutes she would be back, I pointed out the double standard and how this negatively impacted not only my experience but likely contributed to the fact that males avoid medical care to a higher degree than females....I never recieved any acknowledgement at all. It has been a couple years so I can't recall exactly but for some reason I have the memory that I thought there was something that indicated I should not nesecarily expect a response...don
I have no clout as simply a physician who has had no personal nor professional experience with regard to the issues presented on this thread. The ones who have clout in there expressions of personal but also experiences of others known to them are the commentators and the other visitors to this thread. Again, I have tried to send your views out to the profession by attempting a failed (probably could have been better done by my visitors) attempt at a internet public petition, by writing two articles a few years apart to the "200,000 physicians" reading the American Medical Association News.
What have you all done to "spread the word" to those who could make a difference? Yes, Misty has her website and Belinda is in the process of writing a book (if I understand her activities) but what are the rest of you doing to attempt to accomplish the task that you think is necessary to make changes that I think the medical profession does need to consider and make.
Now it's YOUR turn to DO SOMETHING CONSTRUCTIVE to accomplish the goal. Don't just lean on me to be doing what you all should do. I've kept this thread active for all these years for my education and the education of my visitors and its now your turn. ..Maurice.
Don: I am sorry to hear that you did not get a response from Joint Commission. Did you send an email to a general email address? It is possible your email did not go through. I’ve had some email problems lately and numerous people have told me they did not receive my emails.
I would like to suggest you consider setting up an appointment to talk to the administrator of the practice where you had the ultrasound. They need to know how important it is for them to give men the choice of having a male technician for intimate male procedures. I also would like to encourage you to consider setting up appointments to talk to administrators of urology clinics in your areas to educate them about the importance of them hiring more male assistants and nurses. You could play an important role in helping clinics and medical professionals become more sensitive to male patient modesty. While it is impossible to change the whole medical system, you could play a role in helping a number of medical facilities become more sensitive to male patient modesty.
Dr. Bernstein: I agree with you that people who are passionate about improving patient modesty should take actions. So many people have found Medical Patient Modesty’s web site over the past few years. I have had the privilege of helping patients take steps to stand up for their rights to modesty. It has been encouraging to hear of patients having good experiences because of Medical Patient Modesty. Patients have to stand up for their rights. I am looking forward to Belinda’s book and I believe it will be a very useful resource. She also has had the privilege of speaking to medical professionals about patient modesty.
Misty
I think my mistake was not to request at least an acknowledgement it had been received or wanted a follow up.
Actually I did a couple things. At the facility I had to have a follow up and told my urologist I wanted to schedule my own, got the official procedure, called the hospital, told them I wanted to schedule, they sent me back to central scheduling and I told them I wanted a male and while they were a little surprised they complied and I got a male. Looking back I wished I would have just asked the receptionist at the urology office to do it so the seed would have been planted in her head.
As I continued to participate in this blog I began to feel I didn't do enough so I emailed the patient advocate at the hospital. When I did not get a response, I sent a follow up email to the advocate & cc'd the patient services person asking it get elevated to the administrator...that got a response from a patient advocate who tried to hide her displeasure I elevated it claiming she never got the email. I got a call from the woman in charge of the imaging department whom was so great to talk to, she thanked me for bringing it to their attention, they are always looking for ways to make the patient experience better and they were compiling a list of procedures where scheduling would try to ask prior, etc. Now the reality in order for that to work, the urologist office would have to be involved as central scheduling does not have the contact with the patient. But I was impressed by the effort and the attitude of the woman in imaging, she at least acted like she understood and did not think I was being unreasonable. Not a hint of defensiveness...she was a true professional (small hint of sarasim intended). Will it change the world, no, I think it planted a seed and it made me feel more comfortable asking in the future..don
Don,
I’m glad that you contacted the administrator and patient advocate. It is clear that the particular patient advocate you contacted is not sensitive to patient modesty. I have learned that you will get a mixed reaction from different medical professionals. Some medical professionals are much more sensitive to patient modesty and others are not. For example, you could have an urologist who is willing to work to accommodate your wishes for an all-male team, but you might get a negative response from the nursing supervisor at the hospital.
