Patient Modesty: Volume 70
The consensus of what is written here about the medical system's behavior toward attention to patient modesty including the ability of patients to select the gender of those who attend to patients is that IT IS TIME TO CHANGE and respond to their serious concerns. Changing a system requires education of the system regarding the need. This education can occur at the level of the single provider who is attending to the patient and may lead to specific changes for that patient but it is doubtful if such limited education unless done by millions of patients will make any significant community, state or national changes within the medical system. What is necessary is the formation of an advocacy group to educate and apply pressure on institutions, medical boards and governmental agencies to make effective and positive changes and meet the concerns of patients about their physical modesty and to prevent unintentional or intentional abuse by members of the medical profession and their institutions. ,..Maurice.
Graphic: From Google Images and modified by me with Picasa 3.
NOTICE: AS OF TODAY JANUARY 23, 2015 "PATIENT MODESTY: VOLUME 70 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 71.
posted by Maurice Bernstein, M.D. @ 1:44:00 PM
187 comments
187 Comments:
Maurice,
What about a research paper?
You have seen how I have backed up many assertions that I have made in the last 3 volumes with references (and not purely on emotion).
If that were laid out, would that change (or initiate change in) the system?
I had worked as a research assistant while working on my masters. I was told just what I needed to know about the project. I suspect that the research was either used for commercial reasons (sales of something) or that someone with lots of money ("old money") was working on a PhD and able to hire a research team. (FYI: I have never seen any of the research that I did published anywhere.)
As I said, I was given just the parameters that I needed. Others (the person I answered too) were in charge of issues as ethics, citations, conclusions, etc.
I ask you, can you cite a source for parameters for research citing current literature?
Can you give insight (or cite a source) how one goes about presenting such a paper for publication?
From the stories that I see here, most educate providers as we encounter them in the course of our healthcare. I know that I do.
I also received an email from a friend today that she had educated a pharmacist (who is involved in research I believe) about these issues pointing to both your blog and my blog.
--Banterings
I wanted to take some time to talk about how much I appreciate Dr. Bernstein keeping up the blogs about patient modesty. While I do not agree with him on many things, I appreciate his willingness to keep the blogs about patient modesty going. I am glad that he has let his medical students know about this blog. Also, I appreciate Dr. Bernstein letting people vent their feelings and opinions here even when he disagrees with him. I recently tried to comment on a female gynecologist’s article about how the gender of OB/GYN should not matter and she would only approve one of my comments. Many other people shared their opinions in a respectful way on her blog, but she would not approve their comments. She said that it was discrimination when a female patient preferred a female gynecologist. If you all would like to get the link to that article, just email me through MPM’s web site.
I agree with Dr. Bernstein that patients do have to speak up and that they should take actions to educate medical professionals. A number of people here have taken time to educate medical professionals about patient modesty especially Belinda, Banterings, Ed, etc.
I really appreciated Dr. Bernstein’s reply to Ed recently. I am glad that Ed took his business somewhere else when his wishes were not honored
We will never be able to change the whole medical system, but I do believe we can play a role in educating more medical professionals to become more sensitive to patient modesty. There are thousands of hospitals in America. We have to take our business somewhere else if our wishes for modesty and same gender intimate care cannot be honored even if we have to drive farther. It is worth driving farther to a more patient modesty friendly medical facility.
Think about what would happen if more patients went to another hospital because they were willing to accommodate their wishes for surgery. I am sure you all know surgery is a big moneymaker for hospitals. We would see patient modesty violation cases go down if we were able to have a personal advocate not employed by the medical facility with us in the Operating Room. Husbands are allowed to be with their wives for C-Sections so why should it be different for other surgeries?
I encourage you all to check out the testimonial of James who MPM helped to take steps to ensure that he would have an all-male team and colonoscopy shorts for his colonoscopy. You all will notice that this man’s doctor had never heard of colonoscopy shorts before, but was willing to work with him. James did a great job standing up for his wishes.
Misty
Misty, You and your blog are doing a great job helping patients to feel confident to speak up for themselves and sharing invidual stories. It gives patients validations.
It is important to note, though, that not everyone has the same needs with regard to this modesty issue.
Ad advocate in the room would be the last thing I would want. It's just another pair of eyes regardless of who it is. The reason I'm bringing this up is because I think it's important to learn how to trust and have some foundation that your doctor, performing the operation are working on your behalf and while they are in the room,nothing will happen.
Their job is most important after surgery, when you're out, if that's a concern for some patients. Arrangements can be made for the patient to be their own advocate and that consent for anesthesia is revoked until the prepping and draping part is completed before the rest of the team walks into the room.
Advocates do provide a level of comfort for some people. However, it's important to "pick your battles" so to speak. I would much rather perfer a same gender. A patient advocate will be asked to leave if any emergency, or, someone says they cannot stay can happen. So, my point is standing on your own feet is the first course of action. This has to happen slowly, of course, and to start an advocate might be comforting to someone who has recently had a prior bad experience.
belinda
Belinda,
The reality is that with the advances in regional and local anesthesia that have been made, there is much less need to put a patient to sleep for surgery. They're even doing open heart surgery on awake, unsedated patients.
Regional/local anesthesia is almost always safer for the patient as well.
It is my suspicion that medical facilities use general anesthesia and sedation because it is what they are used to and it is easier for them, not better for the patient.
In the past 10 years I have had three surgical procedures, and at my insistence all were done with either local or regional anesthesia. I was fully awake the whole time - didn't even have an IV, except for the Bier block for one procedure.
We do have choices - we just need to stand up and insist on them.
Hex, thanks for the information. I have done the research and they are not going to do a surgery requiring a heart/lung machine and intibation on a patient who is awake. Secondly, it's mute anyway because new findings suggest that the operation is more risky than the 30% of finding a diagnosis and even if they did, there isn't much they can do. I do thank you for sharing and caring.
As an aside, there is a show called, "Getting On" on HBO. It takes place in a hospital and while it's a comedy, much of the humor comes because the situations mimic real life. It focuses on the peronnel and the patients alike (so equal poking).
Coming from where we sit, and Maurice, from where you sit, you might see insights into many issues from both sides. It's funny and when looking at it and mixing with your own real life experiences, very informative and let's you see the other side's point of view.
belinda
Belinda:
It is true that every patient has different needs. I can understand why some patients may feel that an advocate would be an invasion of their privacy. But at the same time, there are many patients who desire to have a personal advocate not employed by the medical facility such as their spouse to be present for their surgery to make sure that their wishes are not ignored. I am tired of hospitals prohibiting patients from having a personal advocate of their choice if they wish. There are many patients who would be at more ease if they had a personal advocate of their choice present.
I agree with you that prepping should be done on patient before he/she is put under anesthesia. I got a horrible case where a hysterectomy patient was given Versed before they prepped her because they did not want her to speak against the male anesthesiologist and male nurse who were there against her wishes. She had requested an all-female team for her surgery.
There are a number of patients who have not had bad experiences themselves, but they just do not trust the medical profession because of research they have done or they have seen family members or friends having bad experiences.
As we both know, there are so many surgeries where you should not have to remove your underwear. Most people here who prefer same gender intimate care do not care about opposite sex medical professionals being involved if they had hand surgery and their private parts were never exposed.
Hexandus:
I agree with you that regional and local anesthesia should be used as often as possible for surgeries. There are some patients who want to be put under anesthesia for surgeries. I feel general anesthesia is overused too much.
Less use of General Anesthesia and more regional and local anesthesia will be great for patient modesty issues. Medical professionals aren't going to be able to get away with exposing patients the way they do if they are awake and alert. Of course they will push the Versed though if they can, which actually results in poorer surgery outcomes.
There are a couple of articles I encourage you to check out:
1.) Is nerve block anesthesia better for surgery?
2.) Sedation Before Nerve Block Increases Risks, Not Pain Relief
It is great you had 3 surgical procedures with regional or local anesthesia. You did a great job standing up for your wishes. What kind of surgeries did you have? Did you have a hard time convincing the doctors to respect your wishes for either local or regional anesthesia?
Misty
Misty,
Shoulder surgery done with a local.
Realignment & splinting of a combined joint fracture/dislocation with a Bier block.
Skin graft with a local.
The shoulder & joint repair surgery were done in a day surgery OR, and the skin graft in the plastic surgery clinic procedure room. For the skin graft, the only people in the room were the surgeon and me.
It was great - didn't have to deal with any of that silly NPO stuff, and I drove myself to and from.
Only had an anesthesia provider for the Bier block - for the other two the surgeon did the local.
Actually I didn't get much push back from the surgeons at all.
It was the administrative scheduling people that were a real pain in the a$$. In all three instances they insisted that the procedures would need to be done in the day surgery facility with sedation, etc. I simply took their canned consent form and lined out and initialed anything I disagreed with, then added any limitations I wanted & initialed those as well.
This happens before you even get to see the surgeon. Once I had a chance to explain my preferences to the surgeons they had no problem with it.
The anesthesia provider was a bit of a pain - kept trying to convince me I should consent to an IV in case they needed to administer any other medications. I simply told her that I did not consent to the use of any other medications, so there was no need for the IV. After we went back & forth a couple times the surgeon looked at the anesthesia provider and told her "you heard him - drop it".
Other than that, the surgeons & staff were great. Not that it matters, but for the record all three surgeons were women.
Hex
I fully agree: speak to the doctor and if the doctor is not interested in listening to you, you should then be interested in finding another physician. By the way, "informed consent" does not mean that the patient is giving consent after having been informed by the doctor. Informed consent also means that the doctor has been informed by the patient just as Hex has provided the example. Remember: "informed consent" goes both ways. Also, of course, the physician has to give "consent to changes in protocol" after being informed by the patient.
But to me, this two-way education and two way consent is one of the ethics of the doctor-patient relationship. ..Maurice.
Just to show you that I do have the rare visitor who will challenge the outspoken modesty concerns of the majority writing here, Anonymous has written the following today on the very first of our Patient Modesty thread titled "Naked" (2005):
i have been examined by male & female doctors. I prefer a female doctor. I find the spend more time, listen & generally create a more comfortable atmosphere.
It does not bother me to be naked under a gown. If you are going to a doctor, you expect to be naked at some point. Doctors & their PA are professionals. I admit the first time she did a rectal/prostate exam it was a little uncomfortable. It no longer is and it's better for me than having a male do it. The doctor is working for your health so you know he/she will see you nude and will touch you
..Maurice
Again, I must post this in 2 parts. Here is part 1:
I am glad that it does not bother that Anonymous poster. They have made no mention as to the relationship with their physician or their past experiences either. Perhaps they have only encountered good physicians. How fast would their opinion change if 5 medical students were brought in just before the prostate exam began....
I do not expect to be naked just because I go to a doctor! Unless I have an rectal or genital complaint, and even then I will decide if I am going to undress. There are alternatives to a physical exam like MRI, ultrasound, and blood tests for prostate.
That is the type of thinking that has put providers in the position that they are in. The thinking should be that I will NOT undress just because I am going to see a physician. Now, I good physician who has earned my trust, might be able to convince me to undress for a complete exam. Everybody (patients and physicians) complain that between reimbursements, EMR, etc. there is barely enough time to investigate the presenting complaint let alone to build a relationship that earns trust.
I have been naked only once for a doctor since I was 10 years old! So there is no reason to expect that one should be.
Let me pose a really radical theory: The healthcare system is an abusive, dysfunctional family.
The saying “Power tends to corrupt, absolute power corrupts absolutely” -Lord Acton, the 19th-century British historian.
His maxim has been vividly illustrated in psychological studies, notably the 1971 Stanford Prison Experiment, which was halted when one group of students arbitrarily assigned to serve as “prison guards” over another group began to abuse their wards. Combine this with human curiosity and a natural sex drive to see that every human being has the potential to impose rules that require the exposure of the bodies of those that they have power over.
Now morality, compassion, and ethics dictate not to do this. Just as some people today (in all professions), give in to criminal urges. More than just 1 person give in to these urges too. We also see people with high social status and much power fall prey to these urges as well.
What if someone in a position of power, who has given in to these urges is able to scientifically justify them as necessary, ethical, and beneficial? Hitler instilled the practice of genocide in to a nation. That is why slavery at one time was so prevalent. The atrocities committed in slavery at one point in our United States were accepted as normal and expected. It was only a minority of outliers that had seen the error of this way of thinking when a whole nation did not.
Here is part 2:
...continued from Part 1...
At the time, slavery was economically necessary. It had been ritualized and ingrained in to society. Rape, abuse, murder, and medical experimentation of these human beings was considered acceptable.
J. Marion Sims, born James Marion Sims (January 25, 1813 – November 13, 1883) was a physician and a pioneer in the field of surgery, considered by some as the father of modern gynecology Due to his use of enslaved African-American women as experimental subjects, Sims is considered a controversial figure by modern historians and ethicists. (Sources: Lerner, Barbara (October 28, 2003). "Scholars Argue Over Legacy of Surgeon Who Was Lionized, Then Vilified". New York Times., Sarah Spettel and Mark Donald White, "The Portrayal of J. Marion Sims' Controversial Surgical Legacy", THE JOURNAL OF UROLOGY, Vol. 185, 2424-2427, June 2011, accessed 4 November 2013, and L. L. Wall, "The medical ethics of Dr J Marion Sims: a fresh look at the historical record", J Med Ethics, 2006 June; 32(6): 346–350, accessed 4 November 2013 .
Why is it so hard to believe that somewhere in the history of healthcare, someone(s) in a position of power and who had given in to these urges, integrated paternalism (absolute power) over the patient which included patient compliance and body exposure (nakedness)? Most providers would defend today's practices as necessary and ethical, not ever entertaining the possibility that they incorrect in their assumptions and these practices could be abusive.
Let us look at an example that occurred in the lifetime of many people alive today: Doctors had been the largest professional group to join the SS. Is that too far back also? Let us go to 1972 then. Did you ever hear about Tuskegee syphilis experiments?
OK, healthcare has changed since then and is now patient-centered, so nothing like that can happen.
Let us go very recent; "Leading US Doctors Condemn “Medical Ethics Free Zone” at Guantánamo Bay" and "Asserted Medical or Professional Complicity in Medical Torture.
Finally, from January 2013; "Absolutely unimaginable this could happen in America."
Blindly following and defending practices without questioning them is why the atrocities of the past have occurred. So why are these practices any different?
Why can't healthcare do better?
--Banterings
The Supreme Court recently ruled that if you are arrested for a minor traffic infraction that would include a broken tail light, they reserve the right to conduct a strip search. Meanwhile, they need a searach warrant to search your home, but not you.
The article referenced in Banterings last post raises this interesting question. What would have happened if the doctors and other medical personnel refused to conduct the search because they had no informed consent and additionally, the patient informed the police and the hospital personnel that they, and the hospital would be prosecuted to the fullest extent of the law, for sexual battery, station. However, if you give the officer a rough time, you could be setting off a set of circumstances you will never forget.
The hospital probably cooperated because in the hierarchy, police trump medical personnel.
I also wonder what would have happened if this person were a previous victim of sexual abuse/assault and had PTSD.
Then, the medical establishment is now faced with additional pressure of an impending lawsuit.
Everyone's best friend is knowledge, enough knowledge that perhaps with the right words would stop such an action in it's tracks.
An x ray would have been sufficient.
They wanted to humiliate this innocent person because they could.
The doctors and other medical personnel would have been complicit in the behavior and would have been found guilty as well.
Learn your rights in and out of the hospital. Knowledge is your best friend.
Update to the incident in Arizona. Hidalgo County will pay $650,000 and city of Deming will pay $950,000. Total 1.6 million. Discipline to the officers. None to date. The doctor was reprimanded for professional negligence. So, nothing was done to the people who caused this mess and the tax payers got stuck for 1.6 million plus expenses. Go figure. AL
I find it interesting that providers seem to have a variety of ways of avoiding the issue.
1. Sequential undraping is not a problem. Men walk around with no shirt all the time. Walk around with not pants but wearing a shirt and it is totally different. The issue is exposure not naked.
2. Patients are naked without real justification. I understand Trauma in the ER is TV, but you see it often, recently a man was impaled with a chunk of wood in the face, several shots were of him laying naked on the table. It happens.
3. While we all know providers viewing a penis and an arm are different, Dr. Bernstein acknowledged it we have all heard the opposite from providers.
4. Society may give blanket permission but it does not usurp the right of the individual. That same society gave permission for reporters to enter locker rooms, at one time to own slaves, for husbands to mistreat their wives, some societies give permission for honor killings...doesn't make any of it right
5. We now have colleges and states that require an affirmative response for sex but we assume patients don't care.
6. We use the word professional liberally to serve us, CNA's with online classes are professionals, reporters are professionals, Police are professionals in ER's where patients are exposed.
7 this is a business, this is about money, this is about efficiency, this is not about patient comfort. Face it.
8. There is only one way to deal with this, be your own advocate, don't expect providers to do it for you, They work for the institution that is responsible for this. Speak up and find someone else if they will not comply.
'that is what I have learned over the years of following this blog. I will take care of myself, because that way I will get it my way, otherwise I will get what they want to give me...that simple...don
I agree completely with Don's list.
To me the most important is item #8 - be your own advocate.
It's pretty much what I've been saying all along.
Working for awareness of patient's modesty/privacy concerns in the medical system providers is a good thing, and will likely make getting accommodated easier, but don't expect them to be proactive in doing so.
The bottom line is that unless/until you stand up for yourself and make your wishes known, and your willingness to go elsewhere if need be, they will continue to do what is easiest/best for them.
Hex
Again I do this in 2 parts:
I found this guideline: Boundary Violations and Misconduct of a Sexual Nature, by the College of Physicians and Surgeons of Newfoundland and Labrador (Canada). We have mentioned how the United Kingdom (England, Canada, Australia, etc.) are more advanced on patient modesty, this is another example. Unfortunately it is only England and Australia that pursues criminal charges.
Note some the examples of boundary violations and of misconduct of a sexual nature:
-- Any behaviour, gesture, or expression that is sexualized, seductive or sexually-demeaning to a patient;
My comment: May be a stretch but...Size profiling discriminates against overweight patients (UCLA)
-- Inappropriate procedures, including but not limited to inappropriate disrobing or draping practices that reflect a lack of respect for the patients privacy, or deliberately watching a patient dress or undress instead of providing privacy;
My comment: How about those harpies on allnurses and their respect for male modesty?
-- Examining a patient in the presence of medical students or other parties without the explicit consent of the patient or when consent has been withdrawn;
My comment: Involving patients in medical education (BMJ)
-- Criticism of the patient's sexual orientation (homosexual or heterosexual or bisexual);
My comment: Remember this back in August, 2014; Patient Sues Doctor For Listing Homosexuality As A 'Chronic Condition' In Medical Records?
-- Requesting details of sexual history or sexual preference in any situation where this is clearly irrelevant, or in a manner that may be offensive or that is solely for self-gratification;
My comment: Obamacare will question your sex life; although not required by the ACA, doctors get reimbursed for counseling about such things as STIs under the ACA, so there is a financial push when it may not be relevant.
-- Not explaining the medical purpose and appropriateness of examination of breasts, genital area and anal area;
My comment: "That's the way we have always done it" does not suffice.
-- Failure to obtain explicit permission from the patient to perform such procedures;
-- Rough and abusive examination and handling of the patient's body, specifically when examining breasts, genital area and anal area;
-- "Examination" of breasts, genital area or anal area without legitimate medical reason (procedure not standard practice and not justifiable);
My comment: Must be the standard of care and be justifiable. "That's the way we have always done it" does not suffice.
-- Touching or massaging breasts, genital area or anal area, or any sustained or repetitive touching of a body part for any purpose other than appropriate physical examination or treatment, or where the patient has refused or withdrawn consent, or would have withdrawn consent if the patient appreciated that such touching did not constitute appropriate physical examination or treatment;
My comment: Dr. Stanley Bo-Shui Chung accused of dozens of unnecessary intimate exams on female patients
Part 2:
These are a step in the right direction, but anything can be justified. We hear all too often that providers complain about malpractice and frivolous lawsuits. Most can be avoided if a provider has built a relationship with a patient and accepts that the patient can choose the level of care that they wish to receive. Just as Twana Sparks, an ENT claimed she gave genital exams to be "thorough" and Dr. Bo-Shui Chung gave dozens of intimate exams on female patients to be "thorough," a patient has a right to choose a "less thorough" level of service (and most do).
In the same way any patient can choose a physical exam from my physician without a genital exam. Women can choose to forego the pelvic exam. Even if the physician feels they are not being "thorough," they only need to be thorough for the level of care chosen. Their fiduciary duty to the patient also dictates accepting the patient's request for the level of care. The ACA further promotes this by encouraging patients to choose how they spend their medical dollars.
Furthermore the standard of care is does not apply UNLESS it is specifically for that standard of care. For example, a physician CANNOT argue that the SOC calls for an anogenital examination for a (wellness) physical when a patient is requesting a "modesty wellness physical." The SOP for a modesty wellness physical" can include alternatives such as PSA testing or ultrasound to assess prostate health, urine and blood tests for genital health, self reporting for hernia, etc.
I think that the ACA will help with some of these issues. Another issue is requiring pelvic exams for oral contraceptives. Under the ACA's anti-fraud provisions, this can be interpreted as extorting unnecessary treatments.
We also see this trend from associations in recommendations for prostate exams, mammograms, pelvic exams, etc.
Just my take.
--Banterings
Please take a look at Doug Capra's new article about masculinity and men's health. Add your comments.
I permanently deleted 2 postings from presumably a "new" visitor who wrote what a couple of my "regulars" considered "fetish stories" which they felt degraded what the "regulars" have been writing. I had to rush away this morning to teach and I did not give the postings adequate moderation at the time.
However, what are true and what are made-up stories to make a point and deliver a message or just being an attempt to deliver a sexually imaginative or stimulating story may be difficult to separate when dealing with a blog allowing total anonymity as this one. ..Maurice.
Maurice,
Let us also take your comment one step further:
Despite the procedure being therapeutic, it can feel sexual. Patients are told physical reactions are normal in anogenital exams (erections for men, orgasms for women) and even providers may be aroused by stimulation of sight, touch, control, etc. (who is going to argue with millions of years of evolution?)
A white coat does not change the way one's body reacts....
--Banterings
Maurice,
None of us whom you know sent in stories with the salious qualities of what was recently written. Additionally, many of us on this blog are not anonymous.
The idea that you cannot tell the difference from legitimate concerns, warranted concerns,justified concerns and pornography are disburbing.
If you notice, I have referred to my situation but never posted anything really with any detail to this blog.
Anyone who has been traumatized does not write in a pornographic style.
It might bode well to discuss these issues with a mental health specialist, but it is clear to me, that some of your thinking that these posts were legitimate discredits those of us who have high standards about these issues and have had the validity of experience. I don't care if you believe that I have had experiences. I have the proof, that I have, that I advocate and someday, this issue will blow up as one of those social issues that finally has it's day with society.
That day is happening faster than one can imagine. As long as people are subjected to cruel and degrading care in the medical arena, the more of me there are to complain. Mak no doubt, we will.
belinda
It is disappointing that you refused to post my submission, but mentioned as one of the "regulars".
Belinda,I apologize if I upset you but you should be aware of the view that unfortunately all moderators of discussion blogs have to take when comments are written by those who are unknown personally (face to face). And that view is one of cautious suspicion regarding motivation and validity of statements. That is why I always insist on references. Now, a few of my visitors have written to me directly personal e-mail (as you have) and that is helpful in evaluation of the individual. But since anyone can write anything to a blog such as mine and it is my responsibility to keep the blog thread honest and of value for productive discussion.
One of my observations with regard to the "validity" of the writers who do not have a "sign in" name with Blogspot.com but are designated as "Anonymous" even though the writer presents a name or speudonym or initials at the end of the writeup is that ANYONE could write a comment and sign off with someone else's name, pseudonym or initials. That is why I would encourage every contributor to this blog to create a formal "sign in" name with Blogspot.com which would prevent such unethical behavior from occurring.
In conclusion, my moderator's reasonable concerns about the validity of those posting or what they have to say should not discourage further discussion since it has been an extremely rare occurrence to withhold or necessity to delete a posting. Belinda, I appreciate your postings. You can write me e-mail for further discussion. ..Maurice.
Maurice, there's nothing to discuss. You refused to post my initial reaction because you couldn't take the “heat”, but the porn was not only fine, accepted as valid, and posted. This not only shows me who you really are, but questions your judgment as well. You probably won't print this post either. It doesn't matter.
belinda
I have nothing further to say but: if I found no merit in the discussions here, I would not have continued this particular thread for 9 1/2 years with the thousands of comments. I would have not repeatedly agreed that a change in the medical system with regard to patient's modesty issues and healthcare provider gender selection. I would not have repeatedly advised patients to "speak to" their providers about their concerns. I would not have urged the formation of advocacy group for change and action from the visitors to this very blog thread. If I found no merit, why would I be currently teaching my first year medical students the importance to attend to their current and future patients' modesty concerns (as expressed as informed consent) even at some sacrifice to a unfettered classic physical examination.
I have every right as a moderator to be suspicious of the intent and accuracy of every posting, particularly when I don't personally know the writer. But I must be showing some degree of personal comfort by what is written here in view of the thousands of postings which I did permit to be published.
There is nothing further I can do or say to emphasize that what concerns are written about here by my visitors has made a positive and constructive impression on my practice and teaching. ..Maurice.
i prefer a female doctor. I do not want a male seeing or touching me. I understand they're professionals It me not them
When you visit a doctor, you know sooner or later you will be exposed. It's normal. Now surely I don't want the doctor/ nurse to forget to close the door but inside the exam room they're doing a job for you. Some procedures are embarrassing but deal with it. There's no dignified way to get a barium enema or prostate exam. It's reality. So unless the doctor has the exam room door open get over it. It's in your mind, not theirs
in response to the Nov 21 question: I have seen this doctor for about 8 years. We have a very good doctor- patient relationship. I've never felt rushed out and I trust both her professionalism and manner
Agreed I likely would not want 5 interns watching. However, at her request, I have agreed to have one intern present. It was a bit embarrassing at first, but if that's the worst thing that happens to me them I am ahead of the game. I agree with a reticence to be naked, but if you trust your doctor I do not see a problem. I'd rather a case of embarrassment than a serious medical issue
Though I wish everyone would set a name or pseudonym with Blogger.com, nevertheless I urge all writers commenting here to at least include a name or pseudonym at the end of the posting so that responses can be more specifically directed to the writer. Thanks. ..Maurice.
Anonymous stated:
i prefer a female doctor. I do not want a male seeing or touching me. I understand they're professionals It me not them
It's reality. If you go to the doctor, at some point you will be examined (intimately) by a male) ... So unless the doctor has the exam room door open get over it.. It's in your mind, not theirs Some procedures are embarrassing but deal with it. It's a reality, just like having to undress.
Does this change your perspective now??? (Your words.)
When you visit a doctor, you know sooner or later you will be exposed.
This is not true. Since I have been old enough to know my body, my rules, I have not had my underwear off at a doctor's visit in over 30 years.
There's no dignified way to get a barium enema or prostate exam.
Yes, there is a dignified way to get a prostate exam; it's called an ultrasound or a MRI. These can detect an enlarged prostate. A MRI can also see places that a finger cannot. A barium enema can be self-administered in privacy.
...but inside the exam room they're doing a job for you.
Good point, they are working for me. If I ask for an exam WITHOUT a genital or rectal exam, I expect that. That is one of the aspects of the ACA (Obamacare), spending your healthcare dollars on what the patient deems necessary. If I go in for a sore throat, I do not expect a genital or rectal exam (this incident actually happened and AAP mentions this scenario on their website. The doctor claimed he was being "thorough."
Let me clarify my point I made after Maurice deleted those posts. Where the posts may have appeared legitimate to Maurice initially, many of us not trained immediately as professionals immediately recognized these as pornographic. Maurice, by the nature of his dedication to this subject DID eventually recognize them for what they were. There is a disconnect between provider and patient in the perception of intimate procedures. I explain how providers lose this perspective using the Stamford Prison Experiment and Milgram Experiment on my blog here:
Even though a provider is doing it for therapeutic reasons, the patient may not experience it as such, but as sexual and/or an assault. The patient will also suffer the same effects as a survivor of sexual assault. Furthermore providers may not realize when procedures that may be scientifically justified may be excessive and/or not socially acceptable. Take the case of William Ayres, former president of the American Academy of Child and Adolescent Psychiatry.
Finally, is the emerging awareness of "intersexed" or gender dysmorphic individuals. In an article titled "What Doctors Don't Know About LGBT Health," physicians are now just learning what many have known for years:
So as a result of that, many individuals born with DSD have actually faced overmedicalization, and have had to undergo unnecessary and traumatic genital exams and surgeries.
What providers consider standards of care, thorough, necessary, the way we have always done things, MAY actually be excessive, abusive, unnecessary, and even criminal.
--Banterings
Time to change? Then help me make this change!
A friend alerted me to this:
The National Association of Insurance Commissioners has released draft regulations expected to impact the makeup of health plan provider networks on a state and federal level, including on the marketplace exchanges set up under the Affordable Care Act.
NAIC in November released draft updates to its Managed Care Network Adequacy Model Act, a model law routinely used by state and federal lawmakers when creating insurance laws and regulations, particularly in regards to the creation of health carrier networks and the adequacy and accessibility of services offered under a network plan.
