Patient Modesty: Volume 71
I would like to start out this Volume 71 with a basic question to help define what is understood as physical modesty and how it applies to this issue as experienced by patients within the medical system. Is modesty of an individual only related to how the individual feels about their own personal exposure to others or does it also includes how the individual reacts to the exposure or "immodesty" of others? For example, is a patient expressing modesty when they see and react to a woman breast feeding her baby in public? or finding someone on the beach with a "bikini"? Does every patient who finds challenges to their modesty within their experience with doctors and nurses also are emotionally upset upon viewing, experiencing what is felt to be immodest behavior by others? In other words, does patient physical modesty concerns actually involve an individual's general philosophy regarding attention to modesty of self but, in addition, also of others? This distinction, I think, is important. ..Maurice.
Graphic: "Bathing Suits" from Google Images
NOTICE: AS OF TODAY FEBRUARY 25, 2015 "PATIENT
MODESTY: VOLUME 71 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE
POSTING COMMENTS ON VOLUME 72.
posted by Maurice Bernstein, M.D. @ 10:45:00 AM
193 comments
193 Comments:
A brief response to Ray writing in Volume 70 who wrote: Are you suggesting that if the relationship has not been “discussed or detailed in the major medical journals,” the relationship [OB/GYN experiences and the likelihood of PTSD] does not exist?. No. But it is unlikely that most physicians, even me at first, would be aware of such a relationship without such publication (and including without the publication in the general news media). ..Maurice.
First let me apologize for not having a correct link in Vol 70, so here is the synopsis of the study on Forwomenseyesonly: Gynecological Procedures Can Cause PTSD
Next I will do this post in 2 parts. I was originally posting this on Vol 70 when it closed...
Maurice, Ed T, Ray, t al,
I agree that this is great. All along I have been demonstrating [call it if you will] a "review of literature" research style proving this exact point.
I started out with my post Patient Dignity 02: But it is Sexual.... When you take all intent out of the equation, and measure the only thing that can be measures and validated, the actions, you see that they are almost identical. So why would one be emotionally traumatic and the other not?
Remember this post: "Rectal exam mistaken for sodomy, a patients personal experience!" (via National Institutes of Health)?
To really illustrate my point I devised a test (half way down the page in blue) on my posts: "Patient Dignity 01: Can a Physical Exam be an Act of Rape?" and "Patient Dignity 20: It's called sticking your finger in my ...."
Yes, I am over the top, possibly inflammatory, and probably offensive. A friend told me just yesterday that I am as subtle as a drag queen. I know this, but look at the denial that I am dealing with. I do warn my readers that my posts may have triggers, be offesnsive, and deal with mature subject matters.
Here are links that recognize that healthcare can retraumatize or be traumatic, and "trauma informed healthcare" can reduce the chance this:
Making Hospitals Less Traumatizing I like this resource because it advocates "Provide a Post Discharge Safety Net".
Trauma-Informed Medical Care? Not at my doctor’s office… (Some good links here!)
RETRAUMATIZING RAPE VICTIMS This is a great article!
Secondary Victimization of Rape Victims: Insights from Mental Health Professionals Who Treat Survivors of Violence This is an excellent research piece, and is something that I noticed in survivors of abuse from in, out, and both in and out of the healthcare system.
JAMA: Reducing the Trauma of Hospitalization
The Federal Government has a technical assistance centerThe Substance Abuse and Mental Health Services Administration (SAMHSA) National Center for Trauma-Informed Care and Alternatives to Seclusion and Restraint (NCTIC) (mental health focused).
Then there 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.
Continued...
Part 2...
One of the most disturbing texts I have ever read was "Behaviour in Private Places: Sustaining Definitions of Reality in Gynecological Examinations." It provides the following insight: "A more drastic form of solidifying the definition by excluding recalcitrant participants is to cast the patient into the role of an "emotionally disturbed person." Whatever an "emotionally disturbed person" may think or do does not count against the reality the rest of us acknowledge."