It’s encouraging that the woman in charge of the imaging department was sensitive to male patient modesty. You will never get the same response from all medical professionals. That is why it is important to find medical professionals who are sensitive to patient modesty. I had the privilege of helping a man who needed a colonoscopy last year to take steps to ensure that his wishes for colonoscopy shorts and all-male staff were honored. He found a great male doctor. He said that the head nurse who was female was very nice and worked to accommodate his wishes. They even ordered colonoscopy short for him.
Misty
I wanted to encourage everyone to check out a new video by a man who is concerned about male patient modesty, Male Modesty In Healthcare Setting by Argh IMO . This man had some bad experiences a few years ago and found Medical Patient Modesty’s web site. He said that MPM really encouraged him. He feels it is important to educate patients about the importance of speaking up.
I really appreciated the white sign that a man holds over his private parts (you cannot see anything at all) around 3:38 of the video that says “This Area is Off Limits ….. Please Send a Male Nurse. Thank You.” This was a great idea. I think that this guy did a great job addressing how important it is for nurses to respect male patients’ wishes for modesty and male nurses.
I really appreciate him encouraging people to check out Medical Patient Modesty’s web site for patient modesty issues at the end of the video.
Misty
Here are some links about how undignified the open back hospital gowns are. The NY Times article is from 2005. This read is good because it discusses the physiological issues associated with "becoming a patient."
The last one is from France (with probably the most liberal view on the body & nakedness) where the nurses lead the way to protect the dignity of the patient in the country.
In the Hospital, a Degrading Shift From Person to Patient
(NY Times)
Birmingham Children's Hospital gown gives "privacy and dignity"
(BBC)
Minding the gap: Colorado State University redesigning the hospital gown
Gown and out: 'Bottom-flashing' hospital robes to be replaced by more modest attire ( DailyMail UK)
Doctors and patients lash out at “undignified” hospital gowns (The Observers)
Maurice, 2 questions for you from your perspective as a physician:
1.) Within our country (some) providers and facilities recognize that the open back gown are undignified, detrimental to the healing process, and psychologically damaging. At what point does these dignified gowns become the standard of care?
It seems to me that if the (all be it non-binding and thus useless) patient bill of rights (that all facilities have), they promise patients will be treated with dignity. Then why do all facilities NOT have dignified gowns? The apparent answer is that costs money.
2.) in relationship to your challenge and patient dignity; you said that you were unaware that patients had the issues discussed here: How do we show the extent of the problem?
When we speak up about our experiences and the effects of, we are dismissed either as it being a psychological issue (made up) or as outliers. You have always been much more respectful than most, and have kept an open mind.
Physicians, other providers, and patients have written about their experiences, all to be arbitrarily dismissed. Dr. Edward E. Rosenbaum wrote his book "A Taste Of My Own Medicine: When the Doctor Is the Patient" in 1988. It was made into a movie ("The Doctor") in 1991.
I can't understand why healthcare doesn't get it? What does it take? The hospital gown is a good example; the lack of dignity, yet most facilities have not changed it?
One thing that strikes me if you go back over these volumes, and other sources is what I would call medical double speak for lack of a better word. While there are some blatant "we are professionals", there are more subtle ways that I believe is a pretty common tactic and that is avoidance or misdirection. I want you to reflect back and think of how many times the question "How could providers/you not recognize this makes the patient more uncomfortable" or more to the point "Did you not sense or see the patient was uncomfortable" I don't recall that question has ever been directly answered by a provider. I think the most honest and direct acknowledgement was that of the young female MD looking for a way to ease the embarrassment sports physicals caused young males. But think hard here, we have heard things like the context made it different, providers assume you are accepting this because you are there, they don't realize the extent etc. But, the more obvious question...ok these are all ways that would explain how providers JUSTIFY the process, but it does not answer the obvious that we were asking. Did you really not think or observe having opposite gender provider present for intimate procedures and exams was uncomfortable or again more to the point made more uncomfortable by opposite gender? Personally I feel they talk all around it because the answer "No I had no clue they were uncomfortable laying there with their legs in stirrups exposed to opposite gender" is not true or perhaps believable. It is so obvious you have to know they are uncomfortable. Now, even yes we recognized they were more uncomfortable with opposite gender but assumed they had accepted it or would tolerate it, or whatever is more believable. But the more common thing is for them to talk around it. If they do admit yes we realize to some opposite gender is more uncomfortable, or yes I knew they were uncomfortable...then it begs the question...why didn't you do something about it?....I could be wrong but if you read back, I don't think you will find to many places where providers directly answered those questions. They might explain why they felt they were justified, what they do to make patients more comfortable, but you won't find many where they admit they were aware of the patient even being uncomfortable...don
don,
They are wearing their magic white coats...