The model Act, which hadn’t been updated since 1996, has been highly anticipated due to the changing insurance landscape under the implementation of the ACA. A controversy over the use of narrow networks on the marketplace exchanges has led the Centers for Medicare and Medicaid Services to investigate the adequacy of provider networks more closely; and the agency said it was waiting for NAIC’s revamped model law before proposing changes to its network adequacy policy for products offered on the 2016 exchanges...
The reason I bring this up is because I made the following recommendations:
Include 2 additional criteria for the following in section 8:
Section 8.B(1)(f) Gender of support staff;
Section 8.B(1)(g) Provide same gender care for;
Section 8.B(2)(d) Gender of support staff;
Section 8.B(2)(e) Provide same gender care for;
Section 8.B(3)(e) Gender of support staff;
Section 8.B(3)(f) Provide same gender care for;
Section 8.C(1)(f) Gender of support staff;
Section 8.C(1)(g) Provide same gender care for;
Section 8.C(2)(c) Gender of support staff;
Section 8.C(2)(d) Provide same gender care for;
Section 8.C(3)(e) Gender of support staff;
Section 8.C(3)(f) Provide same gender care for;
Here is an example of the new criteria:
Section 8.B(1)(f) Gender of support staff;
This can be answered: "All Female," "All Male," OR "Both Female and Male."
Section 8.B(1)(g) Provide same gender care for;
This can be answered: "Female," "Male," OR "Both Female and Male." This is important due to the situation I mentioned above where the urologist is male, but the rest of the staff is female. The following is possible:
Section 8.B(1) For health care professionals:
(a) Name; Dr. So-and-so
(b) Gender; male
(c) Contact information; (555) 555-1212
(d) Specialty; urology
(e) Whether accepting new patients. Y
(f) Gender of support staff: Female
(g) Provide same gender care for: Male
In this situation, the practice can bring in a male nurse from the affiliated hospital to provide for all male care with advanced notice. This is another trend in today's healthcare.
I also included discussion and references to gender choice in healthcare and modesty issues.
Here is where to direct comments:
Comments are being requested on this draft by Jan. 12, 2015. The revisions to this draft reflect changes made from the existing model. Comments should be sent only by email to Jolie Matthews at jmatthews@naic.org.
I encourage everybody to email Jolie Matthews and point out the necessity for these changes. Remember this is just a small change that we can influence that has bigger consequences. Even better is anybody with initials after their name commenting. These regulations expected to impact the makeup of health plan provider networks on a state and federal level!!! Start writing and encourage others to write as well.
-Banterings
Thanks Banterings for your commentaries in the past but especially today, encouraging our visitors to do something potentially constructive to initiate change... change that our visitors want. ..Maurice.
Banterings, my thanks also. I followed your lead and posted comments on the revisions as well.
In an earlier posting, I commented that I would attempt to contact several TV and Radio shows with a medical theme. I emailed 8 different shows with the proposed theme of Medical Modesty. To date there have been zero responses. Either there is little interest or I was not sufficiently titillating in my description. I suspect the latter. In any event, I still read of the same events happening to hapless patients today. The difference is, they no longer catch me by surprise. I do speak up now and it is interesting to see the confusion that this sometimes creates. The medical establishment is just not quite ready for patients to be questioning authority.
I read recently that an exam is much like a one act play where no embarrassment occurs if everyone follows the same script. If any one of the actors (patient, doctor, chaperone) go off script, embarrassment occurs. It is an interesting mental exercise because the actors are in this case, also the audience. If I the patient go off script and ad lib with what is really going through my mind at the time, it forces the other actors to go off script as well and provide real world responses. I think about this now whenever I go in for an exam and make it a point to go off script when necessary. The plot becomes much more interesting and perhaps we can all live happily ever after.
My thanks for all of the encouragement offered in this blog.
Ed T
Ed T, I am so pleased to read what you have attempted and done and your conclusions. This is exactly what I wanted to start happening as a result of all these years of communication on this blog thread.
You might, after appropriate waiting, want to follow up on those "zero responses" in a non-belligerent way but in an attempt to understand the "show's" view of your subject and attempt.
In any event, thanks to you and again to Banterings for moving this thread in the "right direction". ..Maurice.
Ed T,
Thank you for commenting. I hope that the others on here too comment about this as well.
I also hope that you spread the word too!
The problem with radio and TV is that there is not a "big organization" (ACLU, Southern Poverty Law Center, etc.) behind the issue of patient dignity. It also seems to conflict with many organizations' fight for open access to healthcare, universal healthcare, healthcare as a human right, etc. The idea to limit or punish healthcare seems contradictory to the concept of healthcare as a human right. Furthermore, if the healthcare system is so abusive, why would they advocate for more healthcare?
These organizations always have physicians on the board or as advisers. When ever you have a victim of anything, the first thing that is recommended is a thorough physical exam to determine the extent of the harm from the violation of their human rights. The last, and most obvious reason is that elite physicians and healthcare executives/systems are big contributors to causes.
The problem is that these organizations advocate for healthcare, when they should be advocating for dignified healthcare. The thinking is almost "abusive healthcare is better than no healthcare." This is one of the issues discussed in bioethics here and on other blogs like KevinMD: the quality of healthcare for the poorer populations. Here in the US, we refer to it as "urban hospitals" or "rural hospitals." Reference here: The ethics of trainee-patient encounters: Are we practicing on the poor? AND Many doctors treating state's prisoners have disciplinary records themselves.
There is also the issue of money. People believe that these are nonprofits, so there is no money. Let's take an example of some megachurch. First off, the charismatic paster is paid a CEO's salary. Then when they have some campaign, like to send food to Africa, it is shipped via the transportation company owned by the pastor or his brother (which the pastor is paid to be on the board of). Reference: Lifestyles of The Tele-Evangelist...
They guard their "brand" and do not want to get involved with anything that lies outside their "core," especially if it can be perceived as "fringe."
You can see why there is no organization backing this cause.
As Banterings mentioned, medicine in the US s a huge business - to the tune of 3.8 trillion dollars in medical costs annually as of Feb 2014. That's hardly chump change!
We also need to recognize that there are two major components to the health care industry. On one hand we have the doctors, nurses and other support staff who provide direct care to the patients, while on the other hand we have the business managers whose primary and overriding goal is to maximize their piece of the $3.8 trillion pie. What's best for the patients is way down the list of priorities, if it's considered at all.
I don't have the figures on what percentage of that number is for things like administrative overhead, fancy buildings, and other things not directly related to patient care, but I believe the answer would be eye opening.
Quite often, the ability of the first group to provided cost effective needed care is hamstrung by the greed of the business side of medicine. It gets even more muddled when you consider things like physician owned surgical or imaging centers. While many were created with the good intention of providing services while trying to keep costs in check, even that can become a grey area when the physician/owners walk both sides of the fence.
I guess what I'm trying to say is that while I believe most providers truly care about what is best for their patients, the business side of medicine doesn't. These are the folks that set policies and control the purse strings, and unless/until it costs them revenue, they are not about to spend any money or effort to change the status quo.
Hexanchus, so let's challenge the administrators of the healthcare system with the need for attention to the issues described on this thread. Isn't there a practical way to contact the administration of every hospital in the United States (5,723 Ref: http://www.statista.com/statistics/185843/number-of-all-hospitals-in-the-us-since-2001/) to present a view and await hopefully even some acknowledgment of the issues presented? I suspect some would respond. ..Maurice.
Maurice, Hex, et al,
Forgive my cynicism, but historically the only way that change has been brought about is when cost more to do things "the way we have always done them." The use of rectal exams changed after the Brian Persaud lawsuit, even in the ATLS manual.
BTW The physician was NOT found to have used the standard of care in that case, the physician eventually claimed that the DRE was never performed. With no proof, no witnesses, no physical evidence, and an intubated and anesthetized patient, no case.
The same is true of women's choice for same gender care.
Perhaps instead of the hospital addressing hospital administrators, we should be addressing the state trial lawyers associations.
Just a thought, and it is evidence-based....
--Banterings
Allowing us to bring our own chaperones with video cameras to keep doctors in line, and make sure our wishes were followed wouldn't cost the hospital anything. (unless the hospital did something wrong, and there was someone other than an intubated and anesthetized patient in the room to speak up against the doctor and their employees / coworkers in the lawsuit... then it would start adding up until the medical side started to shape up...)
December 15th I have an appointment with a surgeon to discuss something, and I'm going to bring up same gender team, what guarantees I have of dignity, how do I now med students won't be led through as soon as I'm out, and I'm going to see if I can't get the green light to have my girlfriend be there to film the room. We'll see how that conversation goes.
(I always hear about building trust with the doctor... I barely know my family doc... this will be the first time I meet this surgeon, and (if I understand correctly) I might have one more meeting after this before surgery... not a lot of time to build any kind of "trust"... )
Jason K.
Jason K. Excellent. It's communication.
The surgeon will be telling you what he or she has to inform you and you will be communicating and telling what you have to inform the surgeon. But, always keep in mind, it is you and not the physician who needs the procedure for your health and benefit and therefore you should never sacrifice one important need in search of the other. Some compromise has to be also considered. Best wishes. ..Maurice.
Again I must do this in 2 parts:
Jason,
Here are some excellent resources on patients with PTSD in medical settings AND PTSD resulting from medical procedures. The second article validates something that I have asserted for years (and MANY providers have argued with me this is impossible); Medical procedures (especially those involving the genitals), even when conducted professionally and according to protocol, are sufficiently stressful to induce PTSD.
These articles are listed on credible websites such as the National Institutes for Health (NIH) and Springer. Others are from credible periodicals such as Psychology Today, and include references to sources on research sites like NIH and Springer. The rest are organizations that base their protocols on accepted guidelines and what they have learned from working "hands on" with victims, such as NYC Alliance Against Sexual Assault.
If you read all my posts here, I link to credible citations. Nothing I cite is "quackery." Some things may be "cutting edge research," but it is all empirically based.''
When you go for your consult, print out these that you think pertinent to your situation and your demands. Ask that they be included in your medical record (this will help the provider justify to the administrative powers-that-be any accommodations that are made for you). Finally in a comment in this thread, I referenced Dr. Bo-Shui Chung. He (Dr. Bo-Shui Chung)gave dozens of intimate exams on female patients to be "thorough," but as a patient, you have the right to choose a "less thorough" level of service (and most do).
To illustrate my concept of the "level of service," consider the case of Dr. Twana Sparks, an ENT (ear, nose, and throat) who claimed that she gave (unnecessary) genital exams to be "thorough." After presenting this research material, your surgeon WILL be obligated to make accommodations for you.
Links below in Part 2:
I realize that this has to be 3 parts now, so here is part 2:
Here are the links:
Tomophobia, the phobic fear caused by an invasive medical procedure - an emerging anxiety disorder: a case report Published on NIH.
Post-Traumatic Stress Disorder After Genital Medical Procedures Published on Springer. Abstract: The presentation outlines research conducted on 500 women by the author which demonstrated that genital medical procedures could be sufficiently stressful to induce Post-Traumatic Stress Disorder (PTSD). This occurred in women who had been previously sexually traumatised and also in women who had had no apparent previous psychological stress. Factors which predisposed to the development of PTSD were shown to include: feelings of powerlessness and loss of control by the woman; lack of consent; lack of information; perceived lack of sympathy in the examiner; and the experience of physical pain. These factors are compared to the situation arising in sexual assault, sexual torture and circumcision. Preliminary findings of a comparative study of PTSD in circumcised men are described.
NYC Alliance Against Sexual Assault Factsheets: PTSD Information for Women's Medical Providers Note: this has information about men too, but most importantly about PTSD sufferers avoiding healthcare.
Medical post-traumatic stress disorder: catching up with the cutting edge in stress research Published on NIH.
Medical Trauma: When A Procedure Goes Wrong
Pediatric Medical Trauma
Recognizing the Risk of PTSD in Our Patients (The National Institute for the Clinical Application of Behavioral Medicine) Abstract: hen we think of PTSD, many practitioners automatically think of soldiers, rape survivors, or childhood abuse survivors.
Few of us think about other groups of people, particularly the patients in our hospitals, with a high risk of developing PTSD.
According to a new study published in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), one of these groups would include individuals who have undergone orthopedic surgery.
Identifying PTSD in Medical and Surgical Settings Note: This article has good references but fails to take into account that many who suffered PTSD avoid healthcare (especially when it was the source of the PTSD). I believe that those who do finally present for treatment have avoided healthcare so long that it is a "treat or die" situation. ]
End of part 2, part 3 to follow....
Here is the last part, part 3....
Let me make a couple recommendations: Maybe just having your GF there, if the surgeon is uncomfortable with that , then suggest recording the procedure and offering him a copy of the raw, unedited video. Maybe he could prescribe you 5 days worth of an antianxiety prescription to help with the immediately before, during, and after. (I considered this option for myself).
Now let me encourage and support you. I talked to a couple people who are regulars here off-blog, over the last couple weeks be cause I had found a lump in my testicle, had an upcoming appointment with my PCP, and was NOT sure IF I would bring up the lump." I was not afraid of finding out I had cancer, of dying if I chose not to treat or even of losing a testicle. I WAS afraid of the exam, the procedures, hospitals, etc. I was the guy in the "Tomophobia paper above."
Since I take responsibility for my own health, I examined myself. I determined a 99% chance of it being benign. I still had the issue of my doc checking or not. I did bring it up because my wife asked me to. Just as I would sacrifice my life to save her, I was willing to sacrifice my dignity and mental well being for her. I know, the suspense is killing everyone.... It was only a epididymal cyst. He suggested just watch and see. Due to my age, I am at low risk for testicular cancer. Just what I diagnosed, but a second opinion is nice.
I have been dealing with this issue all my life. My solution has been to develop a relationship with my doctor AND take control of my healthcare. This turned out to be an incredibly liberating experience for me. Of course I had an "emotional hangover" for 2 days afterwards. I am creating a post about this for my blog, and will let everyone know when it is up. I have learned much from this blog and from email conversations with people here.
I was ready to roll the dice and take my chances, and hope my diagnosis was correct. It was like I knew, I was totally 50/50 until I was in the exam room, half way through a normal exam, and when asked about any other problems, I took a deep breath, closed my eyes, and just blurted it out.
If I could do it, so can you!
--Banterings
I just made a post on the previous topic, Is Pregnancy a Disease?
"The principal reason is because they are kept away from doctors with their knives." "We have over-medicalized delivery and are doing more harm than good as a result." --Professor Mark Baker, NICE’s clinical practice director and author of the new guidelines. Source: NBC News
I propose the theory that healthcare does not know what is socially acceptable. Perhaps genital exams have been "over-medicalized" and are doing more harm than good. Failure to even entertain the possibility is only sticking your head deeper in the sand.
Perhaps the ACA is good for patient dignity. If all the guidelines say that you need to earn the trust of the patient, all the providers complain that time only allows problem focused exams, then they will begin to omit these "thorough exams." Furthermore, not taking the time to follow the guidelines (and build trust) will expose providers to criminal and tort claims, THEN we will see change.
--Banterings
It is statements like the one I received this morning: "Nurses are prostitutes that take advantage of innocent male patients. They should be prosecuted", as the only statement in the comment, is a posting which shouldn't be published. I am showing this now to demonstrate what doesn't belong in an a discussion of the ethics involved in patient modesty. What isn't defined is what is meant by "take advantage" in terms of a behavior which can label the nurse as a "prostitute". Also what the writer means as "innocent" with regard to male patients is also not defined.
The entire statement from this moderator's point of view appears as an vague accusation which seems more to degrade a class of professionals (almost as an "ad hominem") without explanation or clarity and not a proper example of presentation within an ethics discussion. ..Maurice.
Maurice,
I completely agree.
Let me analyze the statement a little further. Some assertions may seem ridiculous, but it furthers Maurice's (IMHO, correct) assertion that statement was purely inflammatory and possibly pornographic.
Let's assume the statement nurses are prostitutes to be true. Metaphorically the patient (as a customer) would get what they demand. If a nurse said, "undress for this procedure," and the patient said, "you first," then the nurse (either by nature of prostitution or by showing that exposure is acceptable in a medical setting) would then undress first.
Note: The following is not meant to discount, ignore, or diminish suffering, mental and physical trauma, etc. that prostitutes endure and the consequences (PTSD). I do not condone any of the human rights violations that some face, such as human trafficking and forced prostitution. I also acknowledge that there are some who have chosen this line of work and find the profession empowering.
Contextually, from the view of the "John" is about getting his needs met that he can't from a more traditional relationship. Some men, mostly satirically have compared traditional dating and marriage as a financial (or at least with some "consideration") transaction. They conclude that prostitution satisfies the expectations of all parties involved without drama or emotional baggage.
I personally know people who are so entrenched in their careers they use prostitution to satisfy certain human needs. They find it more efficient and more satisfying. That being said, I am sure that many of us here who use "you first" response to attempt to see if providers believe what they say, AND in an attempt to let them "walk a mile in our shoes," we would NOT use the term prostitute (due to negative connotations), but something positive such as empathetic, or understanding.
The only comparison of any validity could be one of 2 possibilities. The 1st being that both deal with the genitals of their clients. The 2nd possibility (and one that may merit further exploration as I will explain below), is that just as providers, (many, but NOT all) prostitutes have become desensitized to genitals and the whole sexual encounter. For many, especially those forced in to it by coercion or circumstances, it is NOT enjoyable, or even pleasant. For some, they have become so desensitized, they partake in extreme forms either by force or for money, not for personal enjoyment or altruistic reasons (the enjoyment of their partner).
Note: I see 2 reasons for further exploration. The desensitizing of prostitutes and how they relate to norms of "polite society." Stereotypically, it is assumed that due to desensitizing, prostitutes behave inappropriately because things such as modesty has been conditioned out of them. The 2nd is that the prostitute may view the encounter as work, not sexual, yet the "John" views it as a sexual encounter.
"Nurses are prostitutes that take advantage of innocent male patients. They should be prosecuted," may indicate someone who suffered a trauma (intentionally or not), by nurses. I would expect that they be called something different, such as "predators." One also questions if this includes male nurses. This also stereotypes nurses not only as abusive (Nurse Ratched), but also as female. The infraction that this person suffered may also be at the hands of other providers wearing scrubs, technicians, radiologists, etc.
Due to the conflicting nature of the 2 statements, I have to think that this is a person who has been severely traumatized emotionally to the point of (almost) dysfunction, they are doing it to fulfill a fetish, or they are simply trying to be an inflammatory troll (a pathy all its own).
--Banterings
I was contacted by a newspaper reporter from Chicago today who would like to do an article about patient modesty and Medical Patient Modesty, but she wants some real stories of patients who have complained about patient modesty violations or had good experiences with medical professionals in the Chicago area who respected their wishes. Is anyone here from the Chicago area? Have any of you ever lived in Chicago area before? If so, please email me.
I also wanted to let everyone know I have started an online directory of men’s only clinics with all male medical staff. At this time, we only have a few clinics listed, but it was worth listing them. Hopefully, we will see many more men’s only clinics with all male medical staff in the future. The All-Female OB/GYN Directory is much bigger of course.
It’s encouraging that there are doctors who understand that there are patients who only want same gender intimate medical care.
Misty
AD Hominem reasoning is not always fallacious, when it
relates to the credibility of statements of fact or when used in certain kinds of moral and practical reason.
Helen Mirren, the famous actress compares nurses to
prostitutes. Now, she's a female and a professional.
Read about it here:
Scrubsmag.com/helen-mirren-compares-nurses-to-
prostitutes/
Apparently, many nurses are not happy with her
comments and she is a female.
Now Scrubsmag.com has their own take on this.
Scrubsmag.com/you-know-youre-a-urology-nurse-
where/
"I've seen more penises than a mohel.
"I love it! 90% of my patients were men.
" it's hilarious. According to them when you cannot
pee and that you have 4 drainage bags after surgery."
There are over 180 nursing sites that celebrate happy
nurses week with this Ecard.
www.interest.com/pin/2524127540855981571
I've seen more penises than a prostitute.
One nursing site has over 6000 likes to this card
with many saying"hahahaha" " I love it"
Can you imagine a man flaunting, bragging, about
how many vaginas he has seen if that man were
a male nurse or male physician.
PT
PT welcome back..if that is you.
Ad hominem statements require more than "hearsay" (the TV interview of Mirren) to establish any degree of whatever appropriate argumentative value one gets out of the statement. This means, in this case (nurses and prostitutes), a statistical analysis, properly completed and documented with specific references to the appropriate literature. Otherwise, this is an insult to every nurse and all those part of the nursing profession. ..Maurice.
Maurice
I assure you, it is me. Ad Hominem reasoning
is essential to understanding certain moral issues. Yet,
how could it be an insult to the nursing industry when
they themselves compare their job to that of a prostitute?
The bragging, boasting and comparing " we see
more penises than a prostitute would ever dream of."
PT
Ad hominem is painting an individual or in this case a class of individuals with a "bad" moral, ethical, behavioral, personal color paint. If this is done by a single or a few individuals particularly anonymously with no backing up the accusation without reproducible and pertinent facts, it is to the harm of any further and all discussions having represented a improper wandering away from the primary argument of the discussion. To this discussion of patient modesty, accusing all nurses who perform their profession on a male patient as "prostitutes" is no support to an argument and casts suspicion on the motivations and the rationality of the one making the argument and the argument itself. ..Maurice.
PT,
Welcome back! The last link: www.interest.com/pin/2524127540855981571 does not work. Can you please recheck to see if you can get the correct link?
On another subject, do you know of additional men's only clinics with all-male medical staff I should consider listing on MPM's online directory of clinics with only male medical staff?
Misty
Ad hominem is simply an argumentative tool. Questions
of personal conduct, character and motives are relevant to this issue,particularly when it involves hypocrisy. From what I see there simply are no reasons to make any ad hominem statements. I'm just simply in agreement with what they say with the comparisons, the parallels and the conclusions they draw. If you read what they say on all their websites how could there be any dispute of a logical argument.
PT
PT
Maurice
My favorite is Ad Hominem Tu Quoque
Just a fancy way of saying do as I say, not as I
do. The actress Helen Mirren was criticized for
comparing nurses to prostitutes , yet it's ok for
nurses to make such an assertion. Now, haven't
I heard a lot of that lately.
PT
Misty
Sorry, the correct link is
www.pinterest.com/pin/252412754085598157
I know of no all male staff clinics anywhere. There is
an all male fertility/urology clinic in I believe San
Antonio,however, it's not confirmed. Recently, I
surveyed a number of urology clinics. A number of
these urology clinics are broken up into two parts.
A prostate center and a section for regular urology
patients. The prostate sections had all female staff
which encompassed medical assistants and Lpn's.
PT
While I don't disagree with PT's disdain for those nurses who make the comments that he has referenced, I strongly disagree that they are representative of the nursing profession as a whole.
As of last count, there are approx. 2.75 million nurses currently employed in the U.S. To suggest that a handful that make offensive comments are representative of the whole simply has no statistical validity.
It's no different than saying that because a small percentage of physicians commit acts of sexual abuse that all doctors are perverts, or that because some caucasians have made racist comments, all caucasians are racist.
Hex
Hex
The statistical validity improves when you
factor in the actual number of nurses who actually
provide patient care to males. For the sake of this
discussion let's exempt ma's and cna's for now.
Thus the number is reduced to about 1.2
million. That's excluding all the administrative
nurses, L&D nurses, Nicu,post-op gyn, pediatric,
most nursing home and the 6% of male nurses
in the industry. Now we can entertain some
percentages.
PT
PT,
Add to that those who hear inappropriate comments and either laugh at them, or ignore them (do nothing about them). If they are not part of the solution, then they are part of the problem.
Here is a great cartoon on "Deviant Art" (G-rated). I think this says it all. The artist based it on an experience that happened to in the hospital.
Perhaps half of the problem are those who see abusive behavior and do nothing.
--Banterings
So... I saw the surgeon today...
When I brought up the concern about same gender staff, he gave a half a chuckle and "assured me everyone on HIS staff is a professional, so I don't need to worry about it", and was incredibly dismissive when I tried to explain that it wasn't an insult towards his staff, but was MY preference for MY reasons... he actually said that "well, once you're out you won't care who's in the room, so it won't matter"... So that's when I asked about wanting my girlfriend to film the entire thing which apparently was "ludicrous and insulting" to him.
I stood up and walked out after that.
Jason K
PT:
I actually have confirmed that all of the medical staff at the all-male urology clinic in San Antonio. They do have one female receptionist at the front desk though. I found some other all-male clinics, but they mostly deal with male sexual problems. Don’t give up hope that we will get more all-male clinics. Men need to demand them. Men need to let their urologists know they do not accept female nurses or assistants under any circumstances. Think about what would happen if men left urological practices that do not employ male nurses for practices that do employ male nurses and assistants. I did learn recently that an all-male clinic has been started in Charlotte, NC. Check out the all-male clinic directory on MPM’s web site. You will notice on Vitality Health’s web site that this all-male clinic is the only all-male clinic in North Carolina.
I appreciate you bringing attention to comments that some female nurses have made. I certainly agree with you that some female nurses make fun of men’s genitals. I know of some real cases that this happened. I do not feel that we can claim that ALL female nurses would make those comments about male patients. But we can be confident that there are always some female nurses at every hospital that will make fun of men’s genitals. I wanted to refresh your memory about how LKT and I responded to a facebook posting you found about female nurses over a year. You can check out the posting on September 30, 2013. Many of those female nurses who made those remarks on Facebook or liked those remarks probably would not say those things around male patients. We often have no idea what nurses do behind the scenes.
There are a number of female nurses who have chosen to work in fields that would not require them to see or touch male patients’ genitals such as Labor & Delivery, Gynecology, flu clinics, etc because they did not want to access male patients’ private parts. If I were a nurse or nursing student, I would refuse to do intimate procedures on male patients due to my moral convictions. I do not believe I should ever access or see the private parts of a man who is not my husband. I heard from a female young nursing student who was very uncomfortable with doing intimate procedures on male patients in nursing school because she believed that she should only do intimate procedures on female patients. She said her professors looked at her like she was crazy when she asked if she could only do intimate procedures on female patients.
Also, I encourage you to think about this scenario. There are many young female nurses or nursing students who really did not want to do intimate procedures on male patients, but they felt like they had no choice and they are afraid they will lose their jobs if they speak up. The medical industry is very powerful. There are actually some female nurses who really do not want to do intimate procedures on male patients, but they are afraid to speak up. I would like to encourage you, PT to check out tbrd450’s comments on All Nurses’ web site about how a young female nurse was uncomfortable with doing intimate procedures on male patients. A veteran nurse assured the new nurse that she would soon become desensitized to male nudity.
Misty
Banterings, joking about a patient's anatomy or physiology and especially in the context of patient modesty is something we never teach our medical students and regardless whether the patient is awake or unconscious. Anatomic issues pertinent to medical management is of interest for expression and discussion but not in the form of a joke.
Think. Cartoons like these, even "G-rated", do nothing but promote anxiety about the medical profession and the day to day behavior of any or all healthcare providers. Not funny. ..Maurice.
A. Banterings
I like your style. Sometimes a visual statement is
needed to get a point across and the cartoon
certainly delivers the message. This kind of
behavior is rampant in healthcare and it's not
just male patients, female patients , but obese
patients, elderly patients and just about any
patient that staff can find an excuse to laugh at.
The cartoon you submitted has actually occurred
countless times, often in more extreme cases
as in the Dr. Twana Sparks incident in New
Mexico whereby patients were assaulted for
years and OR nursing staff laughed at such
unprofessional antics. We can't perform any kind
of random sampling to test the waters so to
speak, we don't need to. These behaviors
tell volumes about how often the occurrences
are. All we need to do is read about them.
PT
Misty
Thank you for all the informative sites. I would
like to commend you for all the research you do
as well as your website and the contributions
you make to this subject matter. You are an
inspiration to a very emotionally charged subject.
I have read some time ago the thread you
mentioned on all nurses and I noted many of the
comments that were made. I'm certain that at
some point you and Belinda along with your website
will play a pivotal role in changing perceptions.
PT
I wanted to respond to this:
So... I saw the surgeon today...
When I brought up the concern about same gender staff, he gave a half a chuckle and "assured me everyone on HIS staff is a professional, so I don't need to worry about it", and was incredibly dismissive when I tried to explain that it wasn't an insult towards his staff, but was MY preference for MY reasons... he actually said that "well, once you're out you won't care who's in the room, so it won't matter"... So that's when I asked about wanting my girlfriend to film the entire thing which apparently was "ludicrous and insulting" to him.
I stood up and walked out after that.
Jason K
Jason K: You did a great job standing up to the surgeon. It is true that all medical professionals are professionals, but that does not change many patients’ minds that they do not want people of opposite sex (medical personnel are not exempt) to see them naked. The argument he used about you not caring about who’s in the room is ridiculous. I wish you could have asked him how he would feel if he was sleeping nude on the top of his bed and a number of women and men in the neighborhood came to in his bedroom while he was sleeping nude.
You showed the surgeon that you are in control of your body. I wish more patients would stand up to him. I am sure he makes a lot of money from surgeries. Out of curiosity, what kind of surgery were you going to have? Are you going to look for another surgeon to see if he will respect your wishes? Remember you also have to talk to more people such as operating room supervisor, nursing administrator, etc. about your wishes.