I even explored past and present abuses committed by providers and explored the reasons that they can cognitively have occurred in "Patient Dignity 16: From Mother Theresa to Dr. Mengele."
I illustrated that "medically necessary" and "being thorough" are not always necessary, AND there are limits to "medically acceptable," namely in what is "socially acceptable" in the case of Dr. Stanley Bo-Shui Chung.
Part of what adds to the trauma is that we are (basically) told that it is in our head, it is not true (so me must be delusional), and so on. We hear that even more so when we reply with "You first." That response is because we can not believe that people who are so educated lack such basic common sense and empathy.
I also have stated, and most of you agree with me, that it is not all providers that traumatize and the traumatizations may not always be intentional.
What is even worse that we have all been missing is that we are told what happens to patients and how exams are performed IS ACCEPTABLE because healthcare says IT IS ACCEPTABLE. When we question this, we are pointed to guidelines. Even when forced to reevaluate guidelines, which only happens from multiple law suits (DREs, Brian Persaud) or legislation (pelvic exams, ACA), most providers resist and ignore the guidelines because "That is the way we have always done it."
Then physicians wonder why they have lost credibility, trust, prestige and face such high rates of burnout. It is paternalistic thinking like that that has relied on oligopolies, "sacred knowledge," and limiting access to resources that put the healthcare system where it is today. That is why physicians are becoming employees and hospitals are turning into WalMarts. It is not healthcare any more, it is the healthcare industrial complex run by bean counters and guided by patient satisfaction surveys.
Maurice said:
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.
It is a major issue! Perhaps the answer is not that they don't know it, but they don't WANT to know it.
--Banterings
I had been kicking this idea around for the past 2 weeks, not sure how to address it with Maurice, but now is a perfect segue. I believe that the name of the thread should be changed to "Patient Dignity:"
As was pointed out in previous volumes, was there is a difference between what is abusive and legal, AND what is abusive and NOT legal. I realize that there may be debate on my use of abusive, but bear with me. I use that term because it describes an attack on our modesty/dignity.
I think dignity is a better term because it is a right granted to us by the nature of being human and ascribed to God. It can not be given to us or rationed, it is always there and must always be respected. Modesty is what we are granted from healthcare, and when we ask more than is granted us, we are labelled irrational and unreasonable. Modesty is a party of dignity. Dignity is respect for the whole person. Modesty is respect for the body.
Using the term dignity affirms modesty because dignity is modesty (the body), and the mind (psychological wellbeing).
The Four Principles, originally devised by Beauchamp and Childress in their textbook Principles of Biomedical Ethics, are considered by many as the standard theoretical framework from which to analyse ethical situations in medicine.
While the validity and scope of the Four Principles of Beauchamp and Childress are often debated, there is no questioning the canonical status of the four principles in the field of Medical Ethics. Briefly, the four principles are:
Autonomy – The right for an individual to make his or her own choice.
Beneficence – The principle of acting with the best interest of the other in mind.
Non-maleficence – The principle that “above all, do no harm,” as stated in the Hippocratic Oath.
Justice – A concept that emphasizes fairness and equality among individuals.
One area that has been greatly debated, and which Beauchamp and Childress have also addressed is patient dignity.
Dignity is often denounced as hopelessly amorphous or incurably theological: as feel-good philosophical window-dressing, or as the name given to whatever principles give you the answer that you think is right. This is wrong, says Charles Foster: dignity is not only an essential principle in bioethics and law; it is really the only principle. ...dignity is the only sustainable Theory of Everything in bioethics. For most problems in contemporary bioethics, existing principles such as autonomy, beneficence, non-maleficence, justice and professional probity can do a reasonably workman-like job if they are all allowed to contribute appropriately. But these are second order principles, each of which traces its origins back to dignity. Source: "Human Dignity in Bioethics and Law"
Dignity was not included in Beauchamp's and Childress's principals because it is too hard to define.
my dignity is easy to define, simply ask me.