It is not even about gender, it is about one person being undress and exposed and everybody else is not.
It is troubling that providers don't see this as a problem.
Here is a cartoon that explains it.
I believe that because providers refuse to address the issue, discount it with attitudes like "we are professionals," and brush it off, that leads patients to suspect they have "ulterior motives."
No other industry other than the porn industry centers around undressing. If healthcare won't answer the questions, patients will fill in the blanks for them.
--Banterings
Don -
Maurice has given a direct response to the question....
**********
Sunday, August 03, 2014 3:17:00 PM, Maurice Bernstein, M.D. said...
"I was totally unaware of the physical modesty complaints laid upon the medical profession prior to reading the comments from visitors to the first couple Volumes of this thread. I was never, never complained to by my patients and I hadn't heard of any complaints by those colleagues I knew."
Said by Maurice Bernstein, M.D. Sunday, August 03, 2014 3:17:00 PM,
*********
Personally, I think "most" medical "professionals" are just so entrenched in their ways, and have these ideas drilled into their heads from the moment they walk in the door to med school that they really do have horse blinders on, and honestly believe that "the ends justify the means", and whatever they do under the armor of their white coat should just be accepted by society without question. How else could they possibly justify sexually assaulting sedated patients and call it "educational"? Not just to the general public, but to themselves.
Jason K
But Jason, does that mean providers are unaware their patients are uncomfortable? Unaware of complaints, unaware they avoid care....the very basic level is comfort, do you honestly believe this means that providers are unaware patients are uncomfortable while they lay there with their legs in stirups? Then why is there acknowledgement/accomodation at some levels but not others? Why would we ask if a woman with her legs in stirups would mind if a male student observes but not others, why would providers recognize med students may not be comfortable but not question patients. At the basic level, did a provider never witness or notice a patient was uncomfortable or distressed with the situation....That question is frequently avoided. So I guess the easy solution is for me to ask bluntly....Dr. Bernstein did you mean that you have never ever felt, observed, or questioned whether a patient was uncomfortable being exposed during a proceedure or exam?....You had no clue they were uncomfortable? ....don
Don you are asking for my personal experience as practicing internal medicine and not as a gynecologist or urologist or a surgeon who does breast surgery. You are asking someone who has been many, many years in my specialty virtually all prior to "9 years ago". So, yes I was aware of the general issue of patient physical modesty and my awareness was the basis of what I was teaching my students in their medical school class all these over 25 years as an instructor. I was attentive to informing the patient about these modesty "sensitive" procedures that I did perform and awaited their informed consent. And during the procedure, which I attempted to complete as rapidly as possible without "hanging around" but still attempting to get the information which was required, I also had my attention to the behavior or any communication from my patient. No.. though I asked the patient (usually during a pelvic exam} regarding pain, I have never brought up sexual feelings or modesty directly as part of my questioning. Yes, as I have said before here and what I have taught my students, is that if the male patient develops an erection during the genitalia exam, it is necessary to immediately educate the patient at the time that this is not a sexual reaction but can be a normal reaction representing a normal vascular and neurologic response. Other than this, to start discussing sex and the need for the patient to control their modesty during the exam is an inappropriate and inflammatory communication with the patient at that moment.
I have no knowledge and have not communicated with gynecologists or urologists or breast surgeons about their practice in this regard..with the exception of the urologist who has written to this thread and has written about his practice here. I think it is the patients' responsibility to do that communication with those specialists if the patient feels it is important to do so prior to an exam or procedure. I hope, Don, this answers your question as specifically applied to me. ..Maurice.
Maurice - you said..." I think it is the patients' responsibility to do that communication with those specialists if the patient feels it is important to do so prior to an exam or procedure."
IMO, the burden falls on the positive action, not the defensive possibilities. By that, I mean the person who is going to be doing the action should ask permission, not that the other person should deny permission for any possible act before hand.
What if the patient DID express concerns about extra eyes before surgery, but the person teaching a class of med students just assumed there was consent, didn't check, and let the students observe?