Misty
PT,
Glad to see you back.
Actually the 2.75 million number (actual number 2,724,570) is the number of employed RN's in the 50 states (does not include the territories) as compiled by the Kaiser Family Foundation in their state health facts report. It does not include CNA's, MA's or any other support staff.
Their report is based on 2011 data, so the actual number is probably a little higher. It is projected that this number will grow by approx. 500,000 additional RN's by 2022.
The sad fact is that there are bad actors in any profession, but you can't paint the entire profession based on a minute vocal percentage. In my lifetime I have encountered both good and bad in the nursing profession, but I will say that number of truly caring good nurses far outweighed the few jerks - and one of those jerks was a male RN.
Hex
Jason,
I respect you for standing up for yourself and walking out. The surgeon's dismissing your concerns out of hand showed a complete lack of respect for you as a person.
I've only encountered that type of attitude once. It ticked me off enough that when I got the "we're all professionals here" comment, my reply was "so are all the hookers down in (insert name of local red lite district), but I have no intention of being exposed to them either." Not one of my prouder moments, but the guy was a condescending sanctimonious jerk bordering on being verbally abusive, and it left him speechless, which was the desired effect. I walked as well, then terminated the relationship with cause, in writing, and found another provider that was much more accommodating. I also filed a formal complaint with my HMO and copied the state licensing board.
Not sure what surgery you're looking at, buy many procedures can be done with a local, regional, or combination of the two, without sedation, which allows you to remain awake and alert during the procedure. Might be an alternative you want to check into....
Hex
Maurice,
You said:
Think. Cartoons like these, even "G-rated", do nothing but promote anxiety about the medical profession and the day to day behavior of any or all healthcare providers. Not funny.
I think that you missed my point on the cartoon: It was based on the artist's own experience in the hospital 5 days earlier!
I don't think anyone on this blog, especially those that suffered at the hands of providers would find it funny. If anything, it is a social commentary (just like the cartoons in the opinion/editorial (op-ed) section of the newspaper. I also think that it shows these events for the abuse that they are.
True, the artist has done other cartoons involving doctors, but these are the "ridiculous" that are designed to invoke a laugh, such as "The reason doctors hate clowns." This particular cartoon, unlike the rest of the artist's work, lacks the element of ridiculousness, the event portrayed is frightening.
My only point for even mentioning the G-rated, was because some of your readers who may not be familiar with deviantart.com may make certain assumptions purely based on the name. The site is actually a great resource for artists to display their work, uncensored.
Why shouldn't patients be warned that this happens. Your comments harken back to the year 2003 when the articles about pelvic exams on anesthetized women appeared and providers rushed to downplay the practice. Perhaps warnings to patients about this may heighten awareness where providers will be cognizant and prevent it from happening.
Do you deny that this occurs? How many times is too many? I argue one time is too many.
Dr. Nikita Levy had 1200 videos of patients. Doctors are willing to ask if we own guns for our own safety, yet (many) refuse to address abuses that occur in the healthcare system. Do we not warn our children about strangers?
Why shouldn't a physician educate patients (especially those with chronic illnesses) about protecting themselves from abuses in the healthcare system when they educate them about such things as smoking cessation, diet and exercise, safe sex, etc.?
--Banterings
Misty & Hex - I'm trying to get a Vertical Sleeve Gastrectomy done... (been battling my weight for years and no matter what I do I can't get below a certain point, and I know a couple folks who had a LOT of success with this)
So it's nothing life or death, so I wasn't all that concerned about the consequences of walking out.
This surgery apparently CAN be done with a local... but if it's another a-hole surgeon who doesn't see the issue with gender preference, there won't be a lot I can do about it if I'm alert but sliced open on a table ;)
I'll be drafting up the complaint emails later today and sending them to all the people I should be.
As for painting the entire profession based on a minute vocal percentage... I'm personally going by the ones I've known in my personal life, and it's been a 100% ratio of them being anything BUT professional.
Jason K
I’m back after a year plus hiatus. Banterings and I have been communicating some as of late via e-mail and he urged me to return to the blog. So here I am.
I began reading the postings in Volume 70 from last to first posted.
Maurice, in your 12/15 post to Banterings you write: “joking about a patient’s anatomy . . . is something we never teach our medical students . . .” At first blush I supposed that Banterings had accused whoever “we” are of such instruction or that he had asked you whether or not “we” ever taught students to joke “about a patient’s anatomy.” However, I found that on Banterings’ 12/15 post, he did neither of these things; he expressed his distaste for those who “laugh at” or “ignore . . . inappropriate comments” and suggested that they were “part of the problem.” He then introduced us to a cartoon that depicted what some Americans might consider total fiction but which some of us recognize as occasional reality. When I looked at the cartoon, the first thing that came to my mind was Samuel Clemens’ quip: “Truth is stranger than fiction, but it is because fiction is obliged to stick to possibilities; truth isn’t.”
Before I left this blog in November of 2012, I noticed that you frequently informed us about how “we” instruct medical students. As in the present case, you never told us who “we” are nor explained why you believed you needed to inform, without prompt, our ignorance about “we’s” efforts to dissuade medical students from behaving vulgarly and unprofessionally. Would you please tell us who “we” are and explain why, without a clear prompt, you write about “we’s” efforts to teach medical students to behave within normative boundaries.
You also write: Cartoons like these . . . do nothing but promote anxiety about the medical profession and the day to day behavior of any or all healthcare providers. Not funny.” I submit that the question, “Do ‘cartoons like these . . . do nothing but promote anxiety?’” is an empirical question. I hypothesize that were one to randomly sample Americans from most study populations, s/he would discover that such cartoons elicit congeries of affective responses including anxiety. One might also find that these feelings vary across any number of variables (e.g., occupational status, gender, age). You and I may not find cartoons such as the one sent to us by Banterings funny but, alas, I fear that we might be in the minority among citizens of the U.S.
Ray
Banterings,
In your November 21 post, you mention Philip Zimbardo’s 1971 Stanford Prison Experiment. Zimbardo and his research were influenced by Stanley Milgram, a Yale professor and researcher of social-psychological phenomena. Milgram is best known for his controversial mock-shock experiments on obedience conducted in the early '60s. Zimbardo may be the best known social psychologist alive today. Since he conducted his ’71 study and reported on its finding, his understanding of the human condition has become increasingly sophisticated. The contents of his "The Lucifer Effect: Understanding How Good People turn Evil" attests to that sophistication.
In the early years, Zimbardo limited his explanation of human behavior and social conditions to the social-psychological level. In time, however, he came to recognize that there are also broader social-structural forces that determine social-psychological phenomena, human behavior, and social conditions. He addresses their effects in his Lucifer book and in several speeches that are easily accessed on line.
What is the relevance of Zimbardo’s writings to this blog? The theory of human behavior which he derived from the knowledge gleaned from his and others’(e.g., Stanley Milgram, Kurt Lewin, Solomon Asch) research findings can help explain the disturbing behavior of healthcare providers that have been described by people who have contributed to this blog. Watching Zimbardo do his thing on the internet or reading his book will help move the viewer from the level of description to the level of explanation. I suggest that now is the time to move in that direction.
Ray
Ray, in answer to your question asking "who is we" and "why": "We" is me but also the other instructors in the clinical introduction to medicine which we teach. Thus if I wrote "we", "we" are those instructors and those who supervise our teaching. Professionalism, an important aspect of the course, includes what students and physicians should NOT be doing is part of all our teaching guidance as well as what they SHOULD be doing. ..Maurice.
This is probably going to sound a lot more antagonistic than intended, but ah well... it's me typing it, so it's sort of expected at this point ;)
Maurice, you say that you teach "Professionalism, an important aspect of the course, includes what students and physicians should NOT be doing is part of all our teaching guidance as well as what they SHOULD be doing."...
But you've said numerous times that you have no control over what they do or are taught after they leave you...
Also, what percentage of each years "crop" do you figure pass through your classroom? can you guarantee all the other institutions are teaching the same?
Saying you teach them to act professional as a means of countering our personal encounters with unprofessionals isn't really much of a stance IMO, considering the 2 points.
Jason K
Jason K, in the curriculum I participate, 340 students are taught in their first two years. What I wrote is what they are taught. What happens to the behavior of each and every student after they leave us and move on to their third and fourth years, internship and residency is out of our hands as year 1 and year 2 instructors.
I have no proof of what is being taught at all the other medical schools but from reading education listservs and literature of medical education for these year 1 and year 2 students, I can't conceive that dissimilar teaching is being carried out.
I can tell you and the others here that the way to prevent the "hidden curriculum" being provided to students beyond our control would be in the more careful selection of the attending physician teachers who guide the students through their last two years and to reduce the patient loads in internship and residency and hours "on call" which are important changes in keeping what the students are taught about humanistic professional behavior in the first two years to be preserved and practiced in the students later careers. ..Maurice.
Thank you, Maurice, for answering the first part of my question (Who is “we”?). However, you didn’t answer the second part, possibly because I was not very clear, so let me reword it.
What is your motive for intermittently reminding us that you and your colleagues teach your students to behave ethically and professionally? Sometimes these reminders take me by surprise, as in your response to Banterings, because I do not recognize a definitive catalyst for their inclusion in the blog.
These reminders are not unappreciated by me and, I would suppose, others who contribute to this blog because, if we can take you at your word, they reaffirm in my mind that there is at least one set of physician-instructors who encourage medical school students to treat patients in a manner that preserves their elementary self respect, personal dignity, and fundamental right to privacy. Have I just answered my own question?
Ray
Ray, yes, you have answered your own question. We do not ever set a doctor-patient relationship description to our students which characterizes the physician as the dominant or domineering figure in the relationship. If there is any person in the relationship who sets the patient's limits to their privacy and to their body,beyond the professional standards, it is the patient. This is what we teach and this is the relationship we expect from our students.
It is important for those reading this thread to understand what medical students are taught and expected of them at the outset of their careers despite what has been written here about examples of what is said to be happening to patients later on. ..Maurice.
http://www.cnn.com/2014/12/23/world/asia/china-doctor-selfies/index.html?hpt=hp_t2
Sure, it's China, but still....
It's interesting that administration got punished worse than the ones who were actually posting pics of sedated patients online.
Jason K
Hi Dr. Maurice:
I wasn't sure if my previous posting went through, but regarding patient privacy at teaching hospitals; please explain what my requirements are as a patient. Do I have to let students and residents examine me? I mean, those other than my surgeon? The surgery I need is probably only done at Medical schools. Thank you, Anne
I gained an erection while a nurse was washing me in the shower. She quickly grab my erection, held on to it and kept washing my body.
Why did she grab hold off my erection? It doesn't serve any purpose to hold on to my erection while washing other parts of my body.
I was 20 at the time. She must have been around mid 30s or even 40s, I truly couldn't tell. I understand nurses see penis all the time. So it must have been no big deal for her, but it was a shock to me.
Smitz
It's been a while since this happened, but it was so embarrassing that I remember it like it was yesterday. I was 17 and getting my yearly physical from the school nurse so I would be able to participate in sports for the next year. I had missed the group physical (usually an embarrassing enough event itself) and was forced to schedule an appointment with her in her office during my lunch period. The office was divided in two by a curtain. Her desk and chairs for anyone waiting to see her on the side by the door and the exam table on the other side behind the curtain. Well she and I were behind the curtain with my clothes in a pile on the floor. My undies were around my ankles. Needless to say, it was the full "turn and cough" type of exam.
Suddenly my English teacher rips open the curtain. She glances at me, says nothing, smiles, and begins to chat with the nurse about going out to lunch. After standing there a few seconds in shock I quickly bend and try to pull up my tighty-whities. The nurse grabs them before I do and yanks them back to the floor. "We're not done yet Ashton!" she says firmly. Speaking of which my English teacher is like 40-45, but super busty and looking hot in her low-cut top, so my tiny penis is hard as a rock at this point - though still not very big. I try to cover it with my hands, but once again they are slapped away by the nurse earning a laugh from my teacher. "How can I examine it with your hands in the way?" the nurse asks. I sputter a few words of argument which are quickly rebuffed with "That's nonsense!"
It only gets worse at this point, as a girl I know walks into the office and sits down on one of the chairs in the other side of the office. Because my teacher is standing there with the curtain open this girl can see me too. The sick look on her face soon turns into a smile. Needless to say, I'm thoroughly humiliated. It wasn't until another five minutes of chit-chat, the whole time my little manhood being prodded and squeezed in front of everyone, that I was finally allowed to pull my briefs up. I swear the school nurse got kicks out of doing this sort of stuff to guys all the time. Ashton
Ashton,
Read some of the early volumes in this blog thread. It's all about power and control. Since there's no management, just administrators, in the medical community [including schools], the employees are free to exercise control over patients with impunity. As long as the procedure is completed by the employee, the administrators can collect payment. Enough said.
BJTNT
Anne,
As a patient you always have the right to decide who will participate in your care - doesn't matter whether or not it is a teaching hospital.
If you don't want students or other trainees participating, you need to clearly state that and make sure they note it in your chart.
You also should carefully read the consent form you will be asked to sigh as part of the admission process. If the print is small and difficult to read, ask for a copy with larger print. Cross out and initial anything in the form that you don't agree with before you sign the consent.
Same goes for any other consent forms, i.e. surgical or anesthesia consent forms you may be asked to sign. Make sure any exceptions you want are noted on the consent form in writing - don't just accept their verbal assurances. There's an old saying in medicine - "If it isn't written down, it didn't happen", so if it isn't written down they can pretty do whatever they want and you have no recourse.
Hope this helps!
Hex
Dr, B.,
Looks like there are a couple more fetish posts that need to be deleted.....
Hex
To Hex (here) and Banterings (by e-mail), now you both know the dilemma that a moderator has sorting out the imaginary from the real when the moderator has is dealing with fully anonymous writers and where the moderator has a subject "patient modesty" where all sorts of imaginary juicy scenarios but also real and emotionally tragic events can be detailed on the blog thread, the latter certainly pertinent to the overall discussion. So what is the solution that you can give to the moderator? ..Maurice.
Hello Hex:
Thanks for answering me, but I haven't found it to be that easy, although I'm happy that you've had success. I have never been able to make any changes to medical forms without the management responding that they won't treat me if I don't consent to their practices. I am in medical offices constantly, so believe me when I say I have had no luck. Further, when I do try to dialog with management about privacy, I am treated with suspicion. Some recent examples: when the MRI place told me a student would be observing and I objected, they sent in a manager WITH security guards! This was at a county hospital. Then, at a private surgery center for a procedure using floroscopy, I was made to sign a form saying that they could use the images for anything they wanted. When I objected, they took me to speak with the manager, and she refused to do the procedure unless I signed. I need my treatments, so I signed. This is the US and most of our medicine is private; facilities and doctors don't have to treat us if they don't want to. Further, nobody wants a "problem patient," and the moment I start speaking up for myself about privacy, the whole tone of the visit changes, and then I have to start worrying about my care being compromised. Also, I attend my doctors visits alone as I have no partner or family, and this only adds to the difficulty.
Regarding med school hospitals,
I would still like to ask Dr. Maurice to respond. I have been to two different med schools recently to see spinal surgeons, and both times I was initially seen by a resident. At no time was I asked if this was OK, so I'm assuming it's policy. I looked over their websites, but could not find the policy on this. Please let me know. Thank you. Anne
Anne,
I am not sure if you are familiar with Medical Patient Modesty, a 501c3 non-profit organization that works to educate patients about how to stand up for their rights to modesty. I am the founder of that organization.
I am very disturbed by your experiences. You have been treated badly. I think you need to move on to another medical facility that is willing to accommodate your wishes. It may mean that you will have to drive farther, but it is worth the drive. I helped a young lady earlier this year who wanted a 100% guarantee that a male gynecologist would not deliver her baby. A local hospital near where she lived would not work to accommodate her wishes. The patient advocate at that hospital was not helpful. Fortunately, she found Medical Patient Modesty’s web site and contacted me. I encouraged her to check out two other hospitals that were farther that had all-female ob/gyn practices that had privileges at those hospitals. She ended up switching hospitals. She ended up delivering her baby at a hospital 45 minutes away, but it was worth driving there.
It is terrible that they sent a manager with security guards when you objected to having a student present for your MRI. You have the rights to decide who can and cannot be there for your treatments. I encourage you to file a complaint with the president of the hospital. You should consider not going there anymore unless they are willing to work with you.
I am very disturbed by this:
Then, at a private surgery center for a procedure using floroscopy, I was made to sign a form saying that they could use the images for anything they wanted. When I objected, they took me to speak with the manager, and she refused to do the procedure unless I signed. I need my treatments, so I signed.
This shows how much power the medical community has. Patients are often intimidated by the medical community that they must accept anything. If something like this happens again, I encourage you to not move forward with the procedure and let them know you are going to another hospital. Think about what would happen if so many patients spoke up and refused procedures. I think you should consider filing a complaint about this medical facility and how they ignore patients’ rights.
You may email me directly through this link.
Misty
Maurice:
On 12/16 you wrote, “. . . the way to prevent the ‘hidden curriculum’ being provided to students beyond our control would be in the more careful selection of the attending physician teachers who guide the students through their last two years and to reduce the patient loads in internship and residency and hours ‘on call . . .’"
In my home town, administrators, students, faculty, and non-teaching physicians are all involved in selecting attending physician-teachers, and they employ great care when doing so. Their focus is on credentials, reference evaluations, past student evaluations, patient evaluations, and how the applicant interacts with others during the interview process. The criteria for employment found in these sources are undoubtedly very important. However, they don’t seem to weed out the many physician-instructors who include in their teachings, directly or indirectly, the idea that patients’ dignity and right not to be exploited are of secondary importance. For example, I’ve conducted participant- observation research along with survey research in the community and found that physician-educators rarely obtained consent before using patient’s as teaching subjects even when intimate procedures were involved. Among the correlates of consent expected were patients’ gender, income, occupational status, and level of education but it was found that the only significant correlate was gender; physician-instructors were more likely to get the consent of female than male patients before using them as teaching subjects.
Over the period of the participant-observation research, I personally was never asked my consent in 38 visits to clinic physicians during which medical students were involved. I conducted an ethnomethodological breaching experiment during 28 of these visits. (http://en.wikipedia.org/wiki/Breaching_experiment) The breaching experiment involved challenging physician-teachers when they used me as a teaching subject without my consent with, “I don’t wish to be used as a teaching tool or visual aid for the benefit of your students. I’m here to receive a service, not give one, especially without my consent and offer of remuneration for my service.”
Although I did not always follow through with my demand and no physician-instructor ever turned me down, their responses did allow me to create a typology of responses. The first category of responses was “physician compliance”; physicians verbally agreed and/or asked the student(s) to leave with no or few additional comments. After compliance, some physicians added, “That’s never happened before,” or something similar. One physician proclaimed, “That’s a good lesson for [the student].” The second category of responses was what I dubbed “appeal to higher loyalties”; physicians did not deny that patient preferences were important, but expressed the belief that the teaching of students trumped patient preference. For example, several physicians insisted that the exploitation of patients as teaching subjects was necessary for educating students. Some paternalistically added that, in the long run, it benefitted me. The most extreme response was by a physician who responded with, “I owe it to my students” after which he flung his arms into the air and cried, “I came all the way from California because I thought this community needed me.” CONTINUED
Ray
CONTINUATION
CONTINUATION
A third category of responses was “normalization”; physician-teachers communicated the idea that using patients as teaching subjects was commonplace, normative, or accepted in the medical community and, either explicitly or implicitly, condemned my request as deviant. For example, one physician-instructor proclaimed, “This is the way we’ve always operated. Nobody ever questions it.” A fourth response category was “appeal to special status.” This occurred when physician-teachers begged the issue by pointing out that they were professionals while their students were chosen because of inherent qualities conducive for professional development. For example, one physician proclaimed, “I am a professional and these students are training to be professionals. There’s nothing to worry about.” One physician-instructor actually introduced two of the students accompanying him as “doctor.”
Over a three year period, I interviewed three dozen people who had requested that physician-instructors not use them as teaching subjects or requested that they explain why they were used or being used this way without their consent. I asked these individuals how physicians responded to their requests or queries. All but a few of their answers could be placed in the response categories identified above. The few that could not be so placed could be positioned in a fifth category that I labeled “denial (or dehumanization) of the victim”; the victim of the unethical behavior of physician-teachers, in effect, becomes the offender in the mind of the latter. For example, some patients reported that physicians insisted that it was the patient’s responsibility to get consent not to be used as a teaching subject. By putting the onus for consent onto the shoulder of the patient rather than onto the shoulder of the physician-educator not only trivializes the asymmetric power differential inherent in the physician-patient relationship but it also implies that the miscreant in the patient-physician interaction is the patient not the physician. Arguably, the most egregious experience occurred to one woman who, upon entering a labor and delivery department to give birth to twins, asked that no students be involved. Within minutes a physician-teacher entered her room and browbeat her with accusations of childishness, selfishness, and immaturity. When I asked her what she said, she responded, without elaboration, “I knew my rights.” She happened to be a Ph.D. nurse-instructor.
The point I’m trying to make in a somewhat circuitous manner is that even when great “care is given to the selection of the attending physician teachers who guide the students,” one might still end up with physician-educators who pass on to students a hidden curriculum that justifies, in ways that can be measured and classified, ethically questionable treatment of patients. Why might that be? The answer is multivariate, but I can propose a partial answer, again using a circuitous route. CONTINUED
Ray
CONTINUATION
According to several media sources, the most popular physician-teacher among students, staff, and administrators at the local medical school and hospital is the most popular for at least two reasons. One source of his popularity is the sense of humor he exhibits during classroom lectures and clinicals. Not reported in the media is his penchant for irreverent and gallows humor communicated to students at the expense of patients. A second source of his popularity is that he more frequently than most other physician-teachers permits medical students to use patients as teaching subjects. Not reported in the media is that neither the physician nor students secure the consent of patients first. Nor is it reported that sometimes medical students perform gratuitous procedures that can cause patients physical pain and humiliation. The procedures along with the pain and humiliation are then repeated by the physician bent on confirming or denying students’ assessments.
Moving out of my home town, you and some of your readers are familiar with the research conducted by Ubel, et al. and published in the American Journal of Obstetrics and Gynecology (“Don’t Ask, Don’t Tell: A Change in Medical Student Attitudes after Obstetrics/Gynecology Clerkships toward Seeking Consent for Pelvic Examinations on an Anesthetized Patient”). In this article, the authors cite high-ranking physicians in the hospitals studied who give several specious justifications for allowing medical students to perform nonconsensual pelvic exams on unwitting anesthetized patients, justifications that fit nicely into several of the categories described above. During his medical school days, one of the authors had reportedly defied the defenders of the indefensible and refused to conduct gratuitous pelvic exams on anesthetized patients without first securing their consent, thereby putting himself at risk of retribution. Furthermore, soon after the results of the Ubel research were introduced to the public in the popular media, students at Harvard’s medical school rebelled by refusing to carry out physician-instructors’ orders to perform gratuitous pelvic exams on anesthetized patients absent of consent. CONTINUED
CONTINUATION
Working inductively, an accumulation of these anecdotes along with many others that are not in the purview of this paper reveal a pattern from which several propositions can be derived, four of which include: 1) The deviant behavior (e.g., using patients as teaching subjects without their consent) of non-elites (e.g., medical students) is a consequence of the expectations of and socialization (or resocialization) by elites (e.g., physician-teachers and high-ranking hospital physicians) who control non-elites’ social (e.g., educational) milieu; 2) Justifications and rationalizations for deviance by elites tends to increase the entrenchment of a culture of deviance in which non-elites operate; 3) The higher the social rank of those who justify deviance, the more entrenched the culture of deviance; and 4) The more entrenched a culture of deviance, the more difficult it is to dislodge. Note, as is true of all propositions, these propositions have broad applicability (i.e., they transcend any particular form of deviant behavior) and can be tested using the tools of science.
These propositions have been empirically verified using different forms of deviance. However, I know of no research that specifically addresses the explanations of ethically questionable behaviors by healthcare providers. Nevertheless, given what is known, it is not unreasonable to theorize that the issue of our concern goes way beyond the manner in which attending physician-teachers are selected. The sources of the problem and the manner in which attending physician-teachers are selected lie within the culture and the social structure of the “culprit” healthcare organizations.
I have introduced my theoretical propositions in a somewhat formal manner. Philip Zimbardo simplifies the matter considerably. He might label my set of propositions “apple barrel theory.” Zimbardo recognizes that many if not most people attribute rotten behavior to rotten apples, to misfits, to rogues, to exceptions to the rule. But, he argues, this is seldom the case. Most people who do rotten things, even horrendous things, are really good apples who have been placed in rotten apple barrels, a situation or culture which demands rotten behavior. The third thing he recognizes is that there are people who are responsible for creating, keeping up, and maintaining the rotten apple barrels. These creators, keepers, and maintainers of rotten apple barrels tend to be people who occupy high prestige positions in a group, organization, institution, or society and tend to benefit, in one way or another, by keeping the barrels rotten.
Ray
P.S. Sorry this was so long.
Anne,
On 12/27, you asked “Do I have to let students and residents examine me?” Here’s what you will find in the AMA’s Code of Medical Ethics:
Opinion 8.087 - Medical Student Involvement in Patient Care
(2) Patients are free to choose from whom they receive treatment. When medical students are involved in the care of patients, health care professionals should relate the benefits of medical student participation to patients and should ensure that they are willing to permit such participation. Generally, attending physicians are best suited to fulfill this responsibility.
(3) In instances where the patient will be temporarily incapacitated (eg, anesthetized) and where student involvement is anticipated, involvement should be discussed before the procedure is undertaken whenever possible. Similarly, in instances where a patient may not have the capacity to make decisions, student involvement should be discussed with the surrogate decision-maker involved in the care of the patient whenever possible. (V, VII)
Issued June 2001 based on the report "Medical Student Involvement in Patient Care," adopted December 2000 (J Clin Ethics. 2001;12:111-15).
Unfortunately, the AMA does not have the authority to sanction violators of this ethical code. However, the state’s Board of Healing Arts (or its equivalent) does.
You can find the above at the following link: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion8087.page
or just type in "AMA's Code of Ethics."
Ray
Ray, excellent! Thanks for reporting your observations and conclusions. It is through this "anatomic" and "patho-physiologic" study of physician and medical education behavior that more solidly contributes to understanding and making changes in the system.
From my view, in my school and with regard to first and second year education, none of the unethical and non-humanistic behavior is taught to our students. However, what happens later in the latter years of medical school and residency is part of what we call the "hidden curriculum" (it is "hidden" from us and we have no direct control) and continues to be a "thorn" in the medical education process. Yes, we need to change the medical system and, as an example, not request or more require altruism from ill patients as an alternative to informed consent. ..Maurice.
Hex,
I suppose the “fetish posts” to which you are referring are by SMITZ and Ashton. SMITZ claims that he “gained an erection while a nurse was washing me in the shower. She quickly grab [sic.] my erection, held on to it and kept washing my body.”
Nursing students at the university where I taught until recently are told in Ethical/Legal Nursing that such behavior constitutes criminal battery. However, that’s not always been the case. One of the instructors there, a state representative at the time I spoke with her, who was a student in the early ‘70s informed me that she was taught to flick an erect penis with her finger or squeeze it at its base to reduce its tumescence. She added, “But that would be considered battery today.”
Regarding Ashton’s post, I’ve spoken to people who have had bad experiences at the hands of school nurses, but none anywhere near as similar as Ashton’s. One would hope that if the school nurse was “doing this sort of stuff to guys all the time,” that somebody – a teacher or administrator with a conscience, a parent, someone from the media – would have gotten wind of it. It didn’t take long, for example, for officials to find out about and take action against correction officers who, at the request of two teachers, stripped searched some young male visitors at a D.C. jail (http://www.michaelkeller.com/news/news213.htm). However, I do know of credible sources, including my own mother, who have had to suffer battery and assault at the hands of nurses and physicians. I shudder to think what I would have done had I been present when these things occurred to my 100 pound, octogenarian mother.
Ray
Anne, your experience being confronted with a resident as your physician is part of a teaching hospital protocol. If you happen to have a resident in the latter years of his or her training, you may find a more knowledgeable physician (and they are licensed physicians) than a doctor who graduated medical school 20 or 30 years ago. However, as with the patient being treated by any physician, you must provide consent for that individual (and identified to your satisfaction) to attend to you, teaching hospital or not. You should be free to accept or reject that individual. Period. However, consent or dissent should be informed and with that information about the doctor and about your illness and necessity for prompt treatment, it is up to you to decide whether or not to accept the doctor for your management.
All patients should have their own and trusted general physician who understands the patients' desires and will help to arrange admission to hospitals which can satisfy the patient's wishes. Unfortunately, in some rural areas options for such possible selections may be limited.
I hope this answers you questions. ..Maurice.
Thanks to all who answered me. Ray has done some amazing research and I appreciate Misty and Hex's comments as well.