More to follow on dignity...
--Banterings
Defining the abstract concept of dignity:
Dignity is an abstract concept, while dignity may be difficult to define, what is clear is that people know when they have not been treated with dignity and respect. Let me define dignity to make it simle:
Dignity is: Respecting the answers (choices) that others make to the same questions that we answer as to self determine our own existence. At the very least, the questions cover basic human rights. Dignity can NEVER be negotiated, overridden, or taken away, but it can be ignored by others. We may choose to sacrifice or compromise our dignity for what WE deem a higher purpose.
Our dignity exists in the intrinsic value we have as a human being. Life is not a higher issue than dignity, it is one of the choices that we make in regards to our dignity (i.e. do not resuscitate). One person's dignity can not trample on another person's dignity, for then that is NOT an aspect of dignity in the first person. Not caring about an area or choosing not to make a choice about an aspect of one's dignity IS a legitimate option and that area must be respected in others. Source: Archie Banterings
That is a lot to digest, so let me give some examples. I chose my religion. You may not choose the same religion that I do, but I respect that choice by the nature of me making a choice about my beliefs. A person who doesn't care about religion or does not have a belief system has made THAT as a choice. They still must respect the my choice of religion even though they choose none or that choice is not important to them. A radical religion that does not tolerate different points of view, has two components. The choice of religion falls in the realm of dignity, the lack of tolerance does not.
My dignity is simple to define, just ask me and I will tell you how to treat me with dignity.
Dignity is NOT something that physicians, the healthcare system, OR anyone gives to us. Dignity is NOT convenient or efficient. Dignity is something in us that you cannot take away, but you can disregard it and disrespect us. Disregarding OUR dignity is disregarding your own dignity. If our choices are of no value to you, then neither are your own choices (of value). If you want respect, give it first. The hospital, the exam room, the MRI machine all may be yours, but our bodies and the space around us is ours, you will ask to come in to our space, to touch us, and wait until we allow you to.
--Banterings
Banterings, of course PTSD as a disorder for any patient is a "major issue" and certainly needs to and will be considered by any doctor However, what doctor's are not aware is the incidence of PTSD in their patient population as the direct result of an incident or inattention to the patient's modesty concerns. Banterings or Ray, if you have the statistics and sources, writing a piece for publication in the New York Times medical section would be a great way to start the education. How about even writing a piece to the New York Times on the general issues patient modesty and the medical system as described on this blog thread?
By the way, does anyone want to answer my question posed in the introduction to this Volume about whether patient physical personal modesty is simply a part of an underlying belief that every person needs to be attentive to and display evidence of modesty? No exceptions. ..Maurice.
Hello all!
Maurice:
To answer your question simply: NO.
While I am sure there is tremendous variation in how people feel about physical modesty in various situations, those feelings are experienced within a social context. Being naked with friends in the locker room is a radically different experience than being naked in a medical setting. Being naked in a medical setting willingly (informed consent) is radically different than being coerced into being naked in a medical setting (aquiescent).
Allow me to elaborate. When a health care provider fails to obtain informed consent, he or she has failed to treat the patient with DIGNITY (from thefreedictionary.org - "The quality or state of being worthy of esteem or respect."). Objects do not have dignity; people do.
To my mind, the issue of "patient modesty" as discussed here is a salient example of providers systematically failing to RESPECT their patients. Whether I am required to disrobe unecessarily, stuck with a needle without warning, experience any part of my body being examined roughly, or subjected to medically unjustified diagnostics, I am being treated disrespectfully. The provider has failed to adequately inform me and/or to obtain my consent. Acquiescence does not constitute consent, even if it can be an aspect of consent.
Banterings:
" but they don't WANT to know it."
I agree whether the issue is PTSD as you have discussed, modesty concerns more generally, or issues of DIGNITY/RESPECT even more generally. The more human we insist on being treated, the harder providers must work. It is easier to command compliance than to ask for it.