(or is that just another "bizarre scenarios being written to this thread by Jason"?)
Jason
Jason, ..and so what does this prove beyond what we already know about physician sexual perverts which represent a gross statistical minority of all the medical professionals. So this information provides nothing that we don't already assume. A constructive discussion on this matter would involve how to prevent these folks from entering medical school and how to more rapidly screen these folks out of the profession early in their period of misbehavior similar to the current interest in random drug-screening all physicians in practice. ..Maurice.
1 more point of proof that doctors should be trusted "just because they're doctors". Seems to be getting to be an almost daily thing with doctors being charged for something or other, contrary to some folks insisting that bad docs are the rare outliers.
But you raise a valid point... similar to random drug screening folks, since the pictures were on their computers at work and home, what do you think about medical personnel having their home equipment randomly searched, and homes searched to ensure they aren't keeping the pics on a hard drive in the basement or something, constant monitoring of their personal internet usage to monitor for their personal tastes in porn / voyeurism, random body searches of them at work for things like that gyno photographers pen cam, and randomly sweeping the building for hidden electronics?
Sure, it sounds extreme, but given the authority that society has given doctors, police, judges.... they should be held to an insanely high standard.
Jason
Dr. Bernstein, I read and reread your post. I sometimes read resposnes with a opinion prior to their response. I have jumped to conclusions so I am trying to take my time with your, and my response. My question was very simple, and directed toward your expieriences. Have you observed, were you aware some of your patients were uncomfortable with exposure. Your response was pretty broad, complex, and to be honest a little hard for me to follow. You went into people who were gyn's. sexual arosual, etc. This goes back to my point, when confronted with a basic question...were you aware a patient was uncomfortable...provider oft go into "double speak or misdirection". My question had nothing to do with sexual arousal, sexual feelings, etc. When asked with a simple question the extremes are brought in or the answer to a simple question becomes complicated. I would think the obvious answer is yes I was aware some were uncomfortable. The reason I am so persistant is I believe one of the root causes of this issue is the refusal of providers to recognize it, in other words, denial. I believe by nature providers in general are kind and caring people. The ultimate goal is to help people, to ease pain, to comfort. So, when confronted with things like violating patients modesty causes distress, pain they do not want to be responsible for that pain or discomfort. It goes against their very nature. So they practice self defense by denying it exists or in some cases perhaps justifying it. Thus when asked a simple question do you recognize it makes some patients uncomfortable they go to discussions of ER's, erections, sexual arousals rather than answer a simple obvious question. Does this make them bad, on the contrary I think it shows their good, and desire to "do no harm"...don
Don, the answer is yes: I am aware of discomfort, attributed by the patient with the word or actions related to pain. When this occurs, I have made attempt to explain the pain and as quickly as possible complete the exam. No: I have never been aware of discomfort of the patient which was then attributed to modesty by the patient.
I think it is unwise to make generalizations based on repeated questions only to one physician--me! Unfortunately, I am the only physician day in and day out on this thread. I would suggest an active attempt by those interested in getting answers to their concerns to survey other physicians beyond this blog thread. Yes, it will be a bit more challenging than simply asking me here but I am sure it will give a better understanding what other doctors are aware and understanding about any modesty issues with their patients. Do it but also, and I see the inertia, to describe programs to be started to attempt to make the necessary changes in the medial system that have been discussed here. Get to it! Somebody start an internet petition going, the results of which may provide the clout necessary to stimulate the Joint Commission into action. ..Maurice.
Don - Any medical person who doesn't believe or can't see that people avoid care / have modesty / embarrassment issues really must live with their heads in the sand, and I would honestly doubt if I could trust them to be my doctor if they're that blind.
No, this isn't a jab at you Maurice.
Just the fact that so many men avoid the prostate cancer check they have to put up billboards for "don't die of embarrassment" should tell anyone who thinks about it for more than a half a second that the numbers must be huge, and that embarrassment is the main reason for it. The billboards don't say "it doesn't hurt".... it focuses solely on embarrassment.
So I have to disagree with you that it makes them good because they're trying really hard to do no harm... in my eyes it makes them bad because they're making themselves oblivious to a patients problem.
Jason
Maurice,
Here is a question I have never heard asked, and I am hoping that you can shed some light on it.
How is what is acceptable as patient exposure decided?