Perhaps I should have been more specific about the med school question. To clarify: Recently, I went to two different med school spine centers to visit surgeons. It was my first time at both places. At the first place, a spine fellowship guy met me,introduced himself as a fellow, and interviewed me before the surgeon came in. As I was not undressed and fellows are very experienced and already doctors, I didn't care. At the second school, a very young man met me, said he was a resident, (or maybe a student, I don't remember-they are always purposefully vague and never say what year they are, they just introduce themselves as "doctors") and said he needed to examine me and wanted me to put on a gown. As everything is on CD's these days and I had all my own images, (and I have been to many spine surgeons)I knew this was unneassary. I said my usual line that I use to stay out of hospital gowns, which is that it is too painful for me to dress and undress. I got the feeling that he wanted to see my spinal scar, and my spine (Scoliosis) for his own benefit. I understand that students need to learn, but I can't be that patient as I'm not comfortable.
So, again my question to Dr. Maurice is: As it seems policy for students/residents to do the pre-interviews/exams for the surgeons, (something ordinarily a MA would do in a regular office) how can I refuse this and still see the surgeon? Am I obligated to see the student/resident? Please answer. Also, please tell me if I am required to let these students who are part of the surgeon's team see me throughout my hospital stay and operation. I can't imagine that any med school surgeon will operate on me if I won't allow his residents to assist in the surgery and see me on rounds afterwards.
All my research on this just says "if you don't like students, don't go to a med school" but I have a complex surgery that is best done at a med school.
I see the AMA code of ethics Ray posted, but ethics is not the law, is it? Someone please tell me.
My larger point is that once you start saying things like you don't want students, people see you as a difficult patient, and then they are no longer helpful, nice or even give good care. Many times I am asked to sign something that says I have been given the privacy practices when I haven't...when I ask to read it first, they look at me like I'm crazy. I'm not stupid enough to think that this doesn't get back to the nurse, the doc, and whoever else, that I am a "problem," or non-complaint. From there, it's just a short step toward them refusing to do my surgery.
Thank you so much everyone,
Anne
Anne, follow my advice: if you have a trusted private physician who knows you and your concerns have him or her contact your surgeon and present your requests. Unfortunately, doctor to doctor requests may be more readily accepted by the surgeon than "demands" by the patient. This involvement of the personal physician is part of that physician's responsibilities to their patient. ..Maurice.
Anne,
Most insurancers have "nurse hotlines" to help patients (it is suppose to save money by helping you get the right care the 1st time). Call and have the insurer advocate for you. Most hospitals also have patient advocates, try contacting them before your appointment so that they can help. I am not sure where you live, but the larger metropolitan areas have patient advocates that you can hire to advocate on your behalf, but this is an added expense that you might be able to get your insurance to approve coverage for if they (the insurer) fail to advocate on your behalf. If all else fails, get the media involved. No hospital or school wants bad publicity. The final option, and I really hate to suggest this, is to get a medical malpractice/liability lawyer involved. Most will probably do this for almost nothing with hopes that the hospital will "mess up."
Ray,
Can the apple barrel explain the Holocaust? I have explored the application of the dynamics of the Holocaust to physicians in From Mother Theresa to Dr. Mengele. It is also interesting to note that physicians had been the largest professional group to join the SS (Source: remember.org). Their crimes were so great, that a separate trial took place in Germany for them.
Nazi doctors gave the following arguments in their defense: "involuntary research on prisoners had a long history, prisoners were already sentenced to death, they were only following orders, there were no clear international ethics standards respecting research, the toleration of a lesser evil to tolerate a greater good, those who did not participate might have been killed" (Tarantola, 1993).
There are two famous experiments that can explain the transformation that takes place among medical providers as they go through their training. They are the "Stanford Prison Experiment" and the "Milgram Experiments." These experiments only prove the axiom "Power tends to corrupt, and absolute power corrupts absolutely. Great men are almost always bad men."
We see many similarities between the prison system and the healthcare system: institutions where one group has complete control and dominance over another group to the extent that the subordinate group loses the control over their own bodies. These tend to be the sources of many human rights violations as well. These institutions have been corporatized into the military industrial complex and the healthcare industrial complex.
Many times, these two institutions have intertwined from the Holocaust, to the Tuskegee syphilis experiment, doctors torture suspected terrorists after 9/11, cops forced man to undergo enemas, colonoscopy, and finally recognition that health care can be form of torture in certain cases, says UN human rights expert.
Let me finish my post by saying, this is NOT all healthcare providers. Remember the Harvard Medical School students refusing to do pelvic exams on anesthetized female patients?
--Banterings
Ray
Here is the reference
http://tigerhawk.blogspot.com/2005/05/nurses-secret-
weapon.html
The spoon
PT
Maurice,
Your suggestion that what I wrote “contributes to understanding and making changes in the system” reminds me of some dialogues between characters in Steinbeck’s The Grapes of Wrath. John Casy, the wayward preacher who gave up preaching, says to Tom Joad, the major protagonist in the novel (played by Henry Fonda in the film), “Tom, you gotta learn like I’m learnin’. I don’t know it right yet myself. That’s why I can’t ever be a preacher again. Preachers gotta know. I don’t know. I gotta ask.” And, Tom Joad speaking to his mother, “That Casy. He might have been a preacher but he seen things clear. He was like a lantern. He helped me to see things clear. . . Maybe I can do somethin’ . . . maybe I can just find out somethin’, just scrounge around and maybe find out what it is that’s wrong and see if they ain’t somethin’ that can be done about it. I ain’t thought it out all clear, Ma. I can’t. I don’t know enough.”
Before I ended my contributions to your blog in Nov. 2013, my intent was to test the waters to find out if there was any interest on the part of other contributors, including you, to foster changes in the U.S. healthcare system (or at least one or more of its constituent parts) that would address the problems identified by bloggers. To that end, my contributions tended to reference theory and research and avoided anecdotes except for illustrative purposes. My contribution to which you refer continued in the same vein. More specifically, I employed David Matza’s neutralization theory (the propositions of which have been confirmed by many researchers) in an effort to help understand some physician-educators’ tendency to employ patients as teaching subjects without their consent. CONTINUED
Ray
CONTINUATION
Bloggers occasionally make reference, inadvertently, to theoretical ideas that are pertinent to understanding the behaviors about which they write. You may have done so yourself when on 12/16 you wrote, “. . . the way to prevent the ‘hidden curriculum’ . . . would be . . . to reduce the patient loads in internship and residency and hours ‘on call.’” However, you don’t explain how reducing patient load and hours “on call” would help “prevent the ‘hidden curriculum,’” or at least ameliorate its effects. Maybe you’re thinking what I’m thinking. Patient load and hours on the job, when excessive, can cause interns undue stress and, in general, contribute to adverse working conditions. Many theorists and researchers recognize adverse working conditions as being abnormal. The normal response of individuals who experience abnormal situations is frustration which is not infrequently displaced in the form of aggression toward weak victims (scapegoats) who tend to have little to nothing to do with the frustration. In the case of interns, the aggression may be directed at, among other subjects, patients who come to be seen as “the enemy” or “the other” thereby opening the way for their dehumanization. Aggression may range from treating patients’ disrespectfully (e.g., not explaining a procedure to them, leaving the hospital room door open during an intimate procedure, dismissing their legitimate concerns) to battery (e.g., exposing patients, without explanation or their consent, by “whipping” off their sheets or lifting their gowns while others are present). Aggression may also be passive (e.g., telling vulgar jokes about and using irreverent slang to refer to patients). Those who aggress tend to defend their aggression using rationalization (e.g., attributing the behavior to “human nature”).
The theory I’ve applied here is called frustration-aggression theory, displacement theory or scapegoat theory. Neutralization theory, which I employed in my earlier post, is different in some important ways from but, at the same time, complements displacement theory. The latter is cogently articulated in Theodore Adorno et al.’s The Authoritarian Personality. CONTINUED
Ray
CONTINUATION
The complementarity of neutralization theory and scapegoat theory are hardly sufficient for explaining why some healthcare providers dehumanize patients. Other theories are just as important including, but not limited to, the following: 1) Adorno’s personality theory; 2) Phillip Zimbardo’s situational theory; 3) the learning theories of Edwin Sutherland and Ronald Akers; 4) Erving Goffman’s social constructionism; 5) the labeling theories of Edwin Lemert and W. I. Thomas; 6) Travis Hirschi’s social control theory; 7) and the social-structural and power theories of Max Weber, Jeffrey Reiman, E. Stanley Eitzen, Alex Thio, and David Simon. Tests of these theories suggest that together they go a long way toward explaining many patterns of human behavior at both the micro- and macro-levels. And, together they may help us understand the behaviors of some healthcare providers that are of interest to most of the contributors to this blog.
I personally believe, just as John Casy and Tom Joad believed, that understanding why certain patterns of behaviors and social conditions exist is important for bringing about change. Understanding the “whys” of human behavior and social conditions, that is, the capacity of identifying the causes of human behavior is an important first step in recognizing what variables need to be manipulated and how they need be manipulated to bring about the social change desired. Almost all textbooks on social problems end at this point; i.e., they tell us what needs to be done to bring about social change. For example, a textbook may suggest that to reverse a failing economy and prevent a depression or deep recession requires the employment of solutions identified by Keynesian economics which dictates against privation and, instead, advocates government intervention in the form of economic stimulus and the generation of jobs. Ending at this point frustrates both students and professors because invariably textbooks do not recommend ways of convincing legislators to adopt these alternatives. Fortunately, there are theories and research which do just that and are illustrated by the successes of the civil rights movement, women’s right movement, and the gay rights movement.
Ray
So, Ray, what is your conclusion as how best to change the entire medical system to be more aware and actively mitigate the valid complaints presented here on this "Patient Modesty" blog thread? Is formal and specific research (sociological, psychological, legal, ethical, etc,) the only method for establishing the approach to change? "Speaking up" or "Speaking to" the elements of the system by the patients and their families would be of no overall benefit for change? What would you recommend? ..Maurice.
Banterings,
The answer to your question – “Can the apple barrel [theory] explain the Holocaust” – is a qualified “yes.” Indeed, “apple barrel theory” can help explain events ranging from fraternity hazing to the My Lai and Sand Creek massacres to participation in genocidal activities. More specifically, what Philip Zimbardo calls the “Lucifer Effect” can help explain why some people who no one or few people would ever believe would engage in fraternity hazing, massacres, and genocidal activities (the good apples) do just that. However, the “Lucifer Effect” alone does not sufficiently explain why people participated (and today, in some places, participate) in these activities. I alluded to other theories in my last contribution to this blog.
Ray
Thanks, PT. That made my day. I’ve never heard of the spoon technique. I’m glad the writer never had to use it. However, some years ago a contributor to this blog (I believe) made several posts within which he claimed that a nurse slapped his groin with her hand so hard that it caused testicular swelling and bruising which left him impotent and in constant pain. I don’t recall that his contribution was in any way lurid nor do I believe that he added any levity to his writing; it appeared to be a credible report. I don’t recall the specifics of his story but it is memorable not only because of what happened to him but because of his effectiveness at communicating the emotional pain and distrust that he felt as a result of his experience.
Ray
Ray,
I have heard about "the spoon" personally from one (older) nurse and read about it on a few internet sites and once (somewhere) in print. I am not sure if this is an urban legend "repeated so many times that it is true," if this was taught at some institutions, or part of the hidden nursing curriculum.
What is most disturbing about the post PT referenced if the idea that a involuntary physical reaction (the erection) is taken as a voluntary expression of disrespect to the nurse.
...some of the male patients might behave in a manner that was disrespectful and have an erection.
A trained professional would be aware of these involuntary reflexes. I think that this "attitude" also is present in the topic that Dr. Sherman has written extensively on; the examination of adolescent boys by female providers.
There is most definitely a problem with many providers, some to the point of almost a sociopathy. Look at the issue of pelvic exams on anesthetized female patients that came to light in 2005. How can any rational human being NOT know that this is wrong. As late as 2012 I have still seen physicians defending the practice. Defending this practice is akin to defending the Holocaust. There are thousands of other examples of this ad nausiam.
Note: Maurice, I mean no disrespect here to your profession.
Let me propose a very radical solution...
Myself, many other contributors on this blog (especially Jason), and contributors, authors, victims, etc. on other sites have alluded to "providers as patients" in one form or another. This includes graduated providers serving as teaching subjects themselves. Jason has brought up the notion of medical students practicing on each other to which Maurice has made very good arguments against. Yet, many of us see this as "if you talk the talk, then walk the walk." Everything that patients are told about some of these procedures and practices being acceptable, non-traumatic, necessary, etc., we know NOT to be true. If they were, then why would providers then not subject themselves to them?
We hear every excuse from providers except the most obvious; these procedures are humiliating and traumatic. Every provider who has written an article of why "gender choice of providers is irrelevant to patients" has also stated that they personally have gender choice of their providers. I honestly believe that if providers had to allow student participation in their annual exams, things would be different.
I have stated, "If providers had to perform procedures in the same state of undress as the patients, procedures would be much different.
I have been ridiculed for proposing this, but this serves the same purpose as the saying, "What would Jesus do?"
Perhaps you Ray, can express this idea of mine in a clearer, more concise manner.
--Banterings
Anne,
It is indeed true that behavior committed in violation of ethical codes does not necessarily violate the law. However, knowledge of the ethical codes meant to guide the actions of the occupants of different occupations is power in the sense that it provides you with a foundation for making an argument against behaviors that violate those ethical codes on the occasions you choose to demand your rights or file a complaint.
In addition to the AMA’s statement, many hospitals and clinics include in the documents given to patients (and/or have posted on their walls) the American Hospital Association’s “Patient Bill of Rights” (now called “The Patient Care Partnership”) or something similar which promises that “the patient has the right to considerate and respectful care . . . [and] has the right to every consideration of privacy” ( http://www.patienttalk.info/AHA-Patient_Bill_of_Rights.htm). Some healthcare facilities also include non-exploitation statements in their patients’ rights document.
Ten years ago, Michigan State University Medical School paid women who volunteered to be teaching subjects $30 an hour so that medical students could practice pelvic examinations on them. Some used their earnings to put themselves through college. These patients’ participation was voluntary and non-exploitative for they were paid well for their service. At one time, what is now A. T. Still University ran a clinic in which medical students under the auspices of physicians provided healthcare services directly to patients for discounted charges. Students diagnosed and made treatment recommendations which were then run by their licensed physician mentors for confirmation or alteration. These patients’ participation was voluntary and non-exploitative since their charges were discounted.
By contrast is the involuntary or non-voluntary (non-consensual) use of patients as teaching tools or visual aids by physician-educators and medical students to benefit themselves. To do this, especially without offer of remuneration for the service provided, is by definition exploitative and the exploitation of patients hardly constitutes a show of respect. Evidence of the latter was found by Ubel and his colleagues; most patients questioned did not object to undergoing pelvic exams while anesthetized. It was that their consent was not first obtained to which they took umbrage. The researchers also found that the number of patients who reported that they would consent to pelvic exams if asked coupled with other opportunities for students to perform pelvic exams provided sufficient practice for medical students – a finding that can be used to parry the defender of the practice’s inevitable insistence that a consensus requirement would prevent students from getting sufficient practice.
Ray
Anne, Maurice, Ray, et al,
This is one of the best publications I have ever seen. It is the Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse put out by the Public Health Agency of Canada.
Here is a list of the chapters:
Acknowledgments
The Handbook as a Tool for Clinical Practice
Background Information about Childhood Sexual Abuse
What Childhood Sexual Abuse Survivors Bring to Health Care Encounters
Principles of Sensitive Practice
Guidelines for Sensitive Practice: Context of Encounters
Guidelines for Sensitive Practice: Encounters with Patients
Guidelines for Sensitive Practice: Problems in Encounters
Guidelines for Sensitive Practice: Disclosure
Summary and Concluding Comments
Appendices
What really illustrates the importance of the guidelines outlined in the book are the quotes from the survivors of abuse. Everything in this book is researched cited, and annotated fact created and published by a reputable entity (the Public Health Agency of Canada).
Not only does the book give guidance for handling survivors of sexual abuse, it guides the creation of a practice that recognizes that some patients may be survivors of sexual abuse, the practice may NOT be aware that some patients are survivors of sexual abuse, illustrates who this affects survivors in the healthcare setting, and helps create a practice that is sensitive to survivors of sexual abuse.
I argue that due to the same issues with abuse (loss of integrity and control of one's own body), and the parts of the body involved (the genitals), survivors of abuse in a healthcare setting will have the same pathology, symptoms, and prognosis as survivors of sexual abuse.
I explore the concept of sexual touch on my blog here and here. Here is an article on the National Institutes of Health website titled Rectal exam mistaken for sodomy, a patients personal experience also makes the connection with sexual touch and medical procedures.
If anyone has more citations in linking these, please let me know!
This book gives insight to how procedures when conducted properly, can be assaultive to survivors of sexual abuse (and healthcare abuse.
Anne, note this: I also believe that under the Americans wit Disabilities Act (ADA), providers need to be aware of this and be able to make accommodations.
--Banterings
Ray
The individual you referred to goes by 58Flyer
on Allnurses and actually started a thread there
titled "EEK, there's a woman in my room".
I assure you this is not an urban legend. A
friend of mine many years ago in the military told
me of his experience.
PT
Banterings, I glanced through the Handbook as reached through the link you provided and it appears excellent as a documentation of factors involved in the issues dealing with the reaction of patients in terms of patient modesty and gender selection of their medical providers.
I really appreciate your presentation of resources and also the thoughtful presentations of Ray. The years of my expression "moaning and groaning" on this blog thread, as I have previously written, does nothing to devise ways to understand the current thinking and response of the medical system and does nothing to devise ways to make changes.
I strongly recommend all my visitors here to go to the above link by Banterings and learn from the research presented there. ..Maurice.
Banterings,
You correctly assert that physicians were “the largest professional group to join the SS. Their crimes were so great, that a separate trial took place in Germany for them.”* Left unstated is that SS officials, including SS physicians, adopted many of their ideas and strategies from U.S. physicians who were at the forefront of the American eugenics movement. Adolph Hitler incorporated the ideas of American eugenicists along with the anti-Semitic writings of Henry Ford in his Mein Kampf. An excellent source for finding out about the eugenics movement in the U.S. and its contribution to Hitler’s “final solution” is Edwin Black’s War Against the Weak. Here’s a taste of what he and others tell us about American eugenics, medical eugenicists, and contributions of the latter to Hitler’s “final solution”.
American eugenicists dichotomized people into the “fit” and the “unfit.” The “unfit” included the lower classes, the poor, the disabled, those not upwardly mobile, immigrants from East Europe, people of color, the mentally ill, visually impaired people, deaf people, “imbeciles”, prostitutes, criminals, the disabled, people with various medical conditions such as epilepsy, and so on. Eugenicists in the U.S. advocated the use of selective breeding (positive eugenics) and sterilization (negative eugenics) to weed out inferior elements in the U.S. population. Adherents to the cause included President Woodrow Wilson, President Theodore Roosevelt, President Herbert Hoover, Winston Churchill, Margaret Sanger, George Bernard Shaw, among other famous people. One of its leaders was a self-promoting unscrupulous osteopathic physician named Harry Laughlin. His body was interned in Highland Cemetery in Kirksville, Missouri, the home of osteopathic medicine. Here is how his memorial reads: “He had epilepsy and never had children. Widely known for his research into racial breeding and very special friendship with Adolf Hitler. He received an honorary PhD from the University of Heidelberg in 1936 and the German sterilization laws were based on his model law for compulsory sterilization which was implemented by some 20 states leading to the sterilization of more than 60,000 Americans for being blind, deaf, poor, etc. Coincidentally, epilepsy was one of his criteria for compulsory sertilization [sic] of racial inferiors.” (see, http://www.findagrave.com/cgi-bin/fg.cgi?page=gr&GRid=38445624) Laughlin was honored posthumously by what is now Kirksville’s Truman State University which named a building after him, a building which was razed to make room for an expansion of Truman’s library. Today, Laughlin Pavilion is a healthcare facility in Kirksville. The healthcare it provides is to those who have mental illnesses which, ironically is a category of the “unfit” that Laughlin would have set aside for involuntary, compulsory sterilization.
The first mandatory sterilization law in the world was passed in Indiana in 1907. The law was, for the most part, replicated in an additional 29 states. Some of these laws were challenged in front of the U.S. Supreme Court which upheld their constitutionality. Official records estimate that between 1907 and 1963 more than 64,000 of the “unfit” were involuntarily sterilized. The actual number is probably much greater than that. Most of those in institutions who were sterilized were women (over 60%), usually because of their sexuality, while institutionalized men were most likely to be sterilized because of their criminality. CONTINUED
Ray
CONTINUATION
More compulsory sterilizations were performed in California than in any other state. California eugenicists shared their defense of and information about compulsory sterilization with German scientists and German physicians thereby inspiring a eugenics movement in that nation long after it began in the U.S. Hitler and other members of the German government cited the California model to show that national compulsory sterilization programs could be effectively and humanely implemented and maintained. Some U.S. based charitable organizations such as the Rockefeller Foundation provided funding for eugenic programs in Germany, including the one in which the physician Josef Mengele (nicknamed the “Angel of Death”) got his start. U.S. support of the eugenics movement in Germany, initially modeled after American models, was a precipitator of Hitler’s “final solution.”
Some early to mid 19th century U.S. physicians boldly and overtly recommended that the U.S. government institute a euthanasia program using gas chambers which would rid the society of the unfit, but the recommendation never received much support. Consequently, some physicians who were adherents of the eugenics movement found covert ways of getting rid of the “unfit.” Involuntary active euthanasia was practiced (e.g., giving institutionalized patients who had mental illnesses milk tainted with the TB bacterium) as was involuntary passive euthanasia (e.g., neglect of the institutionalized).
At the same time that U.S. citizens were being informed about the Tuskegee syphilis experiment** on poor African Americans in Macon County, Alabama run between 1932 and 1972 by doctors working for the U.S. Public Health Service, a U.S. senate committee investigation was uncovering evidence that the U.S. Office of Economic Opportunity funded the involuntary sterilization of more than 2,000 poor southern black welfare mothers without their voluntary consent and, in some cases, knowledge. The Tuskegee experiment coupled with southern states’ sterilization programs, the many post-WW II unethical experiments conducted on black prisoners, and the Reagan administration’s delay in addressing the AIDS “epidemic” which killed a disproportionate percent of black citizens set the stage for the widespread belief among African American citizens through the 1980s and into the ‘90s that the intent of government physicians and government officials who funded them was the genocide of black Americans. CONTINUED
Ray
CONTINUATION
As far as I know, not a single U.S. doctor, not one, who was responsible for the deaths, involuntary sterilizations and other harms that resulted from the Tuskegee syphilis experiment, U.S. eugenics programs, unethical post-WW II experiments, or contributions to Hitler’s “final solution,” was ever held accountable for his actions in criminal or civil courts. Not one lost his license or was even given a probationary punishment for his involvement. Not a single U.S. doctor, not one, who was responsible for the effects of the CIA’s “Cold War” MK Ultra mind control experiments (see, http://en.wikipedia.org/wiki/Project_MKUltra) and, more recently, those physicians involved in the abuse and torture (or, more euphemistically, “enhanced interrogations”) of prisoners at Abu Ghraib and GTMO (see, Steven Miles’ Oath Betrayed http://www.npr.org/templates/story/story.php?storyId=5516533 ) has ever been held accountable in a court of law, criminal or civil, for their illegal actions. Not one lost his license or was even given a probationary punishment for his involvement. That no physician has been held accountable for the consequences of the deviant behaviors in question reinforces the maxim that those who commit their crimes from positions of power tend to do so with impunity.
FOOTNOTES
* I believe there were actually 12 trials of Nazi doctors in Nuremberg, Germany after WW II. Arguably, the most famous of these trials was the first one (1946-47). It was labeled the “Doctors’ Trial.” It may be this trial to which you refer. Three of the 23 defendants were not physicians and, I believe, 12 were not members of the SS. One defendant was Hitler’s personal physician and a SS member; he was executed. I recall reading that SS members were more likely to be sentenced to death than those who did not belong to the SS.
** The most thorough publication about the Tuskegee syphilis experiment is James Jones’ Bad Blood. In the book, he details, inter alia, the activities of and justifications used by Nurse Eunice Rivers (an African American resident of Macon County, Alabama employed as a liaison between black subjects and government doctors) and by the physicians involved in the study. An excellent documentary about the experiment can be found at the following link: https://www.youtube.com/watch?v=vmVTmhYa52A Of note is an interview with one of the experiment’s physicians John Cutler who, about 42 minutes into the documentary, gives his justification for not securing informed consent from subjects. An excellent film called Miss Evers’ Boys is about Nurse River’s role in the Tuskegee experiment. One of the noteworthy aspects of the film is how the River’s character tended to neutralize the effects of conscience and external controls before becoming involved with different aspects of the study. You can watch the film at the following site: https://www.youtube.com/watch?v=vmVTmhYa52A
Ray
Banterings,
Thanks for informing us about the Handbook publication. I looked through it – especially liked the “Nine Principles of Sensitive Practice.” It seems to me that all but one or two of these principles could be employed in a healthcare provider’s approach to almost all adult patients, not just those who were child victims of sexual abuse. The authors also try to dispel fictions that seem to be embraced by many if not most Americans such as the belief that only males are child abuse culprits.
However, there is a least one statement made by the authors that has an alternative interpretation than the one proposed by them; viz., “Men in our study spoke about their need to appear ‘tough’ and ‘in control’ despite feeling anxious and fearful during encounters with health care practitioners: ‘Men are tough. Men are macho. Men don’t need [help]. All we have to do is to get over it! Get over it be a man! You know, men don’t cry’. (Man survivor)” There is an alternative interpretation of this man’s words, an interpretation that is consistent with the findings of a study I and students conducted in the past and about which I reported in this blog. I submit that the “Man survivor” may have been communicating his belief about what others, including and maybe especially healthcare providers, expected of him – to be tough and in control. If so, it may be that the man was not expressing a “need to appear ‘tough’ and ‘in control’” but rather a need for an empathetic ear.
Ray
Maurice,
Sorry I have not responded to your question yet. I’ll get there in time.
Banterings,
When I clicked onto the “rectal exam” site, I got something having to do with “educate yourself”; nothing about rectal exams.
Thanks, PT. That’s the guy, alright. What a terrible experience he had.
Ray
This will be in multiple parts:
Ray,
Sorry, I did not put in the correct link. Here it is:
Rectal exam mistaken for sodomy, a patients personal experience!
[ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2141611/ ]
Maurice,
Thank you for the compliment.
One of the things that I do professionally is forensics. I have a few accomplishments professionally that start out, "I am the only one in the United States who..." Due to the delicate nature and for the confidentiality of my clients, I cannot share exactly what they are. But to me, reaching these accomplishments are simply benchmarks for me. Just as I suggest that the healthcare system continually ask can I do better, I ask that of myself. These don't tell me that I am doing the best that I can, they simply tell me that I am improving.
The forensics that I do do not only involve the physiological and mechanical, but the psychological. And not just the psychological of the person, but the psychological of the group (many individuals) and the organization (many acting as an individual). If anyone watches the show NCIS, one "Easter egg" is that Dr. Mallard (Ducky) the coroner is not just a physiological pathologist (coroner), but also a psychological pathologist.
Approaching forensics to include gives insight to perplexities that appear to have no rhyme or reason. A good illustration of this is in Arthur C. Clarke's 2010: Odyssey Two we find the answer to why the HAL 9000 computer killed the crew in 2001: A Space Odyssey. The answer is rooted in organizational psychology.
Enough of my Hollywood examples, back to Maurice in Los Angeles...
Forensically I find it very telling when Maurice stated: The years of my expression "moaning and groaning" on this blog thread, as I have previously written, does nothing to devise ways to understand the current thinking and response of the medical system and does nothing to devise ways to make changes.
Maurice, I am not berating you, please do not take this as a personal attack. This may explain the frustration that some contributors may have expressed towards you. Please feel free to offer any insight or rebuttal, especially if I my view is deficient in any way.
This is very telling because not only is Maurice a member of the system by being a physician, but he perpetuates the system by being a medical school professor. I know that Maurice would reaffirm that he trains his students to the standards of care of the profession. I would even argue that Maurice trains beyond those standards by his commitment to this blog and the insights that he has gained.
I argue that those standards are not good, but just good enough. The Public Health Agency of Canada's Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse are by far superior to the standard of care we have today. If these are the standard of care for the most vulnerable of patients, then why are they NOT the standard of care for all patients?
--Banterings
Continued....
Part 2
This leads us to have to look at the healthcare system from a forensic psychosocial and a organizational psychological perspective. At what point do these (PHAC's standards) become the universally accepted standard of care (the hundredth monkey effect)?
To a certain extent it is group dynamics where individuals with similar characteristics band together to strengthen and protect the group. The group develops an "us-and-them" mindset to protect the group from outsiders. This is hardwired into our brains after millions of years of evolution stemming from when the first humans huddled together in a cave. A very good illustration of this is The Third Wave (a social experiment undertaken by history teacher Ron Jones with sophomore high school students Cubberley High School in Palo Alto, California, during the first week of April 1967).
View the documentary on YouTube here:
I believe that the answer can be gleamed if we can simply answer one of the largest ethical dilemmas faced recently by healthcare: the justification of pelvic exams on anesthetized female patients.