I will try to find a link to great article I recently read about the importance of "informed consent" and "assent".
Cheers,
Charles
P.S.
It would be more difficult to check your oil if you had to obtain the car's prmission to open the hood!
Hello again,
The article I had in mind:
Informed Consent, Parental Permission, and Assent in Pediatric Practice
http://m.pediatrics.aappublications.org/content/95/2/314
While this article focuses on the ethics of obtaining assent from children (patients under 18), I find that they largely apply to adults as well. This seems particularly true in a hospital setting where one's signature on a general consent form is often mistaken as informed consent.
Charles.OX, my introductory question was not about how my visitor here feels about exposing their body to others who were undressed in the same environment but whether the visitor who expresses severe concerns about their bodily exposure in a medical situation actually have an underlying philosophy that everyone should maintain modesty regarding their bodily exposure or dress and this philosophy, of course, also applies to the person holding that view.
Let's create a little test here. To those commenting here about the need to recognize and maintain their personal modesty in the medical environment, how do you feel about observing a woman breast feed her baby in public view? How do you feel about observing a woman at the beach wearing a "bikini"? Do you find some ways men or women are attired which you find as "immodest"? If you think all these observations represent a "wrong" in behavior, might I expect that the same view is carried over as part of their own attention to self when my visitor is engaged with a physician or nurse or tech as part of their own medical care? ..Maurice.
Maurice, in response to your quiz, No I do not find breast feeding in public to be immodest personally but like real estate, it's location, location, location. As far as a bikini on a beach, more power to the women who is proud to wear it, however, it has been my observation that one size does not fit all. When it comes to the attire that is worn in public by the general populace, you can't beat diversity.
What I really believe is that when it comes to personal modesty, it is just that, your own personal comfort level at being exposed to strangers whether it be in a medical exam room or on a beach. If I make an appointment to see a doctor, I don't expect to see the doctor plus a live studio audience unless informed consent is obtained first. No Patient Ambush, no video cameras, no walking in without knocking, just simple respect for the patient's dignity and modesty. "Self" as in self respect and that is all the patient, client, customer is asking for.
Ed T
Dr. B.,
In response to your question at the beginning of this volume, I feel that modesty is a personal value for each individual and I have no underlying philosophy that everyone should conform to some arbitrary modesty standard in bodily exposure or dress.
I'm busy enough taking care of me - it's not my position to dictate to others what their modesty standards should be. I respect each individual's right to make those decisions for themselves, and in return expect they will respect my right to do likewise.
If you're looking for some underlying right wing moralist cause as a major contribution to patient modesty issues, I think you're barking up the wrong tree.
Hex
Hello again Maurice,
You ask, "... whether the visitor who expresses severe concerns about their bodily exposure in a medical situation actually have an underlying philosophy that everyone should maintain modesty regarding their bodily exposure or dress ..."
In my case, NO, but I don't think I have "severe concerns" either. I hope there are many responses. I expect a variety of answers. As I am sure people prefer to maintain personal modesty for various reasons, I imagine varying attitudes towards other's modesty as well.
"How do you feel about observing a woman breast feed her baby in public view?"
Indifferent, but my own modesty dictates that I should not look unless I need to address her.
"How do you feel about observing a woman at the beach wearing a "bikini"?"
Indifferent, unless I find her attractive, in which case, I like it.
"Do you find some ways men or women are attired which you find as "immodest"?"
Yes! Except in situations appropriate to skimpy bathing attire, I don't like to see ass crack or underwear. I don't know that I consider it immodest so much as offensively distasteful. I don't think this constitutes a "wrong". I just dislike it. I dislike ketchup.
Maurice,
I have no problem with other people's exposure. I am very liberal in that respect.
"How do you feel about observing a woman breast feed her baby in public view?"
Good for her, that is the best for the baby. Society needs to get over that.
"How do you feel about observing a woman at the beach wearing a "bikini"?"