Let me clarify...
First you need the site of the procedure/exam exposed (obviously). Next you need any site that needs visual monitoring exposed (lips, fingernails, cannuals, etc.).
Any site that you MAY need access to (chest in case of a cardiac event) should be exposed and draped. Infection control comes into play as well.
How was it decided that exposure of the patient was a gender neutral issue? (We know what changed this; lawsuits.)
Is there some written protocol that each facility can adopt and change? Does each facility write their own?
Is it driven by insurance carriers?
Obviously there have been changes made as to what is SOP from when you were in your 3rd year. What drove these changes? Was it solely lawsuits?
I don't remember who mentioned "boys' high school swimming class," where the boys swam naked. We look at that today (you included) and realize (I really hate to say the impropriety of it, because there is inherently nothing wrong with being naked as long as dignity is in tact, perhaps better to say) that it is "socially unacceptable."
My family had rural land in north central Pennsylvania that I spent much of my youth growing up on. It was nothing for me and my friends from the surrounding farms to go off in the woods, finding swimming holes and go skinny dipping.
This included girls too. Most of the time we left our underwear on, but there were times that we were "naked as a jaybird." There was nothing sexual about it either. It was summer, it was hot, and this was the best way to cool down.
Interestingly enough, in retrospect I see the times that we were all completely naked was when somebody (usually the first undressed) got completely naked. There was an unseen "social pressure" to follow suit.
Yet today, I think that could never happen. I wonder how we as a society went from there to here. I think that the biggest driver has been fear mongering perpetuated by the media sensationalizing (shock value) sexual assaults and kidnapping).
So again I ask, how are the standards determined, and how are they changed?
--Banterings
Jason. Several months ago in a large city near by they advertised on tv about the free prostate checks they were offering. They had brought in 2 mobile clinics ( buses ). When they showed the inside of those buses the whole staff was female. If all their patients are male why would the whole staff be female? I sent a comment to the hospital staffing those buses but never received a reply. AL
AL, write them again and again and again until you get an answer. It may be that the photograph did not fully represent the gender of the providers on the buses. But, you deserve an answer in view of the photograph.. so keep writing.
Banterings, the accepted standard for exposure for any medical exam or procedure is to allow for thorough and valid examination and proper and safe procedures.
These days, with limited time, often the skin is not exposed and there is therefore variable degrees of thoroughness and validity to the examination.
There are no other reasons for exposing the body of a patient other than what I just wrote, Any exposures for self or group interest, which I believe is extraordinarily rare (but obviously publicized) is beyond being simply unprofessional. ..Maurice.
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At Friday, August 22, 2014 10:29:00 AM, Anonymous Anonymous said...
Jason. Several months ago in a large city near by they advertised on tv about the free prostate checks they were offering. They had brought in 2 mobile clinics ( buses ). When they showed the inside of those buses the whole staff was female. If all their patients are male why would the whole staff be female? I sent a comment to the hospital staffing those buses but never received a reply. AL
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Why should the hospital respond? Their attitude is why is someone concerned how they run their business. They have a point. If you don't like the way the hospital runs its business, go somewhere`else where you will be treated the same. Who has the last laugh?
Dr. B. has a point. If you [Al] keep writing, the administrators may develop a form letter and you will get a reply.
BJTNT
Al - IF you get an answer it will likely be the tired old excuse of "there simply aren't enough males to staff them" or like Artiger said about his own practice (or implied, I'm not sure off the top of my head) Women generally make less than men, so they can't afford to hire guys, so women it is...
But definitely find as many emails from the hospital you can find (the PR dept, HR, administration...) and open CC the letter to all of them, so the higher ups can at least know the email is being ignored, and email often. Also use the option to request a read receipt, so in follow up emails, you can say "I saw you got my last email on Sept 4th @ 13:20, but I guess you forgot to reply, so I'm emailing again", which shows administration you're not getting a reply.
You could even make a new gmail account and just ask what their policy on same gender / opposite gender / patient preference care is, THEN ask why the buses were all female.
Jason
Maurice,
You missed the point of my whole question so let me rephrase it:
I am not bashing anybody or any procedure.
I simply question, for instance when you teach your students about a procedure OR a physician is going to perform a procedure, what is the reference for doing that procedure?