Dr. Peter Ubel writes, "I felt a woman’s uterus without her permission." We all know that the research he did in to the subject changed laws. What about all the other physicians who graduated medical school more than 20 years ago?
What is more disturbing is that beyond losing their license or criminal charges, no physician that I know of (other than Ubel... maybe), that has stood up, admitted what they did, and apologized. Whether it be eugenics, the Holocaust, Tuskegee, or the CIA use of physicians for torture after 9/11. So what do they really believe? Physicians are entitled to a patient's body but don't get caught? I know (what I think to be) many good, ethical physicians who are truly empathetic to patients.
This begs a serious question about the ability of healthcare providers ethical decision making, just by the nature that there has be no apologies. It seems that the outliers in respect to the pelvic exams are Dr. Peter Ubel, Dr. Michael Greger, and Hilary Gerber are the outliers.
The 1847, the inaugural Code of Ethics of the American Medical Association (AMA) stated, “The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness, to influence his attention to them.
--Banterings
Thank you Maurice and everyone else for answering me. I should have specified that I have original MediCare and can go to any doctor without a referral..so I'm seeing surgeons on my own as my case is unusual. My GP is not involved. I'm assuming the med school forms I signed lets them have a resident see me? It makes me mad that the residents introduce themselves ambiguously on purpose and NEVER ask permission to see you. We all know this is because if they ask there is a chance the patient will object. I guess I will have to just continue to use my "undressing is painful,"line; this always keeps me out of a hospital gown and in my own clothes. there's no way the surgeon will operate on me if I refuse to see their residents, because I will have set up a hostile enviroment. The thing for me is that I like to be asked, because then I'm in control. But this is impossible to get across from the patient. It would have to come from someone else with authority, someone who is one of them, a doctor.
The larger discussion I want to bring up is that trying to dialog and educate medical professionals about modesty and privacy is easier said than done. I am having sinus surgery on Monday at a day surgery center and we all know I will be given the standard form to sign where I agree not to sue, that they can do anything that they deem medically necassaarry, etc...if I attempt to write anything additional, I bet they won't do the surgery. I am in agony from my sinuses and need the surgery, so I'll have to sign. This is the real problem...we really have NO rights as patients. I say again that these are private doctors and they are not required by law to see any patient they don't want to. Especially in my case as I am NOT in a managed care program. (I had to do this so I could visit various surgeons.) I will likely be asked to remove all my clothing. I am going to try to keep my street pants on, but I'm thinking they'll refuse that. When I have tried to object to anything on forms, or add anything, I have been told that their lawyers will not allow them to operate on anyone who has not signed the forms. I have been told this at multiple facilities.
Also as I said before, once you start bringing up modesty issues (something most health care folks have NEVER heard of) they literally think you're nuts. The atmosphere then becomes hostile. And who wants people who now hate you operating on you?
I wish Maurice would write an article and publish it on PubMed, then I could print it out and show it to the doctors. What do you think. Thanks, Anne
I read through most of the handbook that Banterings posted the link to, and I agree with him that the feelings described would be much the same for those who had been abused by the medical system, whether that abuse be physical or emotional.
It is also my belief that the action points outlined in the handbook should be the way that providers interface with every patient, not just abuse survivors. It's about respect.
Based on my own experiences, that of family, friends and many others I have discussed this with, it is clear to me that medical providers do not automatically deserve to be trusted - they first have earn it by both their words and actions.
Unfortunately, though I believe most providers have good intentions, their hands are tied by the bean counter management types who mostly couldn't care less about the patients and are only concerned with maximizing billing & revenue. If any progress is to be made, this must change.
Hex
Anne,
As the founder of Medical Patient Modesty , I am very concerned about you. Do not give in. Fight for your rights as a patient no matter how hard it is.
I am very concerned about your comments below:
I am having sinus surgery on Monday at a day surgery center and we all know I will be given the standard form to sign where I agree not to sue, that they can do anything that they deem medically necassaarry, etc...if I attempt to write anything additional, I bet they won't do the surgery. I am in agony from my sinuses and need the surgery, so I'll have to sign. This is the real problem...we really have NO rights as patients. I say again that these are private doctors and they are not required by law to see any patient they don't want to. Especially in my case as I am NOT in a managed care program. (I had to do this so I could visit various surgeons.) I will likely be asked to remove all my clothing. I am going to try to keep my street pants on, but I'm thinking they'll refuse that. When I have tried to object to anything on forms, or add anything, I have been told that their lawyers will not allow them to operate on anyone who has not signed the forms. I have been told this at multiple facilities
You need to fight for your rights as a patient. They have obviously intimidated you badly. If they cannot honor your requests at that medical facility, you need to find another one that will honor your wishes even if it means you will have to drive farther. Don’t fall to the lie that you have no rights as a patient. You should be able to wear 100% cotton clothing with no metals in them. You should show all of the medical professionals this article especially 3.1.1 Patient personal clothing.
You should see if they can give you local or regional anesthesia rather than putting you under anesthesia. Make sure you do not consent to Versed. Also, put on your form that you do not consent to urinary catheter. An urinary catheter is not necessary for sinus surgery at all. You may want to print out the article, Informed Patient Consent Is Missing From Urinary Catheters I wrote about urinary catheters from Dr. Joel Sherman’s blog.
Misty
Anne,
If the day surgery center and/or a hospital to which is connected is accredited by the Joint Commission for the Accreditation of Hospitals, then it is required to recognize certain patient rights or risk compromising its accreditation. Among these rights are two that may apply to you. They include the following:
1) “To have your cultural, psychosocial, spiritual and personal values, beliefs and preferences respected. You have the right to wear appropriate personal clothing and religious or other symbolic items, as long as they do not interfere with diagnostic procedures or treatment. You have the right to pastoral and other spiritual services.”
2) “To personal privacy, to receive care in a safe setting, and to be free from all forms of abuse or harassment. You have the right to refuse to talk with or see anyone not officially connected with the health care facility, including visitors, or people officially connected with the health care facility but not directly involved in your care. You have the right to expect that any discussion or consultation involving your care will be conducted discreetly and that individuals not directly involved in your care will not be present without your permission. You have the right to be interviewed and examined in surroundings designed to assure reasonable visual and auditory privacy. This includes having the right to have a person of one’s own sex present during certain parts of a physical examination, treatment or procedure performed by a health professional of the opposite sex and the right not to remain disrobed any longer than is required for accomplishing the medical purpose for which disrobing is needed.”
If any part of either of these standards apply to you and providers refuse to respect these rights in your case, I recommend that you diplomatically inform their ignorance. If they continue in their obdurateness, then you can seek healthcare elsewhere or submit to their requirements. Either way, I’d recommend filing a complaint with JCAHO.
Here’s JCAHO’s list of rights: http://www.palmettohealth.org/body.cfm?id=17
Ray
Ray,
Thank you so much for the valuable information about patients' rights! It is so sad about how many patients think that they do not have rights.
Misty
Ray,
Sorry, I did not put in the correct link. Here it is:
Rectal exam mistaken for sodomy, a patients personal experience!
[ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2141611/ ]
Anne,
Ask for a trauma-informed healthcare approach .
I argue that the standards of our healthcare system are not good, but just good enough. The Public Health Agency of Canada's Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse are by far superior to the standard of care we have today. If these are the standard of care for the most vulnerable of patients, then why are they NOT the standard of care for all patients?
This leads us to have to look at the healthcare system from a forensic psychosocial and a organizational psychological perspective. At what point do these (PHAC's standards) become the universally accepted standard of care (the hundredth monkey effect)?
To a certain extent it is group dynamics where individuals with similar characteristics band together to strengthen and protect the group. The group develops an "us-and-them" mindset to protect the group from outsiders. This is hardwired into our brains after millions of years of evolution stemming from when the first humans huddled together in a cave. A very good illustration of this is The Third Wave (a social experiment undertaken by history teacher Ron Jones with sophomore high school students Cubberley High School in Palo Alto, California, during the first week of April 1967).
View the documentary on YouTube here:
I believe that the answer can be gleamed if we can simply answer one of the largest ethical dilemmas faced recently by healthcare: the justification of pelvic exams on anesthetized female patients.
Dr. Peter Ubel writes, "I felt a woman’s uterus without her permission." We all know that the research he did in to the subject changed laws. What about all the other physicians who graduated medical school more than 20 years ago?
What is more disturbing is that beyond losing their license or criminal charges, no physician that I know of (other than Ubel... maybe), that has stood up, admitted what they did, and apologized. Whether it be eugenics, the Holocaust, Tuskegee, or the CIA use of physicians for torture after 9/11. So what do they really believe? Physicians are entitled to a patient's body but don't get caught? I know (what I think to be) many good, ethical physicians who are truly empathetic to patients.
This begs a serious question about the ability of healthcare providers ethical decision making, just by the nature that there has be no apologies. It seems that the outliers in respect to the pelvic exams are Dr. Peter Ubel, Dr. Michael Greger, and Hilary Gerber are the outliers.
The 1847, the inaugural Code of Ethics of the American Medical Association (AMA) stated, “The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness, to influence his attention to them.
--Banterings
A number of people (including me) who come to this blog are concerned about how there are not enough male nurses available for male patients. I wanted to share a female nurse’s concerns she shared with the How Husbands Feel About Male Gynecologists Group:
While I realize this is a "how husbands feel" venue, I am a woman who feels that no other woman should be viewing/manipulating my husband's genitals (so I completely appreciate how "husbands feel").
And it's been a while since I've posted here (I had posted last about my husband's potential shoulder surgery; which is still up in the air at this point) but what I'm posting about now is an unfortunate situation I just encountered in my school district. As some of you may or may not know, I am a school nurse with 18 years of experience. In our school district, the nurses give a scholarship(s) to a deserving senior who is going to pursue a career in the nursing field. This year we had several potential candidates, only one of which was a male; and while I lead the cheer for more men in nursing and he was just as deserving as his female counterparts, I was apparently overruled as, once again, the scholarships went to two females.
So what I'm asking is, if your local school district has scholarships available for potential nursing students, please advocate for any deserving male that may be looking for a future career in nursing. We need more men as to help "even the playing field" for those men who are sick of having to accept being exposed and embarrassed by female nursing care only because "we don't have a male nurse(s) available.Men are deserving of same gender care as much as women are, but men are at a significant disadvantage in that regard in all aspects of health care.
I agree with the nurse’s comments. I am sure PT will be encouraged that a female nurse is so concerned about male patient modesty. I feel that one of the things we can do to increase male nurses is to encourage scholarships specifically for men who are interested in nursing. PT: I am not sure where you live. But maybe you can look into encouraging scholarships specifically for male high school students who are interested in nursing. You should raise awareness about how important it is for us to increase the number of male nurses for male patients.
Misty
This morning I had one of those I do this in 2 parts...
Eureka moments.
I have realized what the core of the patient modesty problem is. The problem is not patient modesty, it is the term that I prefer; patient dignity.
The problem is that physicians (and all providers) presuppose health is his preeminent value of the patient. Modesty, humiliation, emotional and psychological trauma, AND the patient's own preferences are NOT even considered. This concept has been proven wrong time and time again. The National Institutes of Health Paper: "Tomophobia, the phobic fear caused by an invasive medical procedure - an emerging anxiety disorder: a case report" illustrates this fact.
Patients want to focus on "quality of life" issues too, many times they are the more important than extending/preserving life issues. At the very least, healthcare needs to weigh quality of life with equal importance extending/preserving life. Let me illustrate:
What good does it do to save a person's life who was in a bad MVA, and in the course of that intervention the patient's requests for modesty were ignored in lieu of extending/preserving life, only to have the person avoid the healthcare system and die an agonizing death when they develop cancer later in life?
You cannot put this on the person and say that they chose to die in such a manner. There are numerous studies on how traumatic events have affected people's lives. I did some volunteer work with Amnesty International in the early 1990's. They had a play to raise awareness about torture in Africa, that was based on a true story. A teacher seeking asylum came to the Untied States. One of the people helping him visited his apartment only to find the refrigerator and cabinets filled with every type of drink imaginable.
At first it was thought it to be the excess of America, we later learn that he was imprisoned without food or water. To survive, he drank his own urine. That "trauma" haunted him and affected his choices. There are other people who faced similar situations that would only eat half their meal. When questioned by the people helping them they would say that in prison they were not fed regularly, sometimes for days, so when they got food, they always saved some. That behavior was hard to change despite being in a safe place.
Continued
The Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse (Public Health Agency of Canada) and the concept of trauma-informed healthcare approach does acknowledge that healthcare can re-traumatize people.
The largest failure of healthcare is the recognition that healthcare can be the PRIMARY source of emotional and psychological trauma. The following show this to be true: Tomophobia, the phobic fear caused by an invasive medical procedure - an emerging anxiety disorder: a case report Post-Traumatic Stress Disorder After Genital Medical Procedures.
You cannot say healthcare is unaware of the issue of "quality of life". The Wall Street Journal article, "Why Doctors Die Differently" shown that there is a cognition. That leads to the next biggest problem: healthcare as two-tiered system. Patients being told (especially by female providers) gender does't matter, they are professionals, yet they have their own gender preferences of providers in healthcare. (Example: Does it Matter Whether Your Gynecologist Is Male or Female?)
So I ask, if a provider tells a patient that "gender does't matter," yet express their own gender preferences in providers, do they really believe "gender does't matter?"
I charge that they are behaving like Bolsheviks! This all stems from paternalism.
--Banterings
Banterings,
On 12/30 you wrote the following: “There are two famous experiments that can explain the transformation that takes place among medical providers as they go through their training. They are the ‘Stanford Prison Experiment’ and the ‘Milgram Experiments.’ These experiments only prove the axiom ‘Power tends to corrupt, and absolute power corrupts absolutely. Great men are almost always bad men.”
You are correct; the Stanford prison experiment and Milgram experiments can explain (at least in part) the transformation that occurs to some medical students and healthcare practitioners. Also, as I’ve written in the past, these experiments can explain a lot of other things ranging from fraternity hazing to participation in the abuse and "enhanced interrogations" at Abu Ghraib to genocidal activities. However, it would not follow from these experiments that “great men are almost always bad men.” First, neither Zimbardo, who was the author of the prison experiment, nor Stanley Milgram used “great men” as subjects; indeed, their subjects were pretty common, run-of-the-mill type of guys. Milgram’s subjects were overwhelmingly, but not exclusively, middle-aged, white, and middle-income males from New Haven, CT. Zimbardo’s subjects were young, white, and mostly middle-class male students from Stanford. To suggest that the findings from the two experiments constitute “proof” that “great men are almost always bad men” is an overgeneralization. On the other hand, were “great men” used as subjects in an experiment similar to Milgram’s or Zimbardo’s, it would not be unreasonable to hypothesize that the results found and conclusions made by Zimbardo and Milgram would be the same or similar to the results of the experiments they conducted using common, run-of-the-mill guys as subjects.
Second, if we infer from Milgram’s experiment and Zimbardo’s experiment, I don’t think we would hypothesize that “great men are almost always bad men” – close, but not exactly. Instead, we would hypothesize that great men tend to be good men gone bad because of the bad situations in which they inevitably find themselves.* Zimbardo used to call this phenomenon the “power of the situation” and now calls it the “Lucifer Effect.”
* Footnote - Zimbardo, I, and other people with whom I am familiar (especially critical social scientists) dichotomize people into good or evil (bad) with full knowledge that this is a false dichotomy. Unlike some people with true Manichean world views, we recognize that what is goodness and badness varies from one culture to another and from one time period to another. We also recognize that goodness and badness are matters of degree and their causes matters of probability. The dichotomy is called on for the purpose of theoretical simplification and, in the classroom, for pedagogical purposes.
CONTINUED
Ray
CONTINUATION
POWER OF THE SITUATION: MILGRAM’S EXPERIMENTS
Let’s start with Milgram. Milgram wanted to understand the Holocaust or, more specifically, why so many people’s consciences were neutralized resulting in their following orders of political and military authorities to engage in genocidal activities. To do this, he conducted a number of experimental studies to determine the effects of authority on obedience. He varied the situations (or conditions) in which the commands of an authority took place. The most frequent experimental situation depicted on film involved a confederate “learner” in a contiguous room occupied by a “teacher” subject. In this situation almost two-thirds of the 40 subjects followed the command of an authority figure until the later terminated the interaction between confederate and subject. A video of this experimental condition can be found at the following link: http://www.dailymotion.com/video/x24guhr_the-milgram-experiment_shortfilms. A 5-minute version of this experiment can be found here: https://www.youtube.com/watch?v=xOYLCy5PVgM
The experimental situation in which subjects were least likely to follow orders was when the “teacher” subject sat next to the confederate “learner” and had to lift the hand of the latter and put it on an electrode when he gave a wrong answer. In this situation, only three of the 40 subjects followed the orders of an authority all the way to the end. The experimental situation in which subjects were most likely to follow orders was when the “teacher” subject played a subsidiary role in carrying out orders (e.g., getting orders from another and passing it on). In this situation, only three of the 40 subjects did not follow the orders of an authority all the way to the end. The effect of authority on obedience was tested in a number of other situations which are identified toward the end of the longer video.
POWER OF THE SITUAION: ZIMBARDO’S PRISON EXPERIMENT
Now, let’s move on to a discussion of Zimbardo and his prison experiment. A video in which Zimbardo speaks about the “power of the situation” and summarizes his study can be found at the following site: https://www.youtube.com/watch?v=y9vJ1vdYdSM
Zimbardo was interested in understanding prison violence as a result of an increase in the ‘60s and early ‘70s of prison riots. At the time, as is true today, most people, including many scholars, attributed violent behavior to the personal characteristics (e.g., personality) of offenders. However, Zimbardo’s knowledge of Kurt Lewin’s research on the effects of leadership styles on the behaviors of school children (https://www.youtube.com/watch?v=J7FYGn2NS8M), Solomon Asch’s experiments on group conformity (https://www.youtube.com/watch?v=NyDDyT1lDhA), and (especially) Stanley Milgram’s experiments on obedience to authority fostered in him a belief that human behavior, including violent behavior, was more than simply a consequence of personal dispositions; it was also, he theorized, a result of social situations independent of personal attributes. It’s not that Zimbardo dismissed the importance of biological and psychological sources of violence. Indeed, he recognized their importance in determining human behavior in general and violent behavior in particular, especially given the research conducted by Theodor Adorno and his colleagues on the authoritarian personality (http://en.wikipedia.org/wiki/The_Authoritarian_Personality). But the evidence from other research conducted in the late ‘40s through the ‘60s suggested that to limit explanations of violence to human character frailties was myopic. CONTINUED
Ray
CONTINUATION
Inspired by the works of Lewin, Asch, Milgram, among others, Zimbardo became determined to conduct a prison experiment using as subjects a homogeneous group of “mature, emotionally stable, normal, intelligent college students . . . without criminal records . . . from middle-class homes throughout the United States and Canada.” He wanted only this type of young man for the experiment in order to help rule out the effects of personal character defects as determinants of whatever he saw materialize during the process of the experiment. To this end he put more than 70 volunteers for the experiment through a rigorous screening process “and ended up with about two dozen young men [actually 21 young men] who were selected to be part of this study. . . [Ten] of the chosen participants were arbitrarily [randomly] designated as prisoners by a flip of a coin, [eleven] as guards.”
The importance of randomly assigning subjects to different experimental treatment conditions cannot be understated. Indeed, the pivotal work by Donald Campbell and Julian Stanley on Experimental and Quasi-Experimental Design leaves one with the impression that a “true experiment” requires the use of random assignment in order to rule out individual differences as confounding factors in determining results. That is, random assignment of subjects to different experimental groups (e.g., guard and inmate) equalizes, probabilistically speaking, these groups. That means, probabilistically speaking, if there is a measurable difference between or among the experimental groups on the dependent variable(s) (e.g., behavior of guards and prisoners), then that difference must be due to the experimental stimulus or stimuli (e.g., being a guard or being an inmate) rather than another difference between the two groups. If, for example, a larger percent of Zimbardo’s guards than prisoners had parents who worked in law enforcement, it could have been this variable rather than being a guard or prisoner that determined the experimental outcome. Theoretically, random assignment minimizes (or, in the best scenario, eliminates) this possibility. Random assignment, then, provided Zimbardo with a statistical assurance that had the guards in the study been assigned to be inmates and had the inmates been assigned to be guards, the results of the experiment would have been pretty much the same. This is a fact based on a law of probability called the central limit theorem, a law which has a mathematical proof.
Zimbardo “called off the experiment not because of the horror I saw out there in the prison yard, but because of the horror of realizing that I could have easily traded places with the most brutal guard or become the weakest prisoner full of hatred at being so powerless that I could not eat, sleep or go to the toilet without permission of authorities. I could have become Calley at My Lai.” His conclusion was as follows: “Individual behavior is largely under the control of social forces and environmental contingencies rather than personality traits, character, will power or other empirically unvalidated constructs. . . We thus underestimate the power and pervasiveness of situational controls over behavior because: a) they are often non-obvious and subtle, b) we can often avoid entering situations where we might be so controlled, c) we label as ‘weak’ or ‘deviant’ people in those situations who do behave differently from how we believe we would. . . There is a growing body of social psychological research which underscores the conclusion derived from this prison study. Many people, perhaps the majority, can be made to do almost anything when put into psychologically compelling situations – regardless of their morals, ethics, values, attitudes, beliefs or personal convictions.”
CONTINUED
Ray
CONTINUATION
If Zimbardo is correct, good people don’t stand much of a chance when put into a milieu in which the unnecessary dehumanization of patients is normative and tolerated, if not directly reinforced; they are likely to soon submit to cultural (or, more specifically, normative) expectations and contribute by their actions or silence to that dehumanization. If this is so, it seems to me that what really needs to be explained is not why people in some situations participate in the dehumanization of patients but, rather, why more people don’t. Why do some people in dehumanizing milieus refuse to participate or even blow the whistle on offenders?
What is often left unsaid is that Milgram and Zimbardo not only uncovered the Mr. Hydes in the Dr. Jekylls but he also discovered that for any number of reasons, many people will unwillingly engage in stressful, self-defeating, dangerous, humiliating, and self-destructive actions even when opportunities are open to them not to do so. None of Milgram’s subjects, for example, broke off from the experiment no matter how uncomfortable they were with what they were doing until well into the time allotted for “teaching” the confederate, although there was nothing to prevent them from doing so. Similarly, none of Zimbardo’s subjects, whether guard or prisoner, decided to leave in order to avoid the stressful or humiliating conditions that were their fare. Regarding the inmates, Zimbardo wrote: Some inmates “begged to be paroled, and all but three were willing to forfeit all the money they had earned if they could be paroled. By then (the fifth day) they had been so programmed to think of themselves as prisoners that their request for parole was denied, they returned docilely to their cells.”
Knowledge of Zimbardo’s and Milgram’s findings and conclusions not only allows us to understand why Donna Summers, the manager of a McDonald’s restaurant, illegally strip searched 18-year Louise Ogborn at the behest of a con artist posing on the phone as a security worker at McDonald’s main office, it also allows us to understand why this young lady complied with the demands of her boss to strip rather than turn around, walk out the front door, and file a complaint against Summers. Had she done so, it probably would have saved her from the fear that compelled her to perform oral sex on Walter Nix, Summers’ fiancé, upon his command. Similar events occurred at several McDonalds, Winn Dixies, Taco Bells, and Applebees. The following link gives you some specifics: http://en.wikipedia.org/wiki/Strip_search_phone_call_scam Here is a video that portrays a small fraction of Ogborn’s ordeal https://dragontail.wordpress.com/2007/10/08/donna-jean-summers-rewarded-criminal-at-large/.
Hopefully, Maurice, you can use what I’ve written as a segue to the formulation of an answer to your 12/30 question, “’Speaking up’ or ‘Speaking to’ the elements of the system by the patients and their families would be of no overall benefit for change?”
Ray
Hello All!
I stumbled upon this discussion a few days back from a link on Sherman's blog.
I have read 69 and 70; I hope to find the time and patience to slog through 1-68 :).
Bantering ... describing the power dynamics of our beloved Healthcare institutions via the words of Stalin ... BEAUTIFULLY CYNICAL and frighteningly accurate in some respects!
I would like to participate in this discussion.
Before I attempt to weigh in with some of my owns thoughts on any of the subjects, I would like to introduce myself by sharing my first experience with the issue of medical modesty. It was simultaneously my first experience with the dehumanizing institutialized stupidity I have grown to loathe.
Please know that I do NOT regard this as a traumatic experience. Feel free to laugh! I hope that you will enjoy the story and get to know me a little in the process. I also hope to illustrate through my own experience, the real substance of why this discussion (broadly about medical modesty) is so important. Irrespective of what I think about any issue in abstract terms, when I seek medical care, I want to feel safe and respected.
Please read my story in the next post.
My First Surgery - part 1
When I was in the 6th grade (almost 12 years old), I was scheduled for an outpatient surgery at the local hospital. I believe the surgery was to remove a couple of impacted wisdom teeth; it was certainly dental.
I should have been afraid; I was not afraid. Actually, I was curious and even a little excited as this would be a new experience. Furthermore, the only people I had ever heard of having surgery were adults. Not only would this be new experience, it would be an adult experience. That is all I understood. I had NO clue what surgery would actually involve. I am sure my parents explained at least some of it to me, but it did not sink in. You can take a horse to water ...
My First Surgery - PART 2
My mother awakened me at some ungodly hour long before sunrise, as we had to be at the hospital at a slightly less ungodly hour. I showered and dressed in nice clothing, a little nicer than I would typically wear to school. Instead of sneakers, I wore my boots; I didn't want to look like a kid.
I remember walking with my parents down a long corridor toward the surgery area. I enjoyed the thud sounds my boots made with each step. I liked the slight echo of each thud even more. I distinctly remember feeling strangley brave and confident. It felt good, really good!
After we checked in, I was sent to a small room to remove my clothing and put on a gown. I was utterly confused; I had not expected to remove my clothes. I really did not understand what they wanted me to do, so my mom came with me. Dad waited in the reception area. I had no idea what to do with the gown; I had never seen anything like it. I did not want to take my clothes off. I started to feel a little frightend. Mom reassured me that everything was good. She helped me undress and put the gown on. She tied the strings in the back for me.
I felt utterly ridiculous in that thing. I don't think it weighed as much as my socks. It was cold in that hospital; I felt cold, very cold. The confidence I had so much enjoyed just minutes earlier had vanished. I wanted to put my clothes back on and go home.
An old nurse came in to get me. I disliked her immediately. She was mean. She and mom exchanged some words. She told me that I would not be allowed to wear underwear in the OR. I refused to remove them. More words were exchanged. Mom told me to take them off. (I must obey my mom!) Reluctantly, I removed my underwear and handed them to my mother. With only the gown, I felt naked. I was embarrassed and humiliated. I would like to believe that I didn't cry. I don't actually remember crying, but I strongly suspect I did. Suddenly, the mean nurse started speaking to me kindly. She promised me that she would put my underwear back on me before I awakened from the surgery. I emphatically told her not to do that. She did not acknowledge my words. I was horrified. She intended to manipulate my naked body while I was unconscious. I wanted to keep my underwear on for modesty; I did not want strangers to see my privates. The gown barley afforded me any cover. To make me feel better, this dumb nurse promises me that at least one stranger will see me naked and helpless. I was becoming even more upset.
My next memory is being wheeled to the OR on a gurney. I had been covered with a blanket; I felt a little warmer. All I could think about was that nurse manipulating my naked unconscious body. I could see it happening in my mind's eye. If she decided to put my underwear back on me, I was powerless to stop the intrusion. I felt terribly vulnerable, terribly helpless. I was scared!
We arrived at the OR. There were several people in there. The noise and activity distracted me from my fear a little. I was lifted from the gurney and placed on another surface. I don't know if was a bed or table or what. Someone put a plastic mask over my nose and mouth. It smelled strangely sweet. A man's voice told me to relax and breath normally. He spoke to me reassuringly as someone else covered me with blankets. He asked me to count back from ten. I think I made it to 7.
Unfortunately, I don't remember if I awakened in my underwear or not. I guess it's not important. I don't even remember getting dressed or leaving the hospital. I do remember my father expressing surprise at being finished so early as we were driving home. By this time the morning was already ancient history.
I couldn't eat that night because of the stitches in my mouth. Mom or Dad made a milkshake for me. As a child, I loved milkshakes. A milkshake for dinner ... pretty good day!
My current primary care physician is wonderful but he is getting to the age where his retirement is likely to take place in the near future. Therefore, I have begun looking on-line for a new PCP so I’ll be prepared when my current physician is no longer in practice.
One piece of information that I have learned is that a great many of the group practices in the area have become what they refer to as Patient-Centered Medical Homes. This means healthcare will be provided by your physician, AND a care team of nurse practitioners, nurses, medical assistants, specialists and other caregivers — who will work with you to meet all of your health care needs.
Of course the websites present this team concept as a great benefit to the patient but I have some concerns.
• Although, I would be free to choose a male physician, in most cases it is a near certainty that all or most of the other team members will be female.
• Would I pressured to see other members of the team for routine visits such as physical exams so that the physician can focus on patients with more serious health problems.
• Would any personal information I share with the physician routinely be passed on to the rest of the health care team.
If anyone has experience as a patient with this team approach, I would be quite interested in seeing your opinion regarding the concerns I have listed above.