I would look (not stare).
"Do you find some ways men or women are attired which you find as "immodest"?"
Logically yes, but I am such an advocate of free expression, no. Will I look, yes. I have a very strong curiosity. I can also be flirtatious.
Interesting fact: in the state of New York, the law says that anywhere a man can be topless, so can a woman.
I think the issue here in these volumes is the unnecessary undressing/exposure, the coercion, and the attitude of entitlement to our bodies that we object to. Then the dismissal of our feeling with I am a professional, seen it all before. That is why some people respond then you undress too. It is to point out the hypocrisy in those statements.
And what if a provider responded by undressing first? They would have proved they believe what they are telling me and I would be more inclined to trust them. This is NOT ridiculous either. I cannot find the site any more, but there is a hospital in Australia that the trauma physicians wear only a gown to show empathy for the patients. They realize the degradation and humiliation that patients suffer. They realize that the patients have no choice in the matter either. The blog was called impactednurse (I believe). Although I can't find the blog, here is a link to one of the actual photos.
If I find the story again, I will post it.
Even if we were all Puritans, the issue is that someone else is exhibiting power and control over our bodies. We would never impose that on someone else. We, even more so than the average person, are more aware and respecting of other people's values of modesty.
These are the exact same dynamics and the patient is left with a feeling of a loss of control of their person. Insult is further added to the injury with the attitude of entitlement to our bodies, the denial that we have been traumatized, and the implication that we are mentally disturbed or an anomaly.
I believe that the same thinking is used in healthcare that perpetrators of sexual assault use ( please note that the INTENTIONS are different):
Healthcare believes that a patient will tolerate the humiliation, violation and exposure of one's body and personhood in exchange for life. The perpetrator of sexual assault threatens the victim's life in return for their compliance. Victims have stated that they "went somewhere else," "closed their eyes and pretended it wasn't happening," or end up with multiple personalities. They are told, "you did what you had to in order to survive."
Unlike victims of assault, their trauma is not even acknowledged, they are shamed, ridiculed, or berated for their feelings. I am not going to list any references (I have previously), but there are many by patients and providers saying how the patient "goes someplace else" during the procedure, some even recommend they do it).
Maurice, I fail to see how this is relevant to patient modesty. Is this an attempt to say that if we have a Puritanical attitude that we are some how deficient or unreasonable living in modern society (blame the patient)? If we said "everybody naked" yet complain about our exposure, we are deviants (again, blame the patient)?
PLEASE explain what I am missing!
I will gladly accept the answer being your own curiosity.
--Banterings
Banterings, according to the Merriam-Webster On-Line Dictionary:
Dignity: a way of appearing or behaving that suggests seriousness and self-control: the quality of being worthy of honor or respect
Modesty: the quality of not being too proud or confident about yourself or your abilities: the quality of behaving and especially dressing in ways that do not attract sexual attention
It looks, Banterings, that you may have a good argument to support the change of the title of this thread to "Patient Dignity" or more specifically "One Issue of Patient Dignity" On the other hand, from an ethics principle type of title "One Disregard for Patient Autonomy within the Medical System" Any other suggestions?... though I think it is too late to change this thread's title. ..Maurice.
Again I do this in 2 parts:
Maurice,
Perhaps updating the title is all that is needed. For example:
Patient Dignity [Formerly Patient Modesty]: Volume 72
OR
Patient Patient Modesty [Dignity]: Volume 72
I am especially awaiting the commentary that Ray may have on the concept of Dignity. Perhaps he may have a better definition that I may have missed. I have researched the concept, and had not found any acceptable definitions.
Beauchamp and Childress (IMHO) dance about the concept. That is because (I am assuming) neither had the pleasure of the patient experience. I am sure that their view on ethics would have changed, and added the inclusion of dignity.
The first part of my definition is: Dignity is: Respecting the answers (choices) that others make to the same questions that we answer as to self determine our own existence.