Forget exposure, there are (about) ten standard incisions for abdominal surgery. (Theoretically) you could access some of the abdominal structures through more than one of those incisions. How is it decided which one should be used.
Bernard Lown invented the DC defibrillator in 1962. Where are the protocols for using this (that you use to teach your students) written?
Al, can you post a link to the ads or the hospital that sponsored the busses?
You should send a letter to the television station that ran the advertisement. Chances are that they were a PSA. If that station doesn't acknowledge the problem, send a letter to a competing station.
Speaking about gender, I just saw this post the other day on KevinMD (Sexism is alive in medicine). A female physician "bashes" men.
I am not making this up or bashing physicians. There are NO modesty issues in her post. It is disturbing how she treats men in her post.
You can read my analysis of why nothing she says supports her theory.
I am not making this up. Read her post here:
I may have been a little harsh, but I was deeply offended as a man and afraid to hear this coming from a physician.
Where she really crossed the line was when a patient (respectfully) called her "miss," and she countered "I am a doctor."
We all know that one problem in hospitals is not being able ti identify position when everyone wears scrubs.
Finally everyone might find this interesting, coming from me. Monday, I have an appointment to have a "dermoid cyst" removed from my temple. My wife will be there holding my hand.
The surgeon is an acquaintance of the family. He did wrist surgery on me some years ago and a bunch on family members. I kept my underwear on (despite being told to remove them by the prep nurse) for the wrist surgery. I trust him, he has earned it.
When he did my wrist, I was so afraid that my BP and HR were so high, they almost cancelled. I spoke to the anesthesiologist, told him the problem and asked for a sedative. I did not want to see going in to the OR.
I very good friend of mine from high school (she is a D.O. now), her aunt was one of my OR nurses.
It will be in his office in a chair with a local. I felt safe, dignified, and clothed there.
Am I afraid? Scared to death.
Why am I getting it removed after 4 years? I have been afraid to go. My father (respectfully) told me that this may distract from what people think of me professionally. I do very large, sensitive deals. It is all about trust.
Have I been worried about it being serious? Yes. Why am I going now? Pressure from my family and support from them too. Dad even offered to go with me.
--Banterings
Banterings, I don't teach first and second year medical students about any procedures beyond: how to take a history from a patient, how to perform a physical exam on a patient and that's it. We use Bates as the standard for the examination. (if you can access a volume in a local library, you can evaluate all the standards). All other teaching about medical or surgical procedures are done primarily in the 3rd and 4th years and I have no specific knowledge of what and how it is taught. I do know about the "hidden curriculum" which has the potential of being taught to the students in those latter years which deals with the necessity because of pressures of time and responsibilities to teach methods of patient interaction which tends to diminish, at times, humanistic, ethically strict and truly "patient centered" care.
I hope this answers your question.
Check Bates. ..Maurice.
Jason I have to admit at times I think you to be a bit extreme but at times I agree. You got my point completly. If a provider cannot undertand, can not see a patient is naturally uncomfortable being exposed to others, they are blind, not looking, in denial, or stupid. They could not be stupid and achieve what they have academically, i have yet to meet a blind MD but doesn't mean they do not exist. So we are down to not looking or in denial. There are just to many inconsistancies. Why bother draping a woman for a pelvic if they aren't uncomfortable. Have providers never heard the term dying of embaressment? Never seen the ads. I used a very low bar on purpose, uncomfortable, not humiliated, not truamatized, uncomfortable. So one would have to assume the opposite was observed, the patient was comfortable laying exposed to MD's, nurses, students, whomever happened to be in the room. Which is easier to believe...do not mean to be disrespectful at all Dr. Bernstein, but just as you held us accountable and challenged us, brought some things to light, caused me to look at my self, I would say if you never observed a patient being uncomfortable with exposure....why? How could it possibly be in all the years of practice...you never ran accross someone like us? Even if we did not melt down, how could it never cross your mind that a woman exposed to you and whoever....would not be comfortable....while I realize I am biased, it really defies logic........don
I can't explain it Don... except to say that perhaps all my patients found that the value of the exam was more important to them than any discomfort with the exposure. And it also means that I never got a patient who would have such undisclosed concerns that they would have ended up writing to this blog thread. ..Maurice.
"perhaps all my patients found that the value of the exam was more important to them than any discomfort with the exposure."