Thank you,
MG
Charles.OX and MG,
Welcome. Nice to see new people joining. I invite both of you to view my blog (Banterings of a Madman) too. I caution you, I am more gentlemanly here. [LOL]
MG,
As far as team care, pretty much most physicians have other people who handle "lesser" procedures (weight, blood draws/injections, etc.). You simply state that for things such as genital/rectal, reproductive issues, etc. you are exercising your right to same gender care. A better approach might be to work with your current physician. The best source to find another provider is a provider that you trust. My wife is a MA for a specialist. I had a good physician who was promoted to an admin position. The doctor who took over his practice was horrible. She affirmed all my complaints I had of him because her patients who had him as the primary had the same complaints: not listening, switching around medications that are effective, expensive/multiple/redundant tests....
Ray,
You wrote:
Regarding the inmates, Zimbardo wrote: Some inmates “begged to be paroled, and all but three were willing to forfeit all the money they had earned if they could be paroled. By then (the fifth day) they had been so programmed to think of themselves as prisoners that their request for parole was denied, they returned docilely to their cells.”
This also explains why patients do not fight for their dignity. They have accepted the role of patient, sick, subordinated, naked... Providers take the silence as consent.
As to the middle class white males: I believe that they are an excellent pool because traditionally who entered medical school. The only glitch I can see is that historically, a unusually higher percentage sociopaths, serial killers, etc. tended to be of this demographic. Today they are finding many more sociopaths, serial killers, etc. to be female and minority; thus more reflective of society and healthcare demographics.
I think that you can relate both infractions to modesty and patient abuse to child abuse. If you look in news reports you never saw child abuse 50 years ago like you do today. There are only 2 possible answers; it didn't happen or it wasn't reported. I think that it was the latter. The abusers used their power and dominance over the victim to normalize or hide the abuse (such as abuse by clergy). I see three factors that both have accounted for more reporting of abuse and the higher number of female and minority sociopaths:
1. ) Civil Rights
2. ) Proliferation of the media
3. ) The Internet (real time information)
Civil Rights not only taught people to stand up for what is right, but advanced human dignity where everyone demanded it. It also allowed women and minorities to gain the same status as white males historically had. I am not necessarily saying that the power makes a sociopath, it may just give female and minority sociopaths opportunities they were previously not afforded.
The media has brought the abuses to light. We see those in power; politicians, clergy, physicians, etc., are all human and fallible. We hear about news stories that happen in remote, rural places and get a true sense of how prolific the abuses are. The Internet (real time information) has also shown us how fallible those in power are, with access to information, we see that they don't know as much as we (or they) thought. This has also eroded their power. Victims are no longer quiet and can gain global support to come forward.
The societal changes explain why more don't abuse. What was acceptable 20 years ago (pelvic exams on anesthetized women without explicit consent) is criminal today. Just as deviance needs the deviant, the norm that is infracted, and someone to label the deviance, I put forth that norms have changed thus reducing the number committing the acts.
--Banterings
Banterings,
I’m sorry I did not promptly respond to your 12/31 prompt, “Perhaps you Ray, can express this idea of mine in a clearer, more concise manner.” Lately, I’ve been running around like a head with its chicken cut off. That said, I think you did a commendable job without my interference. Maybe I can add to what you wrote.
OUT-GROUP SOCIOPATHY
You wrote, “There is . . . a problem with many providers, some to the point of almost a sociopathy.” Well, that might be considered hyperbole. On the other hand, at the risk of appearing ad hominem, I think just about all of us are out-group sociopaths – even President George H. W. Bush. He shed tears for the families of U.S. soldiers who died during the invasion of Panama. However, following the publication of pictures of crying Panamanian mothers kneeling beside their children killed by U.S. bombs, he said, “It was worth it” and excused the killings as “collateral damage.” He proved to be an excellent role model for Timothy McVeigh who used Bush’s dismissive response to justify the deaths of children in the government building he bombed If there is such a phenomenon as out-group sociopathy, then it is not unreasonable to hypothesize that the greater a healthcare provider’s view of patients as members of an out-group, the more likely s/he is to lack empathy for them and to dehumanize them.
DAVID MATZA: NEUTRALIZATION THEORY
You follow up with, “How can any rational human being NOT know that this [students conducting nonvoluntary pelvic exams on anesthetized women] is wrong.” In fact, the physicians to whom you are referring may believe it is wrong. David Matza’s neutralization theory explains why they may think it is wrong but do it anyway. It’s because they neutralize internal controls (e.g., conscience) and external controls (e.g., threat of formal sanctions – e.g., law suit – and informal sanctions – e.g., criticism from colleagues). Using Matza’s theory, we would hypothesize that physicians who sanction nonvoluntary pelvic exams by students are at least somewhat committed to the prevailing social norms. This hypothesis would be confirmed were the physicians in question to answer “nay” to the questions: “Would you want to be treated in this manner?” And, “Would you want a loved one treated in this manner?” CONTINUED
Ray
CONTINUATION
Although when compelled to be candid the physicians in question may recognize the legitimacy of the prevailing norms, they may, at the same time, brush them aside in practice. Applying Matza, brushing aside prevailing norms in practice may be a consequence of having learned certain neutralization techniques that justify, a priori or in advance of, the offending behavior. These techniques are learned in the process of interacting with others. One can refer to Ubel, et al.’s research to formulate a testable hypothesis. Ubel and his colleagues found that 20% of students studied experienced a disintegration of ethics between the time they began and the time they ended their OB/GYN clerkships.* However, the authors did not study why the disintegration occurred. Using Matza, one could hypothesize that these students were resocialized in a manner that allowed them to neutralize controls against what they originally believed was unethical.
It may be that one neutralization technique that nullifies controls against dehumanizing patients and is learned by some students in the process of becoming a physician is appeal to higher loyalties (e.g., “Students need the practice.”). Another may be appeal to special status or appeal to entitlement (e.g., “We’re professionals and are entitled to take liberties not available to others.”). A third is dubbed normalization (e.g., “It has always been done this way.”). A fourth may be “denial of injury” (e.g., “What’s wrong with it; nobody is hurt.”). A fifth may be “condemnation of condemners” (e.g., “It’s people like you who rock the boat and cause trouble.”). Another technique is called “denial of the victim,” whereby the victim becomes the deviant in the mind of the provider (e.g., “The patient shouldn’t feel that way; s/he is childish, irrational, immature and selfish.”). Matza calls the final technique “denial of responsibility” (e.g., “The doctor told me to do it; I do what I am ordered to do.”)
* Ubel, et al. did not actually find a disintegration of ethical beliefs in 20% of the students between the time they began and following the completion of their OB/GYN clerkships. In order to have drawn this conclusion, they would have to have conducted a longitudinal study comparing the beliefs of one sample of students before and after their clerkships. In fact, however, they instead compared a sample of students before they started their clerkship and a sample of different students who had completed their clerkships. To conclude that 20% of the students experienced ethical disintegration requires one to assume that the two sample groups were the same or very similar on important criteria.
THE HOLOCAUST AND DEFENSE OF THE INDEFENSIBLE
You write that, “Defending this practice [nonvoluntary pelvic exams] is akin to defending the Holocaust.” Again, this statement might be taken as hyperbole. Were you to go on Bill O’Reilly’s show, he would try to make a fool out of you for making such a comparison. That’s because if O’Reilly has a critical thinking bone in his body, he tends not to show it. As I said in my post over a year ago, the two can be linked theoretically and empirically. Some of the same justifications used to defend the Holocaust were (and still are by some) akin to the justifications used by those who defend nonvoluntary pelvic exams on unwitting patients. CONTINUED
Ray
CONTINUATION
PHYSICIANS AS PATIENTS
In the last part of your 12/31 contribution, you appear to recommend that physicians and medical students do what Max Weber referred to as the practice of verstehen and George Herbert Mead called “playing the role of the other” but what most of us dub “walking in the shoes of another” or “viewing the world through the eyes of others.” I don’t know what objections Maurice expressed, but sociologists and anthropologists have been practicing verstehen (http://en.wikipedia.org/wiki/Verstehen) for years and, consequently, have contributed not only to their understanding of people from cultures different from our own but to the understanding of students and the general public (e.g., by reading National Geographic) who read their works, thereby breaking down the tendency of people to be ethnocentric. Consequently, I approve of your suggestion with one caveat; viz., playing the role of the patient by medical students or practicing physicians should be voluntary. The irony of this caveat is, of course, that if playing the role of patient is voluntary, then it is highly likely that the only ones who would do it (if anyone) would be those who don’t need it. CONTINUED
Ray
CONTINUATION
There is a short paperback book by Dr. Edward E. Rosenbaum that was originally titled A Taste of My Own Medicine” and is now titled simply The Doctor. I think you will like it. It details Rosenbaum’s experience on the other side of the stethoscope. A film very, very, very loosely based on the book is called The Doctor and stars William Hurt. I think you will like it, too. At the end of the book, Rosenbaum recommends that students spend some time playing the role of the patient. In the movie, the doctor Jack MacKee demands it of his students.
I saw the film a long time ago in a theater. At the end of the film, the audience in the theater burst out laughing, cheering, and clapping when MacKee compelled both his male and female students to stand near their assigned hospital cubicles dressed in gossamer-like hospital gowns as a battle-axed looking nurse brought in urinals, enema bags, and the like. The message was clear; these students were going to learn what it was like to be humiliated and dehumanized in a healthcare setting. Having read the book, I knew that Rosenbaum would never have commanded such a thing of his students nor approved of anyone else demanding it of their students. I too would argue against the requirement that students submit themselves involuntarily to procedures that are not necessary for their health, especially if the procedures are degrading, humiliating, or dehumanizing, and especially if the procedures are invasive (as occurred in the film). I take this position even if compelling students to play the role of patient increases the likelihood that they will be compassionate and empathetic patient advocates. And, I take this position for the same reason I object to uninformed patients being compelled or cajoled to undergo treatment and care they don’t need and for the same reason I object to the unnecessary involuntary or nonvoluntary dehumanization of patients. That’s because to do so violates two universal ethical principles that I hold sacrosanct – informed consent and voluntary participation. A number of physicians I know make the same argument as I; they recognize that compelling students to go through humiliating treatment they don’t need is unethical. Sadly, however, they do not recognize as unethical unnecessarily exposing patients to humiliations they don’t need, a position justified speciously by comments such as “You’re being irrational” (condemning condemners), “We’re professionals” (appeal to special status), “It’s done all the time” (normalization), and so forth.
Second, why would anyone believe that exposing medical students to adversity against their will would produce compassionate and empathetic patient advocates? The empirical evidence suggests that exposing medical students against their will to humiliating experiences for the purpose of making them compassionate and empathetic patients advocates would 1) at best, have little to no positive impact; 2) any positive impact would be ephemeral; and 3) at worst, would be counterproductive, decreasing rather than increasing students’ compassion, especially among those who are high in authoritarianism.
Ray
Hello again,
Banterings: thank you for the welcome.
.. I will certainly check out your blog ..
"This also explains why patients do not fight for their dignity. They have accepted the role of patient, sick, subordinated, naked... Providers take the silence as consent. " ( Banterings or Ray ???? )
This statement combines two very different answers to the question of "why patients do not fight for their dignity".
1. they have accepted the role (Zimbardo)
2. They can't. They are too sick. (extreme example: a comatose patient)
I have personally been in both situations. I have also fought for my own dignity with a few limited successes.
In spite of the fact that I know better than to be so arrogant , I will summarize Zimbardo's conclusions in one statement.
If alpha has power over beta:
A. alpha will abuse beta because it can
B. beta will accept abuse because it perceives it must
As has been stated here many times and in a myriad ways, it is a power dynamic.
Alpha will cease to abuse beta when it no longer can. This will occur when power is equalized.
In reality, this means:
- BETTER LAWS
- AGGRESSIVE LAW ENFORCEMENT
- AGGRESSIVE PURSUIT OF CIVIL LITIGATION
Ultimately, the problem is political.
As far as fighting for one's dignity as an individual apart from a broader political movement, I think success will largely be limited to situations where alpha behaves as if it has more power than it actually pocesses.
That said, those situations in which alpha over reaches would occur much less frequently if all capable betas would fight for their dignity. Those situations would be even less frequent still if we were to fight for one another's dignity, including those unable to fight.
Ultimately, the fight must end, and that can only happen through law, law enforcement, and the courts. Betas must fight politically.
It is fundementally a problem of asymmetric power.
I am pleased to say that what has been missing for all these Volumes until recently is the absence of the "nitty gritty" of elucidating the possible mechanisms by which the modesty and gender "malpractice" occurs. After having been, over these years, saturated with the disturbing actions of the medical system, we, with the help of our recent theorists here looking at the mechanisms behind those actions and this may lead the way to solutions. ..Maurice.
Banterings,
On your Jan 3 post you suggest, “The group develops an ‘us-and-them’ mindset to protect the group from outsiders. This is hardwired into our brains after millions of years of evolution stemming from when the first humans huddled together in a cave.”
You’re suggesting that the ‘“us-and-them’ mindset to protect the group from outsiders” has a biogenetic origin. Gerhard Lenski, among others, posits a materialist theory to explain this “mindset.” It is the economic mode of subsistence, he suggests, that determines the development of a collective “us-and-them” mindset. Homo sapiens were hunters/gatherers for the largest percent of their existence. Hunters/gatherers tended then and tend today to live in what Karl Marx called a state of “primitive communism” characterized by a high degree of social egalitarianism, no formal government (and, consequently, no laws and no formal social controls), frequent nomadic movement, no sense of territoriality, no word for warfare, little conception of personal property or possession, and no specialization of labor. Hunter/Gatherers in short, tend to be very peaceful people. They therefore tend to welcome outsiders and, consequently are vulnerable to the efforts of people from more complex societies to dominate and subordinate them. There have been, of course, exceptions to the rule. One exception were the mounted hunter/gatherers of the plains (Sioux, Arapahoe, Cheyenne, etc.). However, they were horticulturalists before becoming hunter/gatherers following the introduction of horses by Spaniards. Few hunter/gatherers maintain this mode of subsistence. Most eventually become horticulturalists or pastoralists. Horticulturalists have a slash-and-burn economy which, in the early stage of development, involves the use of digging sticks and, later, metal hoes – a consequence of the invention of metallurgy. Horticulturalists tend to be more sedentary than hunter/gatherers, they develop a sense of territoriality to protect their crops, social inequality begins to develop, warfare first occurs, and slavery first appears. In short, it is among horticulturalists that “an ‘us-and-them’ mindset to protect the group [or what the group has] from outsiders” first appears.
Some years ago, I instructed nursing students and was invited to give talks to nursing classes about ethical issues. One of the issues had to do with privacy rights. Your attributing a social phenomenon to biogenetic forces reminded me of some students’ responses to what I had to say. They, especially those who were already employed in healthcare, and some nurse-professors dismissed the dehumanization of patients (including the commission of battery of the sort described in this blog) by attributing it to human nature; i.e., biogenetic factors (nature) rather than sociogenic factors (nurture), they believed, caused providers to dehumanize patients. However, their claim was less of an explanation, as yours is, but more of a justification for the dehumanization of patients. This justification is an example of the neutralization technique called “normalization.” After all, if we are all biologically programmed to dehumanize subordinates, then we are not blameworthy when we do; the biological justification absolves us of responsibility and accountability for our actions.
Ray
And here is an article about Medical Scribes in "Fortune"
and there is no mention of any concern about the patient and whether the patient wants a "stranger" in the examination room. It's all about the "good" to the physician. There definitely is definite "blindness" of this writer about the activities of the medical profession regarding concerns of the patient. On the other hand, this is "Fortune" and it is about the best way to see more patients and increase income for whoever. ..Maurice.
This will be extremely long, and I must submit in 4 parts.
Charles.OX,
In regards to:
"This also explains why patients do not fight for their dignity. They have accepted the role of patient, sick, subordinated, naked... Providers take the silence as consent. "
The stanford Prison Experiment not only showed how the guards could become corrupted with power, it also showed how the prisoners could become powerless. The prisoners furthered Martin Seligman's and Steven F. Maier's theory of "Learned Helplessness".
If you read Joan P Emerson's paper, "Behaviour in Private Places: Sustaining Definitions of Reality in Gynecological Examinations", you will see one of the strategies to elicit (force) compliance is to discount, ignore, etc. the patient when they raise objections. After that, "qui tacet consentire videtur" (silence gives consent. Sometimes accompanied by the proviso "ubi loqui debuit ac potuit", that is, "when he ought to have spoken and was able to").
issue discussed on this blog and elsewhere, most notably in international diplomacy: the Silence Procedure and in matter of sexual assault and rape (Silence Does NOT Equal Consent). In healthcare: What Is Implied Consent, and "Informed Consent" (Stanford Encyclopedia of Philosophy).
Ray,
Perhaps I should have said that homo sapiens or human societies have a greater propensity for "us-and-them" thinking. We further need to take into account in the acquisition of the neutralization technique Pavlov's Dogs (Classical Conditioning) and the Asch Conformity Experiments
(classic footage from the Asch conformity study).
Let me also address "Great men are almost always bad men". That is the complete quote of John Emerich Edward Dalberg-Acton. I think the better quote is "Power tends to corrupt, and absolute power corrupts absolutely."
Another issue that these theories of "The Lucifer Effect" that we are exploring here fails to address the issue of "great men." The reason for this is that there are 2 groups that dehumanize patients in the healthcare setting; those born sociopaths and those suffering "The Lucifer Effect" (out-group sociopathy, situational sociopathy, or learned sociopathy, perhaps...).
Continued...
Part 2:
The first group, those who are sociopaths before entering the medical profession also tend to be megalomaniacs. Healthcare is just a way that they can disguise their deviant behavior and avoid being caught. There is a certain amount of truth in the portrayal of Hannibal Lecter and other modern sociopaths having a connection to the medical/psychological professions. Even Jack the Ripper was thought to be a surgeon.
The second group are just ordinary people. I think they are best described by Admiral William (Bull) Frederick Halsey Jr.;
“There are no great men. Just great challenges which ordinary men,out of necessity, are forced by circumstance to meet.” These are the people that we call "great." Many such Mahatma Gandhi and Mother Theresa would describe themselves as very ordinary people. Perhaps that is the problem, coming from ordinary, that newfound power is like an addictive drug or an aphrodisiac.
Let me illustrate with Shakespeare's "The Tempest," transformed in this landmark science-fiction film; Forbidden Planet (1956).
Space men travel to a planet ruled by expatriate Pidgeon who has built a kingdom with his daughter and obedient robot Robby. There the good doctor is plagued by his mad quest for knowledge through his "brain booster" machine. Ostrow explains to Adams that the Great Machine was built to materialize anything the Krell ( the original alien inhabitants) could imagine, projecting matter anywhere on the planet. However, with his dying breath, he also says the Krell forgot one thing: (Freudian) "Monsters from the id!" Adams asserts that Morbius' subconscious mind, enhanced by the "plastic educator", can utilize the Great Machine, recreating the Id monster that killed the original expedition and attacked the C-57D crew.
Note: this is a possible explanation of the evolution of "The Lucifer Effect." I will further simplify my example: A physician/resident/clerk, acts ethically in treatment of patients, one day encounters a patient who does not need an intimate exam. The provider pushes for the exam and justifies it to the patient and perhaps to himself as medically necessary. Think Dr. Stanley Bo-Shui Chung (accused of dozens of unnecessary intimate exams on female patients) If for no other reason, then just out human curiosity, he uses the inherent power and achieves the intimate exam. He may not be aware that his motives are non-medical, he may ascribe it to "medical curiosity" or "being thorough." Subsequently, it becomes easier to "push" these exams when the curiosity arises. He feels a sense of satisfaction when these are completed, again he may ascribe the satisfaction not as "sexual" but as "medical."
Continued...
Part 3:
Eventually there becomes a desensitization to seeing women, to satisfy that nagging curiosity, he progresses to doing this to men too and eventually children. Having been taught to put emotion on the side and rely on logic, he justifies this. The definition of a sociopath is a person who lacks a sense of empathy, moral responsibility, or social conscience, and devoid of emotion. Lacking emotion and conscience, logic is the only tool used to make decisions. The goal that logic is direct to is determined solely by our pleasure drives (the id).
(Reference: Id, Ego and Superego .)
That is because a medical education conditions the Superego out of decision making because the Superego makes mistakes. It makes choices that counter logic (the Ego). Logical thinking is encouraged. The Ego grows and the Superego is reduced. The medical education takes no account for the ID. Saying that medical students are taught ethics does nothing, that would be the ID, which is repressed by the medical education.
The pattern of escalation follows that of a serial killer to the point where the devient behavior has become normative. (See: John E. Robinson, Sr.: The first Internet Serial Killer and Serial Killers: The Method and Madness of Monsters.) This endless line of patients satisfies the massive amounts of desire that the Id produces. A few remain unsatisfied and need to progress beyond the professional boundaries. That is where we get our Dr. Melvin D. Levine's (via NY Times), Dr. Nikita Levy's (via CBS), and Dr. William Ayres' (via Mercury News).
Continued...
Part 4:
Perhaps this can shed light (or vice-versa) on the contemporary and controversial topic of "Radical Islam" I have very good friends who practice Islam, and they, like most Muslims, are good people who condemn these terror acts for what they are. Yet how can some, even Americans, be swayed? Let us look at that culture and see parallels with a medical education. Replace "Islam" with "medical education" and "America/the west" with "patients demanding dignity" and you will see the similiarities.
...While many Muslims adapted to the fast-paced changes common to Western industrialization and modernization, some Muslims rejected them. Instead, they created a rigid ideology imbedded in the traditional values and laws of the Koran. This is the phenomenon known today as Islamic fundamentalism, or Islamism...Islamism came to be seen as a struggle to return to the glorious days when Islam reigned supreme. It represents a yearning for the "pure" Islam as practiced by the prophet. Not unlike the American Amish, the movement rejects much that is innovative. Islamists, however, take the rejection of modernity a step further. They perceive those who have introduced these innovations (the West) as its enemy...Source:
...In some cases, Islamic extremists even describe sharia as a superior form of “democracy” ...Acts of Islamic extremism includes terrorism, human rights abuses, the advancement of sharia-based governance, bigotry towards non-Muslims and rival Muslims and overall hostility to the West and, in particular, Western democracy. ...Islamic extremism is the primary national security and human rights concern of the world today... It is firstly the primary motivator of acts of terrorism worldwide. Secondly, as Islamic extremists gain power and rule, human rights abuses – including oppression of women, homosexuals and religious minorities as well as governmental tyranny, sectarian warfare and bigotry inherent in sharia law – come to the fore...Not all Islamic extremists carry out violent acts. Islamic extremists can advance their goals using non-violent tactics such as activism, developing interfaith coalitions with unsuspecting non-Muslims, fundraising, building political influence and the overall spreading of the ideology. These extremists follow a doctrine called gradualism. The largest Islamic extremist group to use this method is the Muslim Brotherhood.>Source:
Perhaps like paternalism, radical Islam is what we get when when the group refuses to relinquish the archaic rules that solidified their power and status and the subservience of those to whom they were suppose to serve. Just as many radical Muslims were educated in western schools and had western values, they were replaced by a sociopathic ideology that they justify.
I respectfully submit this for critical debate.
--Banterings
Banterings,
Your use of Zimbardo’s observation (that prisoners “had been so programmed to think of themselves as prisoners that when their request for parole was denied, they returned docilely to their cells”) to help explain why patients do not fight for their dignity is right on.
Charles.OK
You’ve offered a perspicacious assessment. I’m afraid you’re correct. I too believe that the root of the problems which are addressed in this blog is differential power or, more specifically, asymmetrical power with the advantage going to the healthcare provider with his or her greater authority and higher status than the average Joe and Jane. Because of this advantage, when providers who misuse or abuse their authority to dehumanize are challenged by patients, they tend not to take these challenges seriously; they dismiss them offhand, sometimes with extreme arrogance and obtuseness, as aberrant. We patients become the offenders or the deviants in the mind of the offending provider.
One ought not be surprised if providers rebut your argument with something such as, “You are the one who wants the power to control. You want to control my behavior. You’re condemning me for the very thing you’re guilty of.” This is, of course, an example of “denial of the victim” (the victim becomes the wrong-doer), and is what psychologists call projection (attributing to others the foibles in oneself). My God in heaven, why wouldn’t patients like to have some control over providers (or some control of the situation in which they find themselves) in the sense that they want to prevent providers from trampling on their rights to self-respect, dignity, and privacy in the same way they want to prevent anyone from killing them, beating them, raping them, assaulting them, robbing them, and so forth. We are given some protection from the latter by law and law enforcement and, alas, I agree with you, it appears as though we can only get protection from the former using the same means. A perusal of Paul Starr’s “The Social Transformation of American Medicine” informs us about how allopaths used the political and legal systems in the U.S. to legitimize their profession and to gain and maintain (with lessening success as of late) control of the healthcare system. Patient’s who want to make significant changes in the healthcare system to protect their rights have little choice but to do the same thing. CONTINUED
Ray
CONTINUATION
Of course, “all capable betas” will not “fight for their dignity,” as we have operationalized this concept in this blog; not everyone, even some and possibly the majority of those outside healthcare fields, feel humiliated when they are unnecessarily exposed nor offended when they are used as teaching tools or visual aids without their consent. And, of course, you are correct that the more people who “fight for their dignity,” as we understand this concept, and who “fight for one another’s dignity,” the greater the likelihood of success. I would add, the greater the number of people who come on board even though they have little or no fear that their dignity will ever be compromised by healthcare providers, the greater the chance of success. The first is difficult enough to obtain, the latter is even more difficult. Yet, social movements counted on the participation of those who had little fear that they would be subjected to the phenomena against which they protested. For example, the middle-class young people of many races and cultures from northern states who participated in Freedom Summer along with their adult leaders had no fear of being subjected to Jim Crow discrimination and segregation that was legalized in southern states. The success of these civil rights participants was measurable. Similarly, a social movement dedicated to humanizing healthcare would increase its chance of success were it to gain the support of those whose perceived risk of being dehumanized was low.
It would be thrilling indeed if a social movement dedicated to humanizing healthcare garnered the support of many millions of people; systemic changes at the national level might be likely to follow. However, changes that involve fewer participants can take place and be successful at the local (e.g., specific hospitals) and state levels (and sometimes at the national level, especially when constitutional rights are involved). Witness, for example, the struggle of Faith Myers in Alaska who, with the help of other patients, attorneys, the media, political leaders, and others managed to get a law passed in Alaska allowing mental health patients to choose the gender of their nurses when intimate care was involved.* This case was introduced in, I believe, Maurice’s 34th Volume The following link is about Myers’ ordeal: http://www.americanvoiceinstitute.org/PERSONAL%20HEALTH200514.htm#67
The law that was the upshot of her struggle is addressed at the following link: http://juneauempire.com/opinion/2014-04-04/state-mental-health-laws-are-work-progress The statute is Alaska Statute (AS)18.20.095 — “Gender choice for intimate care.” I tried to find the text of this law but was unable to do so. Maybe one of you will have success finding it and sharing it with me.
* A poorly argued piece about the Myers’ case and the bill (HB 220) introduced in the Alaska House can be found at this “truth about nursing” site: (http://www.truthaboutnursing.org/news/2005/apr/05_ap.html Myers also sued to protect psychiatric patients from being forced to take drugs in some circumstances. She won this case before the Alaska’s Supreme Court: http://juneauempire.com/stories/071006/sta_20060710003.shtml
and http://www.psychrights.org/States/Alaska/CaseOne.htm
Ray
Banterings,
You write, “Perhaps I should have said that homo sapiens or human societies have a greater propensity for "us-and-them" thinking.” I’m not sure what your antecedent for “greater” is. If you mean “greater than the other dozen or so human-like hominids” then you may be correct, but we’ll never know if these hominids had a lesser propensity than Homo sapiens for “us-and-them” thinking since they all died off while their subsistence economy was still hunting/gathering. Assuming cranial capacity is predictive of inventive potential and given that Neanderthals (Homo neanderthalensi) had, on the average, a larger cranial capacity than Homo sapiens, one might argue that had Neanderthals not become extinct about 30,000 years ago, their societies may have eventually evolved through the same economic stages as Homo sapiens. Apparently, there is some evidence that Homo sapiens interbred with Neanderthals since some contemporary humans carry Neanderthal DNA. If so, that gives new meaning to calling someone a Neanderthal. Whatever the case, the propensity for “us-and-them” thinking tends not to be characteristic of the simplest hunting/gathering societies no matter the species of the genus Homo. However, this does not mean the people who lived in these societies did not have the capacity for this thinking; they simply did not have the need.
You mention the Asch experiments. I addressed the Asch studies a few days ago as follows: “However, Zimbardo’s knowledge of Kurt Lewin’s research on the effects of leadership styles on the behaviors of school children (https://www.youtube.com/watch?v=J7FYGn2NS8M), Solomon Asch’s experiments on group conformity (https://www.youtube.com/watch?v=NyDDyT1lDhA), and (especially) Stanley Milgram’s experiments on obedience to authority fostered in him a belief that human behavior, including violent behavior, was more than simply a consequence of personal dispositions; it was also, he theorized, a result of social situations independent of personal attributes.”