You can see from the responses here so far, regardless of what our views of modesty are, we all respect how others view their modesty. It keeps within my definition of dignity. Historically, those who have head their human rights most severely trampled upon, have risen up to be the greatest champions for civil rights and respecting others. Two people who immediately come to mind are Rosa Parks and Malala Yousafzai (the girl shot by the Taliban in Pakistan for attending school).
Wikipedia has an excellent summary of medical ethics here:
One of the problems in medical ethics is that they allow the physician to override a patient's wishes, but the rational is based on incomplete reasoning. Well known are the conflicts between autonomy and beneficence/non-maleficence.
"Autonomy can come into conflict with beneficence when patients disagree with recommendations that healthcare professionals believe are in the patient's best interest. When the patient's interests conflict with the patient's welfare, different societies settle the conflict in a wide range of manners. In general, Western medicine defers to the wishes of a mentally competent patient to make his own decisions, even in cases where the medical team believes that he is not acting in his own best interests. However, many other societies prioritize beneficence over autonomy."
Continued...
Part 2:
Even justice conflicts with autonomy. A patient is never offered an MRI (or other radiology) when they object to a "hernia exam." Every physician would argue that the test is too expensive, too overly used which in turns lessens availability and raises healthcare costs (justice) and exposes the patient to needless radiation (beneficence/non-maleficence). The incomplete reasoning reasoning is seen in every physician's response to radiology as an option; it is quick, is harmless, routine, then that is usually followed with descriptors such as silly.
That is based on the false notion that "Few people would argue that [physical] health, even if broadly and positively construed, is the only thing that matters in life. " (Source: NIH "Treating Patients as Persons: A Capabilities Approach to Support Delivery of Person-Centered Care") The article goes on to point out: But in the absence of clear and strong reasons to value person-centered care intrinsically (or at least not just for its contribution to health status improvement), its proponents have little scope to argue against health care policies and practices that might undermine it. And some policies and practices do tend to undermine the responsiveness of health care staff to patients as persons,
What is missing is the concept of mental, psychological, and spiritual well being. Beauchamp and Childress, and other ethicists look at the concepts of "physicians' right to pursue life and health to the exclusion of other social values," AND "people should give priority to health above other goals in their lives."
This is contradictory to people who become firemen, soldiers, or martyrs (such as Święty Maksymilian Maria Kolbe [Saint Maximilian Maria Kolbe]. These people put "doing the right thing" above physical health and even mental health. Perhaps it could be described as "spiritual health," fulfillment of the person, or the Buddhist concept of bodhi (enlightenment).
--Banterings
Banterings,
With respect to the autonomy/beneficence debate, all the ethics arguments really don't matter that much as they have no standing in law.
By contrast, in the U.S., there are numerous court decisions that specifically address informed consent and affirm the right a patient with capacity to make medical decisions, including the right to refuse treatment, even if that refusal may be life threatening.
The bar for capacity to make medical decisions isn't all that high - all that is required is that the patient can understand the implications of his or her decisions and whether he or she is, in effect, willing to live with the consequences of those decisions. Further, there is case law that says a patient's refusal of treatment may not be used to challenge their capacity to make medical decisions.
Finally, the U.S. supreme court has, in upholding a decision by the 9th Circuit, ruled that refusing treatment that is likely to result in the death of the patient is not an act of suicide, but is merely allowing a disease or medical condition to run it's natural course.
I actually had a chance to discuss this issue a while back with a friend who is a justice on the 9th circuit - the bottom line is that the 1st, 4th, 5th, 9th and 14th amendments give the individual very broad rights of self determination, and the courts take these rights very seriously.
Hex
Just as an aside, I have maintained from day one that the whole patient modesty issue is really one of dignity and respect.
Hex
Hex,
I am with you on the issue of dignity as well. I have used that term from day 1 on my blog.