Have you ever heard the expression "grit your teeth and bear it"?
Just because a patient goes ahead with the exam, and even remains silent, their body language should tell you that they're not comfortable.
Personally, I HATE needles. But I know I have to get them from time to time.... I look away and keep quiet... but the person giving me a shot usually comments to the effect "Not a fan of needles?" and asks if I'm one of those people that passes out.
Without me saying a word, and being there for the "procedure", they still picked up on my body language.
Not to be disrespectful, but I'm with Don on this one, that I find it impossible to believe you've never had a single patient who was uncomfortable.
Perhaps before you started this blog and didn't realize the scope of this issue, would it be possible you just weren't looking for or picking up on their body language?
Jason
Jason, for years prior to this blog thread I was attentive to "body language", the physical behavior of a patient. This language is one of the most important parts of a physical examination and we stress this to all our students. It is the part, beyond the stethoscope and ophthalmoscope which suggests underlying physical and emotional abnormalities. You cannot be a complete physician with only ears and touch and perhaps smell. Perhaps a best example of missing "body language" is the handicap physicians have with answering calls from patients "over the phone" or if the doctor is "texted". And yes, when we are doing an exam we are attentive to any squirming or withdrawal movements which indeed may even interfere with a proper exam but needs to be attended to by communication with the patient. So please don't attribute a physician's non-recognition of mental distress by not attending to "body language". I will say again and again, the folks here can make all the assumptions they want but if the patient does not SPEAK UP BEFORE OR AT THE TIME OF DISTRESS... well, then the patient is missing a chance to unambiguously convey physical modesty concerns or distress to the physician. Maybe some patients are so "modest" in their communication abilities that they cannot bring themselves to express their underlying physical modesty.
I say, if a patient doesn't "speak up" they will only be hurting themselves and the doctor will go on as I have all these years assuming that the patient was satisfied with the exam based on the doctor following the informed consent presented to the doctor by the patient. ..Maurice.
Banterings, I saw your comment on "Sexism is alive in medicine" and thought it was spot on, needed to be said, and wasn't disrespectful or confrontational!
I made a similar comment about the "miss" reference and we'll see how long it lasts. Did you get any feedback indicating why they deleted your comment?
Ed
Don, drapes do serve a purpose. People are visual. A gynecological drape is used specifically to spare the patient from viewing themselves while the doctor views them. While you are just as exposed, it is there for patient comfort and it does have merit for most patients.
I do feel that some are giving Maurice a very hard time. Context is everything. If you are going to have a rectal exam, expect exposure. If modesty is an issue for you, wear, boxers backwards as Misty suggests. If you don't want other personnel in the room, speak up.
As a young woman with fertility problems a find older male physician was recommended to me. Sadly, he passed away and when I came to my appointment I'm greeted by a very handsome young male doctor. I'm thinking...no way, am I taking my clothes off.
He greeted me in the waiting room.
While speaking, he took both of my hands in his and said, "Don't worry, we are going to fix this".
Immediately, my feelings of modesty disappeared and were replaced with the kindness of this man and his intentions. I can't say I even remember any exam but there were a couple and yes, I did go on to have two healthy children.
When I explained after the birth of my first child, he was appalled at the cruel and degrading treatment I was subjected to.
It's this absence of common sense that Don speaks about that is at the crux of this modesty issue.
When medical procedures cross normal social boundaries, personal ones, that's when patient's become traumatized. It's up to the medical community to address these issues with health psychologists so that these issues can be procedure oriented to ensue the best outcome, both medically and psychologically.
When bodily exposure is involved and the teaching hospital wants students to observe, it's absolutely necessary to tell the patient how many eyes will be on them and what gender inhabits those eyes. Not doing so is a recipe for disaster.
belinda
Dr. Bernstein has indicated that he did not have a female assistant present for his male patients who he did intimate exams on. I am sure that Dr. Bernstein had some male patients who were uncomfortable with female assistants or doctors. For those male patients who felt modesty was important to them probably felt that Dr. Bernstein met their wishes for modesty since he was male and no one else was present. That’s probably why they did not talk about their feelings.
Dr. Bernstein: I do have some questions about your female patients.