It is true that the classical conditioning theory of Ivan Pavlov (and his salivating dog), a psychological theory, can help us understand why some providers dehumanize and why some patients “take it” without complaint. So too can another psychological theory; viz., B. F. Skinner’s operant conditioning theory. The psychological theories of Sigmund Freud, Alfred Adler, and Jean Piaget are also helpful. Edwin Sutherland’s differential association theory is a social psychological theory that can be employed for understanding why providers dehumanize. Some theorists have incorporated Matza’s neutralization theory into Sutherland’s theory because of their compatibility. And, Ronald Akers has, in effect, translated both theories into the language of the operant conditioning theorist. So, if we combine all the posts that deal with explanations, we find three sets of explanations that help us understand why providers dehumanize and why patients submit to dehumanizing treatment; viz., psychological explanations, social psychological explanations, and sociological explanations (which I addressed in a previous post). CONTINUED
Ray
CONTINUATION
Regarding Acton, both his sentences (his “Power tends to corrupt . . .” and “Great men . . .” sentences) were written cautiously in the sense that he used “tends to” in the first sentence and “almost always” in the second. Had he written “power corrupts . . .” and “Great men are bad men,” only one example to the contrary would be necessary to disprove his statements. For this reason, I don’t think Zimbardo would disagree with Acton; instead, I think he would be more likely to use the knowledge gleaned from his studies to qualify the statements as per my earlier post.
You mention sociopaths in healthcare. Although many social scientists use the terms sociopathy and psychopathy interchangeably, I prefer (based on the conceptualization of the two concepts in the Diagnostic and Statistical Manual (DSM))* to think of them as different on some important criteria and prefer the label psychopathy in some of the cases presented in this blog.
I occasionally read about psychopathic healthcare providers who murder patients, apparently to satisfy some amorphous internal need. Arguably, one of the most prolific serial killers in the history of the U.S. was the psychopath Dr. Michael Swango, to whom I may have alluded in an earlier blog. You can read about him here: http://en.wikipedia.org/wiki/Michael_Swango.
Sadly, the lives of many innocent people may have been spared early on in Swango’s career had there been a will on the part of many people in authoritative positions to hold accountable hospital administrators and healthcare providers when they refused to report suspicious activities and probable crimes in healthcare facilities where they worked. Although the primary fault for the killings lies with Swango, James Stewart argues persuasively in “Blind Eye: The Terrifying Story Of A Doctor Who Got Away With Murder” that Swango was able to avoid arrest in large measure because healthcare providers turned a “blind eye” to his depredations. Indeed, in some cases he was counseled by colleagues to keep a low profile or, in one instance, to leave the country because the law was hot on his tail.
* At the following link is a good discussion of the difference between a psychopath and a sociopath: http://www.psychologytoday.com/blog/wicked-deeds/201401/how-tell-sociopath-psychopath
Ray
This post is extremely long, so I have to do it in 4 parts and an epilogue...
Ray,
Great references!!! [as usual...]
Note: I will use the term "pathy" now until I comment on the difference between sociopath and psychopath. This is the article Ray referenced, "How to Tell a Sociopath from a Psychopath" that I will be referencing.
I differentiated between the learned in medical school "pathy" and the born-that-way (psycho)path. The latter being very few in number and more of an anomaly. This will also explain why I used the term "sociopath."
Edwin Sutherland’s Differential Association Theory is one of my favorites. It is where we get the axiom "Prisons don't reform, they make professional criminals." I always finish that with "I went to Catholic School for 12 years, what does that make me?
In regards to psychopath and sociopath i like the differentiation that psychopathy is biological and sociopathy is result of socialization. I think that when "normal" people are socialized, psychopaths are socialized too, but instead of growing empathy for others, they learn how not to get caught. The article that you referenced also stated:
...sychopaths are often well educated... psychopaths carefully plan out every detail in advance and often have contingency plans in place. Unlike their sociopathic counterparts, psychopathic criminals are cool, calm, and meticulous. Their crimes, whether violent or non-violent, will be highly organized and generally offer few clues for authorities to pursue... Psychopathy is related to a physiological defect that results in the underdevelopment of the part of the brain responsible for impulse control and emotions.
That fits perfectly with the Banterings' Theory of Superego Repression (Nullification).
Theories of socialization such as Charles Horton Cooley's Looking-glass Self, George Herbert Mead's Social Behaviorism, Sigmund Freud's Id, Ego, and Super-ego, James Henslin's Gender Socialization and others (Klaus Hurrelmann, Lawrence Kohlberg, Carol Gilligan, Erik H. Erikson, George Herbert Mead, Judith R. Harris) are important for two reasons: First looking at how psychopaths socialize (this is when they learn to mimic emotions among other things) validates the second. The second is we look at how providers are re-socialized to a learned sociopathy (if you will).
Two of these socialization theories stand out in relationship to this thread. Sigmund Freud's Id, Ego, and Super-ego which Banterings' Theory of Superego Repression is based upon. This also takes Freud's theory one step further in that the Ego is attributed as the logic center (the brain) and is separate from the "self." The "self" is a combination of the consciousness, Id, Ego, Super-ego, memories, experiences, and other components.
This being said, logic needs to be taught as well. Teaching a child 2+2=4 does nothing for the Superego or Id. Perhaps teaching addition is "adding" is a better statement and 2+2=4 is a truth (Superego). Banterings' Theory of Superego Repression acknowledges that the Ego can be grown. This then leaves us with providers who have a repressed Superego, a strong Ego, and the Id =we all have. With the repressed Superego, the Id is not balance hence the dehumanization of patients.
The second is James Henslin's Gender Socialization. This has bearing because of the issue of gender choice in healthcare, or better yet the lack of gender choice in healthcare. This implies that there is a de-socialization then re-socialization of providers. I do not believe that you can unlearn the morals that we were socialized with as children, we can learn more and grow the Superego, we can't erase it and rewrite it. We can repress it though.
Continued...
Part 2
This can be seen in children whose mothers were abused growing up to be abusers. This was what was put in their Superego at that critical time when it was empty and needed to be filled. We can also explain that children who reject the premise of abuse have grown their Ego to reason that this part of their Superego is corrupted. Although they may not abuse ever, they have a tendency or predisposition to.
I do not like the description of the sociopath as being a trailer park dweller. I think that this is an incorrect assumption because sociopathy is attributed usually to a childhood trauma. Therefore they have had their socialization interrupted. They never learn empathy or how to fake (mimic) it.
Sociopaths tend to be nervous and easily agitated. They are volatile and prone to emotional outbursts, including fits of rage. They are likely to be uneducated and live on the fringes of society, unable to hold down a steady job or stay in one place for very long.
So what about healthcare providers? Most were normally socialized but they are taught to repress their Superego, hence Sociopathy being learned. Sociopaths tend to be nervous and easily agitated. They are volatile and prone to emotional outbursts, including fits of rage. How many surgeons does this describe?
In 2008, The Joint Commission became so concerned about “behaviors that undermine a culture of safety” that it issued a Sentinel Event Alert on the topic and developed a Leadership standard requiring all hospitals to have a code of conduct as well as a process for managing disruptive and inappropriate behaviors. Now there is compelling evidence that some behaviors contribute directly to medical errors. This was a prominent finding in Rosenstein and O’Daniel’s work,1 in which respondents commonly indicated a reluctance to call or interact with certain doctors to clarify or question orders for fear of provoking a hostile response...
In its Sentinel Event Alert, The Joint Commission describes disruptive and intimidating behavior as including “overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities,” and it goes on to say that “intimidating and disruptive behaviors are often manifested by health care professionals in positions of power... Source:
Continued...
Part 3:
I think that taking the 2 definitions (sociopath and psychopath) we can put together a good definition of providers that dehumanize patients:
Provideropaths tend to be nervous and easily agitated. They are volatile and prone to emotional outbursts, including fits of rage. It is difficult but not impossible for them to form attachments with others. Many are able to form an attachment to a particular individual or group, although they have no regard for society in general or its rules. In the eyes of others, they will appear to be very disturbed.
Provideropaths are unable to form emotional attachments or feel real empathy with others [outside their group, i.e. patients), although they often have disarming or even charming personalities. They are very manipulative and can easily gain people’s trust. They learn to mimic emotions, despite their [repressed ability] to actually feel them, and will appear normal to unsuspecting people. They are often well educated and hold steady jobs.
When committing [infractions to patient dignity], Provideropaths [are following] carefully planned out in advance [protocols/guidelines] and often have contingency plans in place. They are cool, calm, and meticulous. Their [infractions to patient dignity], will be highly organized and generally offer few clues for authorities to pursue [as a crime]. Intelligent Provideropaths [are] excellent white-collar criminals and "con artists" due to their calm and charismatic natures.
There are providers that reject the suppression of the Superego. I present Dr. Peter Ubel and the Harvard Medical School students refusing to do pelvic exams on anesthetized female patients. Perhaps in the growth of their Ego, they realized the consequences of repressing their Superego. More simply that it was wrong to do pelvic exams on anesthetized female patients because the Ego (logic) showed that there was no medical necessity and that contradicted "First, do no harm."
Using Banterings' Theory illustrates the mechanics of the Lucifer Effect". the Stamford Prison Experiment, Milgram Experiment,Pavlov's Dogs, the Asch Conformity Experiments, etc. are the tools used in the mechanics of the repression of the Superego. "Power tends to corrupt, and absolute power corrupts absolutely." This shows the predisposition that human beings have to making the situation favorable to themselves (the Id) when they can make the rules. " Great men are almost always bad men." This is the time when human beings ARE able to make the rules.
Philosophies like Machiavelli's "The Prince," Karl Marx's "Communist Manifesto" are just reinforcements of the Ego to justify atrocities done. Along with being the logic that chooses what to do (balancing the Superego and the Id), the Ego also logically evaluates the logic that it (the Ego) uses in decision making. Atheists (or more appropriately agnostics) see no physical proof (pure logic) of God, therefore they do not believe in God. That is not good or bad at face value, it is just their logic. Believers tend to reason that statistically (also pure logic), the chances of life have had to be guided by at the very least "Intelligent Design."
Banterings' Theory thus explains the Holocaust. Germany after WWI, with the economy and whole social structure in ruins called people to question traditional logic. The Reichstag fire of 1933 satisfied the Superego in saying this was wrong and the Id this was wrong as an attack on the Id and not morally wrong). When, in the rare instances, the Id and Superego are in concert, there is a tendency NOT to regulate the Id [as much] because it seems to be in check by nature of agreeing with the Superego. That is how (and when) "An eye for an eye" is justified.
Continued...
Part 4:
This can explain medical students in "you are saving lives." The Superego says saving lives is morally right. The Id says "saving lives makes me feel like God." Repression of the Superego (how else can one justify cutting off all the clothes of a person) along with the Id not regulated as much (Superego and Id agree on saving lives), the patient's requests to be covered with a sheet for dignity are ignored by the provider's Id because it is an attack on the provider's power (the Id) and on their altruism (Superego) of saving the patient's life.
This is a lot to digest and follow, I realize that. My theory does explain many situations of abuse.
The whole healthcare model is an aberration to social norms and mores. The only reason that society was forced to accept it was that it held the ultimate bargaining chip, our lives. When healthcare told us that their sacred and forbidden knowledge required us to be totally naked under a gown for wisdom teeth surgery as a means of infection control, we accepted it. There has been a change in thinking where we see quality of life issues (particularly mental health) just as important as preserving live. After all, who wants to live their life in a prison cell of depression and PTSD from a healthcare encounter? The internet has shared the sacred knowledge where we see that much of what is practiced is ritual and tradition rather than hard science. (Think the secrecy and traditions of the Free Masons.) Healthcare is losing its bargaining power.
Two prime examples are the "trauma log roll and rectal exam," and "DRE in constipated children."
It’s a well known scenario: The blunt trauma patient is decided to have a mechanism of trauma that warrants a trauma CT. The primary survey is nearly done. Everyone is ready to move – but, oh no!, we nearly forgot the two final steps of ATLS: the log roll and the digital rectal exam!...
For blunt trauma, there isn’t really any good evidence or theory behind the log roll. For penetrating or suspected penetrating trauma, a log roll is necessary for excluding wounds on the back of the patient...the log roll seems to be the least stable way of moving a patient – both for the spine and for pelvic injuries.
The digital rectal examination (DRE) is useless as a general screening tool in trauma, and only seems to be there for getting back at patients for waking you at 3:30 in the morning. Still, most surgeons are really anal about the digital rectal exam... in the latest version of ATLS, DRE is not mandatory anymore. So, engage brain and include the stats below in your decision making...(Source: )
US replaces x-ray for diagnosing childhood constipation: British pediatricians at a London children's hospital are using ultrasound to assess the severity of constipation in children. They have found that ultrasound is a good substitute for abdominal x-ray, with its radiation exposure, or a digital rectal examination, a procedure that children find unpleasant and disturbing.
Dr. Bhanumathi Lakshminarayanan, a pediatric gastrointestinal specialist, and colleagues from Evelina Children's describe a system they developed for scoring ultrasound exams of constipated children in an article published in Pediatric Surgery International (December 2008, Vol. 24, pp. 1379-1384).
According to the study, the scoring system enables pediatricians to accurately measure fecal loading in a consistent manner. It also provides a tool to assess the long-term improvement of patients undergoing treatment for chronic constipation.(Source: )
Continued...
Epilogue:
Maurice or any other providers reading this, I ask the following questions:
Were you aware in the latest version of ATLS (September 2012), the log roll is NOT recommended and the DRE is not mandatory anymore?
Were you aware for the new guidelines for the use of X-ray or ultrasound replacing the DRE for diagnosing childhood constipation?
Did you know that the X-ray guideline came out in 2008 and the ultrasound guideline came out in 2009?
I have to wonder how many providers still use the DRE in constipated children and trauma???
Finally, Maurice can give real insight to this...
What is the first things that medical students learn (anatomy, disease, public health)?
Orientation begins the re-socialization process before students even enter a classroom. This begins the Superego repression process. I would bet dollars to doughnuts, that if med students (for all provider disciplines) had to take an ethics class off the medical school campus, prior to the first med school class and even orientation, taught by med school professors, there would be a different view of patient dignity. That is because according to my theory, that you are growing the Superego prior to the tools and situations that teach the repression of it. You also grow the Ego in the sense that this is a new logic taught by the med school.
Harvard has a tradition of ethics (especially in their Business School). It is no surprise that it was Harvard Medical School students who first started refusing to do pelvic exams on anesthetized female patients This only furthers my theory.
--Banterings
Banterings, I was teaching the abdominal physical exam to two separate groups of 6 students each all afternoon today and then observed them practicing on each other. I instructed them about the need to be aware of their patient's modesty issues when they shortly perform this exam on their ward patient experience. In fact, the faculty of the first and second year students are quite aware of the importance of stressing patient modesty. In fact, the students are told that how they properly drape and attend to the modesty issues will be closely watched in terms of grading when they perform their OSCE standardized skill examination on their standardized patient near the end of the school year.
As I have written previously, medical students in their first two years are well aware of modesty issues of the patients to the extent of limiting proper effective examination because of the student's own personal concerns that what they are doing may upset the patient in terms of the patient's modesty. And as I have previously written, limitation of proper effective examination for example of the feet by trying to examine them through the stockings, unwilling to ask the patient to remove them or allow the student to do so. ..Maurice.
A nurse lifted my gown and exposed my genitals for no apparent reason. She later asked me to have a shower.I refused her assistance to get out of bed.
She asked me if I needed any help having a shower and I again refused her help due to her poor attitude.
She was getting upset because I had twice refused her help but she deserved it as she showed a poor attitude towards me by lifting my gown without my permission.
There are some nurses that are interested only in themselves and like to perve on patients.
LAD
I need help from my visitors regarding my Moderation responsibilities.
After approaching 10 years of commentary on this "Patient Modesty" thread with stories from anonymous visitors such as from LAD today, how should I decide whether the story is made-up to make a point (such as to cast a shadow on all nurses or doctors) or to provide "a little sexual stimulation" to our readers and. if so, consider not publishing it. Don't we all agree after skimming through all 70 Volumes that there are nurses and there are doctors and there are techs and OR folks who behave as though they are interested only in their own self- (perhaps) prurient interest and not for the benefit and comfort of the patient. How much more does this fact have to be repeated and repeated to us on this blog? So where do I draw the line with regard to publishing or not-publishing these "stories"? And they are simply "stories" as long as the incidents are not identified with names, places, dates including the name of the patient such as incidents we have all seen published in the newspapers.
With regard to LAD's "story", what I would be most interested in is whether "he" spoke up to the nurse (and asked to specifically understand the nurse's rationale for actions), to the administrator if the nurse's responses were unsatisfactory.
So, how would you suggest I moderate the stories like the one by LAD? Help me. ..Maurice.
Maurice,
I know what you have stated before. They are taught patient modesty throughout all their 1st & 2nd year classes. The question was more a hypothesis to my theory. If you follow my thinking, the emphases on logical, scientific based thinking, reduces any effect that moralistic/ethical training would provide. I am NOT saying that this grows immoral behavior (the Id), I am theorizing that the repressed Superego leaves the Id less in check.
I was wondering if ethics was one of the first classed that med students take. I am not even sure if an ethics class is required for a medical degree. Again, my theory puts forth that growing the Superego (such as an ethics class) before the formal medical education begins will (in the theoretical sense) be the most effective.
I was not implying that the instruction by you or your school of your medical students was in anyway deficient. On the contrary, they receive a superior education by the nature of your awareness of these topics on this blog. You have to love what you do, by having this blog so long and so many years as a physician and a teacher, not to mention how you protect your students such as defending their integrity as you did in responding to me.
I would hope that you can see that there may be a correlation. It also may be a marginal problem because not all providers exhibit disregard for patient modesty. But, we saw the largest and most vocal outcry by the Harvard medical students, and I wonder if there is any correlation to Harvard's tradition of ethics that lead to such a large number of students rejecting the status quo?
I was also hoping to hear your thoughts of the idea of teaching an ethics course first and separate from, yet as a part of the overall medical education.
Continued...
LAD,
Welcome to the blog. You are going to learn much here.
Maurice, as to LAD...
These are stories are important because they reminded us that change is still needed. He stated: A nurse lifted my gown and exposed my genitals for no apparent reason. I am not defending the nurse, but she felt there was a reason even if it was "I am entitled to." LAD also did not say she "fiddled" with his genitals and referred to them correctly.
She asked him if I needed any help showering, again most nurses do this. He was obviously uncomfortable with her attitude for the liberties that she initially took. His last statement is obviously and justifiably emotional as he had his bodily integrity violated. I am sure that the consensus here is this is not one of those "porn" posts that occasionally sneak on to here.
He is just another casualty of the healthcare system on patient dignity. His story lacks some detail, such as the procedure he was in for and when it occurred. Obviously it has traumatized him to some extent with him finding this blog and posting. As I said, part of my counseling degree involved placement in actual therapeutic settings. I had noticed that sexual assault victims experienced the same traumas as people mistreated by healthcare and both avoided healthcare.
Another common factor, as is with all traumas, I s the victims trying to empower themselves. Perhaps it is a survival mechanism, not letting my self be the victim again, a form of healing, or both. Part of that is educate themselves about what happened to them and seeking the company of others who have experienced the same trauma. I am sure that you can see just from my own recent problem the therapeutic value. There is also the axiom that "Knowledge is power."
So I say, "Welcome LAD." As he reads the posts and interacts with us, he will be socialized as to the norms and mores of this discussion.
As to those of you not aware, this past November I found a lump. I seriously debated with myself bringing this up to my physician or not. Since I take responsibility for my own healthcare, I knew where it was I didn't need to worry. My wife was worried more than me. What scared me more than a bad diagnosis was becoming a patient.
It was an epididymal cyst. Benign and common in men over 35. From the empowerment I gained from fighting for patient dignity, what I had learned (especially from this blog, Maurice and all the contributors), because I had developed a relationship my physician over the last 10 years, and I trusted him, I told him. I even let him examine me. It ended up being a positive experience that added to my trust in him.
If nothing else, this blog helped one person gain the confidence (by knowing how to protect their own dignity) I allowed a testicular exam. So for that, I thank you all.
--Banterings
Dr. B.
Porn on this thread has not been a problem. I can only recall three posts [two posters] that were obviously porn in this thread. So, don't be concerned about a few creeping in. Let's just have the rest of us call them out [as was done]. I was too interested in making a point to Ashton to call him out. I should have told this to Ashton. Your story about the nurse and the teacher is believable because they both had the power to control you. Your classmate had no power and those with power aren't big on sharing which told us your story was porn. Submit your future posts to the medfest blogs.
BJTNT
Maurice,
I agree with Banterings. Although credible descriptions of bad experiences in healthcare organizations up my blood pressure, I appreciate their continued inclusion lest I forget why I am contributing my two cents to this blog and to reinforce my belief in the virtue of seeking ameliorative change.
Personally, I’d prefer to defer to your discretion when it comes to deciding whether or not to include a post. Deciding on the criteria for inclusion or exclusion would be more difficult than was the task before the U.S. Supreme Court in Jacobellis v. Ohio (1964) when, in an effort to identify the criteria for hard-core pornography, a frustrated Justice Potter Stewart proclaimed, “I know it when I see it.”
At first blush, LAD’s description of his experience seems credible. Like you, I would prefer some detail from LAD. Greater detail would provide more data for determining the likelihood that the anecdote is fiction. Personally, I would never add the name of the offending provider or the hospital at which the offence occurred for fear of legal reprisal. Unlike the media, I am not protected by the First Amendment.
I'll add my two cents. Upon leaving my bed on a morning in 2008, I noticed that my right leg had swollen to 1 ½ times the size of my left leg. At the hospital’s emergency room, I was diagnosed with deep vein thrombophlebitis and pulmonary emboli. I spent five days in the hospital. During that time, I was hooked up with electrodes on my chest and my vitals monitored. Every so often, a nurse entered my room, told me that she needed to replace or clean the electrodes, explained that to do this she would unsnap my gown at my shoulder (or I would do it) and pull the top of the gown back to do what needed to be done. All but one nurse followed the same procedure. My wife, a masters-prepared nurse and attorney, who taught nurses working on their four year RN degrees, would have awarded each one of these nurses an “A” had she been their professor.
By contrast, one nurse entered my room, told me she was going to change or clean the electrodes (I don’t remember which). I began to unsnap my gown at my shoulder to allow her access to the electrodes when, without a word, she pulled the sheet aside, grabbed my gown, and tried to pull it up. She didn’t get very far for two reasons. First, I weighed 240 lbs and was lying on the backside of the hospital gown. Second, I knocked her hand away and exclaimed, “What in God’s name are you trying to do. Let’s do this correctly.” I then unsnapped the gown. When she was done I scolded her with, “I strongly recommend that you learn how to treat your patients with respect and dignity,” to which she replied simply, “Okay.” Were she my wife’s student, she would have been expelled from the nursing program so fast her head would spin. CONTINUED
Ray
CONTINUATION
I wrote two letters and sent them to the hospital’s CEO and public relations officer. In the first letter, I commended the several nurses who behaved properly. In the second, I wrote about three inappropriate events that I experienced there, two were committed by physicians and one by the nurse described. I made several reasonable recommendations regarding what could be done to eliminate or reduce the likelihood of repeats in the future, none of which required structural changes. I also pointed out that the nurse’s behavior constituted criminal battery and provided a copy of the appropriate Missouri Revised Statute as evidence. I signed my name and added my credentials on both letters.
I didn’t expect the CEO to respond and, true to form, he didn’t. CEO’s of organizations seldom get involved with what to them are the day-to-day trivial irritants of the sort I described. Even when they know a subordinate has committed a crime, they tend not take much note. Only when they perceive the irritant morphing into an imminent threat to the organization or themselves are they likely to act decisively. Only then are they likely to take consumer complaints seriously.
The public relations officer did respond. Her voice over the phone appeared to suggest that she was noticeably upset, she understood how I felt (although I wrote nothing about my feelings in the letter, but presented the facts only), she agreed that the nurse behaved improperly, and tried to assure me that appropriate action would be taken. However, she would not tell me what that action would be because of “confidentiality issues.”
I often wondered about the function of organizations’ public relations officers. They’re a relatively new addition to the corporate world. The few readings I’ve completed in organizational sociology suggest that the addition of public relations officers tends not to foster organizational changes for several reasons. One of these reasons is that public relations officers are not hired to provide data on how to best serve the interest of consumers. (The same tends to be true of ombudsmen, especially those employed internally.) They instead tend to be hired to “cool off the mark.” This is an expression used by pickpockets. “Professional” pickpockets are likely to work in pairs. When they see a potential victim (a “mark”), one will pick his pocket and the other will hang around. When the “mark” realizes his wallet is gone, he, of course, becomes upset and angry, which increases the likelihood that he will report the theft to the police who may then come to the scene where the best pickings are and ruin everything for the pickpockets. The function of the pickpocket’s accomplice is to approach the “mark,” express sympathy by recognizing the wrong that he has had to suffer, and convince the “mark” that going to the police would be a waste of time.
If this story – minus the editorializing and analysis – was not mine, if it were communicated to me by someone else, I would be inclined to believe it even if the writer did not give his or her name, name the offending nurse, and name the hospital where the event occurred. And, I guess almost all of the people who have contributed to this blog would find the story credible. But, I wonder about people in healthcare, especially nurses or nursing students, since the offense was committed by a nurse. Could it be that people in healthcare fields, especially nurses, would be less likely to think the story credible than people outside of healthcare fields? There are a number of reasons I would hypothesize an affirmative, but I’ll not address them here. I’ll instead end with an admonishment from my dear old mom, who was similarly and not infrequently admonished by her father, a physician and the CEO of a hospital, with the expression – “What do I have to do, draw you a picture?”
Ray
Ray, thanks for your analysis of my question and providing your experience. I certainly would congratulate you on attempting to "do the right thing" in your response to the one nurse's behavior and that goes along with my ongoing advice on this thread for the patients to "speak" to the offender and their employers hopefully to educate and to make some changes in behavior or policy.
I want to emphasize with regard to naming the names of the patient, offender or institution, my policy is that this is for my own knowledge only in order to provide confidence to me that this is not a "made-up" story but I would not, as I have also never done in the past, publish those names within the visitor's comment.(Exception: the names and acts already published in the media and thus publicly known) I have deleted identifying information since the "other side" was not contacted and thus didn't have a chance to defend themselves on my blog. But documentation for me with real names and even means of contact would make my decisions to publish (again without naming) easier! ..Maurice.
Maurice,
I see. That’s reassuring. However, I doubt if you’re protected by First Amendment press freedoms. Some years ago, a sociologist was threatened with jail if he didn’t give up names of his research subjects and notes he had taken after he published an article about crime in the restaurant industry. He refused to do so. He wasn’t jailed only because the police were able to get the information they wanted from another source.
Not too long ago, I read a piece published in the Sherman/Capra blog that quoted a nurse making racist statements about penis size. Apparently one reader tracked down the nurse and where she worked. The nurse’s name and the hospital at which she worked were not published in the Sherman/Capra blog. One or more of those who were informed filed a complaint with the hospital, I think, but not with the State Board of Nursing which may have taken more a punitive action than the hospital. The nurse eliminated her post. Ethics aside, I wish this could or would have been handled in a different way so others of us could have taken action.
Ray
Although this is an "off-topic", is there or should there be a difference between the legal "freedoms" allowed the press and what should be allowed a blog? In what way is a publication by the press reporter different from publication by the moderator of a blog?
..Maurice.
Ray,
The name of the nurse was published but later removed at the request of the original reader who discovered her name. Complaints were filed both with the hospital and with Florida state board who elected to take no action.
I have never been reluctant to name names but try to notify those mentioned in the article so that they have a chance to respond. They almost never do.
It is timely that the topic of real patient stories of abuse have come up. The following is a true story and I am looking for comments and advice on how to proceed as I value the opinions of the regulars to this blog.
About 2 years ago, I had a very bad exposure encounter in a surgeon's exam room. I made an appointment to have pain in my groin and abdomen examined for a possible hernia. As I was sitting on the edge of the exam table wearing only an exam gown, there was a knock at the door which promptly opened and in walked the surgeon and his female assistant. I was taken by surprise, later finding out that this was known as a "Patient ambush". This was before I had been introduced to this blog and had not yet found my "voice". The doctor made a quick introduction, never mentioned his assistant and promptly began the examination. Opening the gown at his request, I tried to shield my privates from the view of his assistant. He put his hands on my hips and rotated my body so that he could see better and, of course, so could his assistant. I was completely embarrassed and could feel my face flushing. I glanced over at his assistant and she was staring directly at the area of examination. She glanced up momentarily and noticed that I caught her staring, quickly diverted her eyes with what seemed like a smirk but eventually continued her observation. The doctor completed the examination and left. He sent her back in later after I had dressed with a prescription and instructions to come back in four weeks.
I felt completely humiliated when I left. After spending the evening searching the web about similar experiences, I found out what Medical Chaperones were all about.This was also my first introduction to this blog.
The next day, I called the office to complain to someone in authority. After explaining the reason for my call to the receptionist, I was put on hold for a couple of minutes. When the line picked up it was another female voice asking me about the reason for my call. I explained my discomfort and embarrassment with the third party in the exam room. She then said very matter of factly that she was the third party in the exam room and that was company poilicy. I told her that she was never introduced as such and also asked her if she was a nurse. She was rather indignant when she replied that of course she was a nurse.