I am versed in the laws surrounding informed consent. The problem is that the law is routinely ignored, see Dr. Joel Sherman's article: "Informed consent is missing from Pap smears and cervical cancer screening". Informed consent includes offering a patient EVERY option whether reasonable or not, even if not covered by insurance. Dr. Sherman has also written about sports physicals being needlessly embarrassing. One has to wonder IF anyone who ever objected to the hernia check (whether it be sports or employment) was offered radiology or was the issue just coerced with threats of denial of validating the form?
My point is that providers can justify anything the way ethics (and laws) are written. Think of the phrase that appears in chaperone laws and guidelines: "where practicable". Even before providers are in a situation subject to law (treating real patients), they learn and are subject to ethics (school). There is a deficiency in their ethics, and that is because the focus should be on dignity (see my post above).
Using the example of ethics is to further the notion that this is about dignity, and modesty is part of dignity.
We are both on the same page.
--Banterings
You know, the term "dignity" seems to me more applicable to the healthcare provider rather than the patient. As a physician, I am not interested as to whether my patient appears dignified or expresses dignity. I cannot, professionally, separate the care of the patient "appearing or behaving that suggests seriousness and self-control: the quality of being worthy of honor or respect" or appearing and behaving otherwise.
It is the healthcare provider who must act and respond to the patient with dignity ( that is, meeting the criteria for professionalism). It is us, the professional, who must be act and sen as "worthy of honor or respect".
Thinking it over, attention to the modesty requests of the patient is purely an ethical requirement: it is patient autonomy. Healthcare providers cannot perform their responsibilities, in this era, with the philosophy of paternalism: the patient's desires and decisions must be trumped by the conclusions and directives provided by the healthcare provider who knows "what is best for the patient".
I think, the issue before us here on this blog thread is the "cleaning up" of the remnants of the paternalism era still infecting the medical profession and move on to observe full patient autonomy as patients attempt to deal with their own illnesses and that includes the issues of patient modesty. ..Maurice.
Maurice,
You are confusing the definitions:
1. the quality or state of being worthy, honored, or esteemed
2. high rank, office, or position
3. formal reserve or seriousness of manner, appearance, or language
Source: Merriam Webster Dictionary Online
You are confusing #3 and #1. It is not "patient appears dignified or expresses dignity." It is that intrinsic (in my case Judeo-Christian) value we place on human beings as being made in the image of God. (There are other religious, moral, and ethical concepts similar to this).
My point is that as a physician you realize that you are treating a person and NOT fixing a car. I recently read (I can't remember where, here possibly) this comparison made. The author said, could you imagine if the mechanic had to ask the car permission to open the hood. The difference is dignity, namely human dignity. So yes there is a difference, it is a human and physicians do need to ask permission to "open the hood."
Human dignity is why a physician would treat a homeless person with the same standard of care and respect as the president.
So as a physician, you should be concerned with a person's dignity. I refer to the book (again) by Charles Foster: "Human Dignity in Bioethics and Law." Perhaps I have not fully explained the concept, this book will certainly help clarify the concept.
--Banterings
Dr. B.,
Dignity goes beyond a simple definition. Referring to sources cited on Wikipedia, dignity is a moral, legal. ethical and philosophical concept that incorporates the idea that a human being has an inalienable right to be valued and to be treated ethically. In other words, to be treated with respect.
Human dignity can be violated in multiple ways. The main categories of violations are, humiliation, objectification, degradation and dehumanization.
Compare these to the nature of the modesty violations that have been repeatedly voiced here - sound familiar? It should, as manifestations of these actions are frequently countered when dealing with the medical system.
I agree with you that the remnants of the old paternalistic system need to be cleaned up, but I also feel that the biggest obstacle to this is getting the medical system to recognize and accept that it need to change.
Hex
Banterings,
I agree that we are on the same page.
You wrote "My point is that providers can justify anything the way ethics (and laws) are written. Think of the phrase that appears in chaperone laws and guidelines: "where practicable"".