Did the female patients who you did intimate exams know in advance that you were going to do intimate exams on them when they scheduled the appointments? Or did you announce at their appointment that you needed to do intimate exams on them? I know of some women who do not care about their modesty and they schedule appointments with male gynecologists. We all can pretty much conclude that patients who schedule appointments with opposite sex medical professionals probably do not have significant patient modesty issues. There are so many female gynecologists today. Women often schedule appointments with female gynecologists so male doctors are not going to see many of those female patients for intimate procedures.
I have another question for you: Didn’t you treat many patients for non-intimate health issues such as diabetes that did not require exposure of private parts who never had any intimate exams by you? Most people who value their modesty do not care about the gender of the doctor and nurse for procedures that do not require exposure of private parts. For example, I am sure that most men here would not hesitate to let a female nurse give them a shot in the arm.
Misty
Belinda you miss the point, I realize drapes serve a purpose, it is because providers recognize the discomfort these procedures cause. They provide drapes to ease that, so there is recognation of the issue. My point was providers HAVE to be aware of the issue to provide the accomodations they do, otherwise why would they bother? That was my point, how can you provide accomdation on one hand, and claim ignorance on the other.
Blieve me disrespecting Dr. Bernstein is the last thing I want to do. I have a great amount of respect for him for doing this, Often he stands alone, but just as he and others have challenged patients to do some introspect, I would put the same forward. To contend that in all of the years of practice, none of the 1,000's of patients were uncomfortable is...hard to comprehend. To say he did not recognize it, is difficult but possible given the mind's ability to deal with unpleasant or difficult things. Repression of memories of abuse is not uncommon. Does anyone here really believe none of the 1,000's of patients Dr. Bernstein have had were uncomfortable being exposed? Do you really believe that Dr. Bernstein? What are the odds of treating 1,000's of people none of which were uncomfortable with this? That does not mean Dr. Bernstein was aware, or his mind allowed him to acknowledge it. And that is the crux of my argument. The argument that providers have no clue, or have no reason to believe patients may be uncomfortable being exposed defies logic. The possiblity that they are in denial for self preservation, or self defense mechanisms do not allow them to acknowledge this, even to them selves....that I feel is possible..don
Don, my comments weren't directed at you. What I meant is that Dr. B is taking a little bit of a beating because the most important element of this discussion is being left out.
That important element is context.
It's one thing if you're in an exam in a doctor's office. You have the right to exclude you don't want in there, to wear what you want (despite the gown they sometimes give you.
It's when something that crosses that fine line between what we have known and accepted as social norms and when those lines are crossed (for whatever reason) that people have problems.
Personally, I never felt discomfort during an exam with a male doctor, even an intimate one, because I selected that person to
treat me and was aware, but not concerned about my state of undress for a few minutes when the exam was conducted. I am not the same person today as a direct result of cruel, degrading treatment.
Art Stump talks about this crossing of lines so well in his book about unnecessary personnel in his operating room setting and the psychological upsetting experience as a result of that fine line being crossed.
This is where your common sense issue has it's best effect.
One last point. We may not always agree with each other. If I have a comment directed at an individual, I will do so. But, most of all, we are friends with a mission in common. We all have different reasons for being here. All of us deserve feel valued and respected here. Otherwise, what's the point.
Thanks again to Maurice for hosting the blog, for listening and learning, right with us, and if you notice, he never makes it personal and neither should we.
I miss PT too, even though we differed on some levels so if you're reading, we'd love to have you come back.
It's very difficult to communicate via e mail, blogging because sometimes our intent is read differently by different people. I try to keep that in mind when I'm not sure I understand something.
belinda
Understood Belinda but who gets to decide what context matters? Providers have applied context one way for patients, and another for providers as evidenced in students. Who gets to say the context of being a patient means discounting modesty, but being a student learning to do these very things to patients the context does not warrent them compromising? If we are going to use context to paint patients with a broad brush...why does that brush become so narrow for students? Who here has not had a police car pass them going no where in paticular, sometimes with their family in the car, when you are doing the speed limit. Do you think that policeman sees or will admit how wrong it is for him to have a different set of rules for him and his fellow officers? Or do you think he has somehow justified the double standard in his head? Have you seen a female reporter say she knows it is wrong, that it makes some atheletes uncomfortable when she is in there while they shower and dress? Do you think any of the would allow or be comfortable with the reverse?,,,,,,,,,,,,,Context is in the eye of the beholder, it can not be determined for you....don
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