To make a long story short, I asked for the Chaperone to be waived on my visit in four weeks. She refused and said that she was sorry that I was uncomfortable but it was their policy. I calmly asked her to cancel my appointment and that I would seek care elsewhere and ended the call. She called back an hour later and said the doctor would waive the requirement for my next appointment. I also followed up with a four page letter to the doctor regarding the traumatic and possible long term effects of this type of non consensual encounter along with a printed set of typical chaperone guidelines which included informed consent. Never got a response.
In an effort to consolidate my medical records, I secured copies of all my records recently. In reading through the documents, I was surprised to find reference to the phone call. While it did give the reason for my call, it gave the Nurses response as " I told the patient that if he was uncomfortable having me in the room, I will not be in the room. The patient stated that he understood."
Not only is this not what happened but by her signature, it was evident that she was a Medical Assistant and not a nurse at all. After reading that, it made me wonder if the doctor ever received my letter at all as it was also evident that she screens his mail.
Upsetting as all of this is, I am not sure how to proceed or even if I should at this point. Any suggestions?
Ed T
I wish I could answer your questions, Maurice. You’ve made the first a legal and a moral question. The second may have already been answered by the courts. I’ve not read or heard arguments associated with either.
Regarding the nurse who made the vulgar racist comments, was it the State Board of Healing Arts (or its equivalent) or the State Board of Nursing to which the complaint was directed? In MO, compared to the former, the latter appears to be more likely to take action against a nurse who violates the law or nursing ethics.
Ray
Ed T, I would be interested to know the rationale for the "policy". I congratulate you on your handling of your case. ..Maurice.
This will be in 2 parts:
Ed T,
Here is where I would start; I would write a new letter to the physician. I would chronicle the events and the inaccuracies in your medical records. Include a copy of the original letter and state you fear that the physician may be not have received the original letter. A nice touch is to have a condensed form of the inaccuracies. A spreadsheet works nice. Four columns ONLY: The date of the document, the name or reference number of the document, what was stated, the correct description written as close to incorrect vernacular. Your explanation and expression of feelings are in the letter.
This spreadsheet is nice if there is an internal investigation or correction. It makes the physician's life easier than asking his admin assistant to compile the list from your letter. At the end of the letter, list the attachments. Put everything in a 9"X12" envelope so the sheets are not folded. Being most private practices are being bought up by healthcare corporations, I would not go over the physician's head (at first). State that in the letter as well. If you send copies to anyone else, include a "CC" in the head of the letter.
I ask that Maurice address (confirm) the following. When I write about physicians, I use the term "physician" because it shows more of an appreciation of what they do and it is a preferred term among them/ Doctor is not a derogatory term or a slur, but more of a "not familiar with the inner-workings of healthcare" term, dare I say unempowered patient. As I understand it, it is due to PhD recipients being addressed as doctor. When I write, I always (try to) use "physician."
Occasionally I will do a piece and use "doctor" for 2 reasons: First the audience is not empowered yet and not familiar with the difference, which leads to the second. When searching, to increase my rankings in search engines I use "doctor." (Read:Search engine optimization (SEO) for more info.) The only exception I found is that surgeons prefer to be called surgeon due to the nature of surgery. Maurice, PLEASE COMMENT!
Once the letter is complete, deliver it in person!!! Show up at the office, tell the receptionist you need to speak with the physician for a minute. They will press what it is about, that is part of the admin assistant's job to shield the executive from the mundane. I would say it is a records request or something on those lines. Whatever you say it is, she will insist you leave it with her.
This can be a double edge sword, if it sounds too threatening (like a law suit), he may try to avoid you OR he may rush out immediately. You may decide to say that it is something you need to deliver to him personally. Again, address it in the letter. Perhaps in large type in the very beginning. He will probably pull the documents out to see if it is a lawsuit, so you don't want him to hand it to the admin assistant when he sees it is not a law suit.
Continued...
Actually this post will be 3 parts, so here is Part 2
Now I would like to speak about medical assistants. They get a bad reputation. The reason is that our experience with them is the 20-something female. They are not mature. In key ways, the brain doesn't look like that of an adult until mid 20s. That means the structure, now comes the learning and practicing of mature situations. People are not ready to deal with naked bodies until they are at least 30. (Could this be the problem with nurses, techs, etc. Even though they may be 27 years old, it is almost the same as if they were 16.) See National Institutes of Health "The Teen Brain: Still Under Construction".
There is also the issue of licensing. Some states require it, some don't, and in some states it is done by private organizations. Everyone who has read my posts and my blog know I fight for patient dignity and I pull no punches. You also know I support providers in wanting them to be the best they can and acknowledge that external forces like insurance companies and corporations are part of the problem, (but I do not absolve them). I freely admit that I can be "over the top" sometimes.
In full disclosure, my wife is a medical assistant. She did not go to school for it until after she turned 40. Fortunately the specialist she works for does not require a person to undress. I will tell you that she is one of the most compassionate providers I ever met. She routinely helps patients to and from their cars, and has even given patients rides home when they were dropped off on days the office was closed due to snow or instead of having them wait for their ride alone when they were the last appointment.
She would be more embarrassed than the patient if in Ed T's situation (the exception that she would be turning away). I think that she is more compassionate than her daughter who is an RN. I know what she went through for training. I helped her study to pass her classes. She so often commented on the immaturity of the other students in her class who were 20 years younger.
Continued...
Part 3, the last part.
I miscalculated the number of characters...
I think that there is also the perception that they are clerical. She works at a small practice, father and son (father recently passed, was in his 90's). She does everything: reception, sets appointments, takes patients into prep, then in to exam room, sterilizes instruments, assists in surgeries, wound care, billing, orders tests, makes pharmacy calls, and helps patients to and from their cars. She has been doing this over 20 years.
She was trained to do injections, blood draws, vitals, assist in surgery and exams, etc. When I was thought to have HBP (is was white coat syndrome), she took BP readings that I presented to my physician. She and many other MAs do much of the work that nurses use to do. Obviously the issue is the cost os two qualified professions doing the same task.
The other part is that it is a 2 year degree and many technical schools offer it. The perception of technical school students has been that of those "not smart enough to go to college." In the wake of rising tuition and student debt, technical schools are being lauded as a better value with higher lifetime earnings. Here in Pennsylvania nurses do not need a 4 year degree. She could have gone in to a nursing program but she got a grant for the MA program.
Perhaps part of the solution for nurses, MAs, techs, etc. is a "residency" requirement or more years of training requirement (to get more mature providers), but then we risk "learned situational sociopathy" and the hidden curriculum (we have been currently discussing) that we have with physicians. When my wife went to school to be a MA, it was the early 90's. Her employer had just sent her (previous) job and many thousands more over seas to a cheaper workforce. Her grant was that of retraining, and healthcare was something that would be difficult (though not impossible) to send overseas.
She was able to be trained and find a good paying job in a relatively short amount of time which makes this program appealing and explains why many in this field are from lower socioeconomic classes. The exact same reasons that technical educations are becoming the choice for many middle class students today. Perhaps part of the abuses of providers in these positions stems not only from the age and maturity level but of someone from a lower socioeconomic classes gaining similar power as a physician (and their perceived high status) over many (perceived) upper class patients (can afford healthcare) who may be perceived as oppressors of the lower socioeconomic classes.
--Banterings
Two topics:
1. Regarding Banterings question: "Doctor" and "Physician" are both expressions of our professional activity but, of course, "Physician" is more specific and not as ambiguous as "Doctor" unless the words "doctor of medicine"(MD) is applied. There is also "doctor of osteopathy" (DO) whose duties and professional status is accepted in the United States as virtually that of an MD.
2. Now, how do I appraise the following posting this thread received today?: the anonymous individual sending it was writing a "cartoon commentary" and is worthless for publication and serious consideration on this thread OR it is coming from a truly mentally disturbed individual whose comment should suggest prompt psychiatric help is needed? ..Maurice.
"I despise hospitals and crooks, perverts and liars that work there so much that I will never allow myself to be lowered to their corrupted standards.
I have a knife I keep with me at all times and when something serious happens to me, instead of being taken to the hospital I'm prepared to cut my throat and get it over with. There's nothing that will change my mind. There's just too much evil and corruption in today's medical systems. You might recognize me in the news. Thanks for all your help here.
Destined to die"
Maurice,
You ask that we help you appraise a posting. Were the quotation to which you refer put on an exam I was taking and the options were: Is this writer a) writing a ‘“cartoon commentary’ . . . worthless for publication and serious consideration, b)a “truly mentally disturbed individual” needing “prompt psychiatric help,” c) not enough information to make a determination, I would answer “c.”
One might suggest that these options are not necessarily mutually exclusive; the writer’s intent may be both a “cartoon commentary” and the submission may be indicative of someone who has psychiatric problems. Nor are the options exhaustive; there are other possible “answers” such as, “The writer is writing a cartoon commentary which is worth publishing.” Regarding the latter, it may be that the writer is being sardonic, sending us, in a cynical manner, a message. For example, the writer may think we tend to go overboard in our accusations of inappropriate behavior by healthcare providers. If we were able to inveigle such a motive from the writer, it could have practical implications for future submissions by regular participants.
Whether future submissions of the sort you quote are meant to be “cartoon commentaries” or the crying out of a person who has been so traumatized and made impotent by people in healthcare that he would want to cut his own throat rather than be taken to a healthcare facility, I believe it would not be inappropriate for you to post them and then you and we can do some probing in hopes of finding out the truth of the matter.
Ray
Ray, should a function of this thread to investigate the details and the "truth" of what was written and the psycho-social and biologic details of the anonymous writer and investigate the validity of what was written? How can we do this when no documentation is available as to who is the writer and no documentation of the facts in the story? I don't think this is possible for either me as the moderator and you and the others as blog visitors. We cab only act and decide on our own "first impressions" since there is nothing more to make valid decisions.
In medicine, assumptions of a diagnosis without any documentable facts, is not a method to be encouraged. ..Maurice.
"Time to Change?" was the Introduction to this Volume on Patient Modesty. It may be time to change some of the narrative which has been coming to this blog thread. I received the following this morning to be considered for publishing:
"My father got raped by nurses. Andy "
What value does this posting contribute to the issue of patient modesty and gender selection of healthcare providers and how to make the medical system attentive to these issues and create changes in the medical system to make the medical care process and procedures more comfortable to patients beyond just looking for a cure of the physical symptoms? Doesn't everyone know, after reading the newspapers, about bad doctors, bad nurses, bad priests, bad police officers and bad patients or other folks who kill doctors?
So what more does the comment which I reproduced above or the others I recently acknowledged contribute to anything we want to do on this blog thread? Certainly we are not able, on this blog, to generate a statistical analysis of the "bads" and apply it to specific groups of healthcare providers. The general concerns of my thread visitors has already been adequately defined by the thousands of descriptions over the past almost 10 years--more is no longer necessary.
Now is "time to change" what is written here from the "bad" to the "good", from further descriptions of "destructive behavior" to discussion regarding "constructive attempts to change the system" and to make "the bad" (in all its variations) less likely to happen to all patients. It is "time to change" what is written here. Doesn't that make sense? ..Maurice.
Maurice,
I guess you can count me among the 20-30 something computer nerd crowd. I had wanted to learn more about computers and web sites. After teaching myself all I could since 2001, in 2009 I went back to school for a degree in web development. I think I have some insight here.
First, go to the "design page" of your blog (link probably upper right since it is your blog). Select "pages" and add a page that is "rules for posting." Say be descriptive, what you being treated for, etc. Feel free to express your feelings... but do not insult, flame, speak the truth though, use technical terms not slang (give examples), and so on.
Next, where you have ...Comments to exceed 4096 characters (NOT WORDS)... say be sure to read rules for posting, and link to the "rules for posting" page there.
You may also want to include that this is not a porn or fetish site, everyone here takes it seriously, and while you are the first line of defense, the community also will flag inappropriate content.
That being said, let me comment on the "raped by a nurse comment." In a discussion I had about the 2008 case of Brian Persaud and NewYork-Presbyterian Hospital, I put forth a simple question: A normal, average person is mistakenly put on a gurney, wheeled into an ED, clothes cut off, the staff ignores his pleas to stop are ignored, facing all sorts of invasions of his body.... how would a normal person react?
Would they NOT be combative? Are we NOT hardwired with fight or flight?
Yet part of the justification in that case was that he was combative. What would a normal person's life be like after that? How would they view the healthcare system?
So someone subjected to the "healthcare experience," even when those indignities are allowed by guidelines (although not necessary, look at ATLS's change in the use of the DRE resulted from that case), would that person also NOT suffer similar mental trauma?
When a person is discharged do they ask about their experience or evaluate their mental health? I think not. So these may be people emotionally expressing what has happened when we discuss scientifically, philosophically, and legally here. That is not to say that we do not discuss emotion, it is just the manner that we do discuss it.
--Banterings
I understand and acknowledge that "bad" thing happen in the patient-healthcare provider relationships which may lead to permanent emotional injury to the patient. Unfortunately, there have been no doctors or nurses to write their understandings to this blog except for Artiger, a surgeon, who wrote back in the Volume 60's and whom I think expressed his awareness and understanding of patient modesty and that "bad" things should be avoided.
So, as long as I, as moderator, understand, there is no need to describe further "bads". They all are well documented in past Volumes.
Yes, maybe emotional ventilation to a blog thread may be therapeutic but what would be more effective would be frank ventilation directly to the objects of the profession who have created the "bad", to their superiors and to the medical or nursing boards or the law enforcement if a crime has occurred.
Let's move on to making changes to prevent the "bads"..Maurice.
Maurice.
I'd like to add my feeling to your last post. You mentioned that only one healthcare provider has taken the time to post here. Over the years you have had Doctor's, Lawyers and a hospital compliance officer. All come on your blog, post their thing, then disappear not to be heard from again. So much potential lost. One day, for whatever reason, the voice of this blog's moderator will go silent. Who will fill his shoes ? In the early years I found myself disagreeing with Maurice more than I agreed with him. Maybe I'm wrong, but I detect a change in Maurice. As of late he acknowledges that there is a gender preference and some experiences can cause PTSD. What will this blog do when he's no longer the moderator?
Haven't we posted enough examples of modesty violations here ? We need to combine our efforts into a world wide movement. Doesn't anyone have any idea's how to bring change to the healthcare system or must we continue to do it alone ? I'll end this with one final question for Maurice. How much flak have you taken from your peers over the years about moderating this blog? AL
Regarding your question (“should a function of this thread to investigate . . .”), it’s not for me to say. On an earlier post, I opined that it seems apropos to me that you use your own discretion regarding what to post and what not to post. I believe the same regarding the function of this thread. On my last contribution, I expressed my belief that “it would not be inappropriate for you to post” quotations of the sort about which I commented. I happened to find it worthwhile and relevant, but you and most other people might not. In the past, you have posted things I did not find worthwhile and, therefore, chose not to address them; others, on the other hand did.
I personally do not find the assertion, “My father got raped by nurses” useful enough to be included on this thread. Interestingly, I may have believed differently a few years ago at which time I spoke with a woman who said that she refused to get healthcare because she didn’t want to be “clinically raped.” At the time, I considered this comment to be hyperbole so I did no probing and she offered no specifics. Nevertheless, what she said implanted in my mind an idea for research which is relevant to this thread and which I described in some detail more than a year ago. I won’t bore readers with the details again unless someone wants an encore.
That said, if you choose not to post personal anecdotes, a choice which does not seem outlandish to me in the least, I would still like to see references made to current media reports (positive, negative, or neutral) on issues about which we are concerned, especially if these reports are used as illustrations for a point being made or a request for the opinions of contributors to this thread.
I haven’t read any of the volumes between the time I stopped participating on this blog a year + ago to the present volume, but I’ve been led to believe by you and Banterings that the tenor of contributions has changed and is moving in the direction of ‘“constructive attempts to change the system’ and make ‘the bad’ less likely to happen to all patients.” I’m all for continuing to move in that direction. We may be able to do so with the greatest speed if we stop including for consideration personal anecdotes of bad or good experiences with healthcare providers. I’d be the last to quibble with that option.
We’ve taken a step in the right direction, I believe, by our efforts to understand and explain why the “bad” things about which we are concerned happen to patients. Right now I am working on a response to the questions you posted on 12/30. Sometime soon, if all are amenable, we might consider articulating exactly what it is we want to change – or, put in another way, what our goals will be – and how we plan to achieve them. I look forward to this exercise.
Ray
To both Al and Ray, thanks for your insightful understanding of what is going on here and my education of the issue. Also, providing the prognosis of the life of this thread or even the blog itself and with me as its moderator.
So this should be the time for the visitors here to go beyond simply expressing "stories" whether true or contrived and proceed beyond this blog to make the changes in the medical system that we agree needs to be made.
Look. As a start. I tried, but only a feeble attempt, to put the issue up on one "petition web site" and I got a few "signatures" but not enough according to the sites protocol to keep the petition going. Yet, I think this technique to start change (to demonstrate the public is interested in what has been written here and demand changes be made) will provide valuable evidence when confronting the representatives of the "medical system".
Can't those of you with better writing skills than me and broader knowledge of internet petition opportunities start out right now to begin the process of moving the action away from this blog's thread and into another more widely distributed and possibly more affective (psychologically impressive) and thus more effective domain? Do it! ..Maurice.
p.s.- In answer to Al's question regarding flak from peers: yes, I have informed them and encourage them to visit here. I have not heard that they have so.. no flak.
Maurice et al,
I have spoken to many physicians, both prominent and obscure. I have invited them to this blog, with no mention of my own blog. The last to be invited was Dr. Peter Ubel. Yes, THE Dr. Peter Ubel. He did not even give me the courtesy of a response (I am assuming he has received my email.)
I have contacted 1 or 2 of the authors of "Using tort law to secure patient dignity."
Most of the people don't even give me a courtesy response. I have also contacted providers that have items posted on their websites that trample on the dignity of patients. Sometimes I get a "we will look in to that from an admin assistant."
What have I taken away from those who supposedly support patient dignity? That they are not interested in collaborating with anyone else. I hate to go back to my theory of superego repression, but my only answer is the "ID." They are egotistically/narcissistically "ruler of a kingdom" and that constitutes, power, prestige, money, or all 3.
I will use these very public figures as an example of those who advocate for social change but also have kingdoms: Senator Pat Roberson (700 Club) and Rev. Jesse Jackson (Rainbow/Push). Where I live, a physician, is the head of a food bank. In the nonprofit annual reports I see he makes about $350K a year. Again, this is the only logical explanation I could come up with.
Where I did my Master's Degree was a religious institution. I took a course on starting/running a nonprofit. I won't go in to the mechanics of it, but there is obscene amounts of money to be made. This may be a cynical outlook, but I have no other explanation. I purposefully did not mention my blog. I was polite and professional in my invite, yet nothing.
I will leave open the possibility that there are many lurkers on this blog, some of them being individuals that I have invited. Perhaps there is a fear of posting or some may be posting under aliases.
I respect that we all need to put food on the table and we have our own projects, but Dr. Sherman, Doug, Misty, and Belinda have taken the time to post. (I know for sure they have books, nonprofits, projects, etc., I don't know what others may be doing.) I also know there may be legitimate reasons that they may not post or cooperate with others; academic integrity, copyrights, contracts/retainers, etc.
Perhaps some of you on here with other projects can speak to "partnering" with others. What was your experiences?
Many of the people I have spoke to do consulting and speaking engagements. I found it is harder to get people who do that together than an east coast and west coast rapper.
I am in the process of initiating a change. I will update you and everyone in a couple weeks on where I am at. I will ask for input as well.
I am just saying that I tried. I am not stopping either. Remember what I have said before: "Give me a lever long enough and a place to stand and I will move the world"- Archimedes, 230 BC
--Banterings
Banterings,
I have too emailed many people including doctors and nurses and many of them did not respond. I find it interesting you mentioned the tort article that was written by several lawyers. I tried contacting the law professor, but she did not respond to my email. Sometimes, people will read emails and then get distracted with many other emails and then fail to respond. Sometimes, emails do not go through. I have learned that email is not 100% reliable. Some of your emails may have never went through. I’ve had friends and family who told me that they did not receive certain emails. Sometimes, spam filter will not allow certain emails even if they are legitimate go through. Sometimes, you have to call people to see if they got your email if they do not respond to your email.
I’ve had the privilege of helping a number of patients through Medical Patient Modesty. Patient advocacy / education is the way to go. We will never be able to change the whole medical system. But we can empower patients to speak up. There are a number of patient modesty friendly hospitals and facilities. I believe that the more patients speak up, we will see improvements. Think about what would happen if a number of modest male patients refuse to use an urology practice because they do not have female nurses or assistants. As you probably know, there has been an increase in all-female ob/gyn practices in the US. Obviously, a number of female OB/GYNs understand that there are many women who do not want male gynecologists at all.
Misty
Maurice,
Back in Volume 67 you stated:
Medicine absolutely does not recognize "PTSD, emotional trauma, psychological trauma, etc" are possible side effects of professionally performed "exams, treatments and procedures due to modesty issues" to the frequency extent as described on this blog.
I just recently came across this on Forwomenseyesonly, "Gynecological Procedures Can Cause PTSD". It references a study in Journal of Reproductive and Infant Psychology Volume 11, Issue 4, 1993, "Post-traumatic stress disorder in women who have undergone obstetric and/or gynaecological procedures: A consecutive series of 30 cases of PTSD".
500 women took part in a study about the psychological effects of vaginal exams, pap tests, and other gynecological/obstetric procedures. Of the 500 women who took part in the study, over 100 women reported their experiences as ‘very distressing’ or ‘terrifying’. Of the 100 women who reported distressing experiences, 30 were diagnosed with PTSD. The study highlights the similarities between the after effects of rape and women’s experiences with gynecological procedures.
There is a lack of research related to PTSD following gynecological procedures. The study quoted above was published in 1993, and there does not appear to be any follow-up research specific to gynecological procedure- related PTSD published since that time. There has been some recognition in the literature given to the trauma of pap tests experienced by women with a history of having been sexually assaulted, but the trauma caused by pap tests themselves is generally ignored.
Some of the phrases used by the women who took part in the study to describe their experiences include:
-"dehumanizing and painful";
-"degrading and distressing";
-"my opinions were dismissed as irrelevant";
-"hurting and feeling violated";
-"very brutal internal was excruciating";
-"it felt undeniably like rape".
30 out of 500 is 6%!. Just as OB/gyn procedures can cause PTSD, there are so many other procedures that can do the same. What about the borderline diagnosis? Those who may not have full onset PTSD, but have been traumatized none the less?
You titled this volume "Time to Change." The time to change was 1993, when this report came out. All that has happened is providers have set themselves up for medical monitoring lawsuits. The alleged “injury” in medical monitoring lawsuits is most often characterized as an increased risk of disease. In this case the disease is PTSD.
So I ask, what obligation do providers have to "primum non nocere" ("first, do no harm")?
--Banterings
Banterings, I have never heard this relationship of PTSD as a result of medical examinations ever being discussed or detailed in the major medical journals. If there is a relationship, I am sure it would be a rare occurrence otherwise if a major issue, as other major issues, physicians would be made aware. More studies like the one you linked should be encouraged. ..Maurice.
Maurice,
I agree with you about more research.
I said (way back) that I noticed the same "symptoms" in survivors of sexual abuse as people who had bad healthcare experiences. When I spoke with survivors who had sought healthcare before and after their abuse, they said that healthcare was as bad as (some ) of the abuse. Unfortunately this was a placement while in school, so I could not do a study.
I have also attempted to use "a review of literature" to measure actions, not motives. Touching of the genitals is touching of the genitals regardless if it is for therapy or gratification. Granted, how the person perceives it makes the difference. Just as a person can have a pleasurable sexual experience with one person, yet a bad one with another (not in an abusive encounter), why would anyone expect that a clinical encounter also not elicit negative results even when not abusive?
I know that you personally have respectfully disagreed with us about this issue, until your eyes were recently opened. I also know that this is only one study, but imagine the insult and injury that we have also endured when others claim that we imagine it, it can't happen, we are disturbed, outliers, etc.
Look at how the recent guidelines are calling for less use of intimate exams and how providers are fighting against them. Does this not further weaken the credibility of providers?
Part of it comes down to providers not possessing "the magic" or "sacred knowledge" anymore. The healing arts is what gave the shamans their prestige in more primitive societies, frightened the church, and gave us the Malleus Maleficarum (commonly rendered into English as "Hammer of [the] Witches"; Der Hexenhammer in German).
Some say that the rise of TV shows like House, Grey's Anatomy, etc. paint a negative picture of providers. It makes them human, and those shows are popular because we want our providers to be human. I would love nothing more than to take my current physician out to dinner. So he gets to know me, I get to know him better. No quid pro quo.
Wasn't that the thing about Marcus Welby, or Doc Hollywood, knowing his patients. Every hospital system has a commercial that has some physician saying "I have taken care of 3 generations," trying to give that small town intimate feel. That is what the focus groups show people want.
Perhaps part of the physician burnout is due to this emotional detachment. Think of it the same as being in a loveless marriage (relationship). Where is the satisfaction. But being in a relationship with someone you love, there are ups and downs, there is hurt and there is joy. At the end of the day, you feel something, even if it was the proverbial "better to have loved and lost then not loved at all..."
There are many good providers out there still. The healthcare industrial complex has not devoured them up yet. Despite all the moaning and groaning, many of us have found, encountered, or may be looking for that provider who we can build a relationship with. And for as hard as we hammer those who are bad, we support those who are good. Some may need more earning of trust than others, but every patient needs that.
I hope that I have built my credibility here. I have shown some of my more advanced thinking, especially in my recent "repression of the superego" theory. I have some more "ideas" that are even more advanced than those. Eventually I will bring them up.
--Banterings
Banterings, thank you, thank you, thank you, you have hit the medical nail on the head. These exams that ignore basic modesty are traumatic for both men and women. PTSD of a kind is the result though no one in the medical field has stepped forward to admit it. If you don't believe me, try finding a councilor who will take the notion seriously.
First, do no harm. But there is harm when you leave an exam room feeling worse than you did when you walked in and the cause is not a diagnosis by your physician but because of the exam itself and who the physician deems necessary to witness it. Trauma induced by the exam itself, now there is a concept that should not be that difficult to understand. Picture, if you will that scene from a variety of different movies where the hapless young man is getting dressed in the school locker room when he is set upon by bullies and forced into the hallway stark naked just as the bell rings and his fellow classmates both male and female pour out into the hall. Of course, the locker room door is locked behind him, he has no place to go or hide. He is completely exposed to the pointing and laughter, cell phones clicking. Everyone is laughing including the theater audience. Now freeze that frame and put yourself in his place. Would you think it so funny? Would you ever forget that moment? Your a minor and would have to return to that school the next day. Could you face your classmates? How would you feel when you entered that locker room again? Would this constitute trauma? Is a violation of your modesty in an exam room any different before you learn that you have a choice?
Again Banterings, thanks for recognizing this for what it is. I can't think of a better reason to always seek informed consent before opening that door to the hallway. First, do no harm.
Ed T
Maurice,
You indicate that you “have never heard this relationship of PTSD as a result of medical examinations ever being discussed or detailed in the major medical journals. If there is a relationship, I am sure it would be a rare occurrence otherwise if a major issue, as other major issues, physicians would be made aware.”
I am not sure what you are trying to communicate here. Are you suggesting that if you’ve never heard about the relationship between OB/GYN experiences and the likelihood of PTSD being “discussed or detailed in the major medical journals,” then it has never been “discussed or detailed in the major medical journals”? Are you suggesting that if the relationship has not been “discussed or detailed in the major medical journals,” the relationship does not exist? Are you suggesting that the only legitimate sources for an article that tests the relationship between OB/GYN experiences and the likelihood of PTSD are major medical journals? Are you suggesting that the only locations that should be consulted by physicians to inform themselves about the relationship between OB/GYN experiences and the likelihood of PTSD are major medical journals?
Statistical relationships between two continuous variables can range between -1.0 and +1.0 with 0 constituting no relationship. When you say you are “sure [the relationship] would be a rare occurrence” do you mean that you are sure the relationship would be close to zero? Are you suggesting that all physicians have been made “aware” of all major issues by reading the major medical journals? Are you suggesting that I could consult with any physician and that physician could authoritatively inform me about the findings of researchers who tested the effects of RomneyCare on mortality rates and published the results in the "Annals of Internal Medicine"? Are you suggesting that I could consult with any physician and that physician will be “aware” of the results of research that compared the use of blood substitutes to the use of saline solution on trauma victims? If you do not mean these things, can you reword your post in a way that clarifies for me what you do mean?
I await the full study by Janet Menage mentioned by Banterings. The abstract suggests that the study has serious, though not fatal, flaws as it did not effectively deal with issues of internal and external invalidity. I would not encourage a replication of this study; I would encourage a study that would be superior to Menage’s by more effectively dealing with problems of internal and external invalidity. One can only wonder whether or not this study on the effects of bad OB/GYN experiences on the likelihood of PTSD has been followed by other studies and if not, why.
Ray
NOTICE: AS OF TODAY JANUARY 23, 2015 "PATIENT MODESTY: VOLUME 70" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 71.
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