This is only true if the patient doesn't know their rights. An informed patient that knows their rights and is willing to politely but firmly stand up for them holds the trump card.
This is why I have repeatedly said that the patient needs to be their own first line of defense in making sure their modesty and dignity are respected.
Hex, I and my teacher colleagues are teaching patient autonomy and the importance of awareness of patients' concerns to our first and second year students Now, I challenge the readers here to start with their actions to create the changes desired for the medical system. ..Maurice.
Maurice,
The reason I asked you questions associated with your statements about the relationship between medical examinations and PTSD is because words and sentences carry unintended meanings and unless the listener or reader successfully beckons a speaker or writer to clarify, s/he is destined to carry those unintended meanings into future interactions with the speaker or writer.
You’ve given a precise response to my second question – a “no” to “Are you suggesting that if the relationship has not been ‘discusses or detailed in the major medical journals,’ the relationship does not exist?” Then you explain yourself in probabilistic terms: “It is unlikely that most physicians . . . would be aware of such a relationship without” there being a publication on it in a major medical journal. This response helps me, I think, answer my other questions, so I won’t try to convince you to answer them.
My major concern is with your statement, “I am sure it [the relationship between healthcare examinations and PTSD] would be a rare occurrence.” To be “sure” about such a thing when one has no evidence one way or the other or after being given evidence of a statistical connection seems strange to me. It contributes to a premature closure of inquiry that can be a death knell for scientific progress. If I applied for a grant to deal with the methodological limitations of Janet Menage’s study but the grantors were “sure” that the relationship between healthcare examinations and PTSD would be rare, my proposal would probably be rejected, not on the basis of merit but on the basis of politics.
Ray
Maurice,
To the first two questions you posed, it depends on the situation. I’ve observed many women breast feeding their babies in public. I didn’t feel disgust, I didn’t feel anger, I didn’t feel titillated, nor did I feel outrage. My feeling was, welllll – blase is the only word that comes to mind. On the other hand, if I were to discover that a woman was involuntarily compelled to breast feed in public because of circumstances, then I might feel pity for her, or helplessness at not being able to help her out, or embarrassed for her, or anger at those responsible for her circumstances, or all of these feelings at once. The same is the case regarding a woman at the beach wearing a bikini, although when I was a young man, I confess I probably was titillated on occasions, but I don’t remember.
Regarding your last question, modesty is a matter of degree. My colleague and I used to run together. He wore no shirt and one of those skimpy Speedo swim suits. I wore a T-shirt and regular running pants. He was too modest to run in the nude but he was less modest than I. His modesty level changed real fast along with his attire when one day, while running alone, a Neanderthal in a truck with a 30-06 hanging above his head threatened to kill him if he didn’t get dressed. CONINUED
Ray
CONTINUATION
Now I have a confession to make. When I first began teaching college, an hour was put aside for faculty and staff to exercise together. The big wigs at the school conjured up the bright idea that formal barriers between faculty and students should be obliterated. The best way to do it, they figured, was to encourage faculty and students to exercise together, party together, defecate together, micturate together, and shower together. Now, my belief and that of many of my colleagues was, and still is, that faculty should maintain some reasonable degree of social distance between themselves and students. The level of togetherness expected by the big wigs went more than a mite too far. Apparently some students figured the same way as I and my colleagues. One of these students wrote a piece in the school newspaper about how disconcerted and shocked he was when he walked into a locker room and saw one of his professors as naked as a jay bird. The student’s chagrin was augmented when the professor called him over to speak to him while, at the same time, soaping his nether parts. He expressed great embarrassment for the professor and ended his piece with the capitalized message, “WHERE’S THE DIGNITY?”
DID I PASS THE TEST?
Now I have a multiple-choice test question for you and anyone else who would like to answer it. Answers to the question will help me formulate an argument which will serve as the next step toward accepting your January 25th at 8:21pm challenge. Here we go.
Use what you have learned from research and theories of Lewin, Asch, Milgram, Goffman, Bandura, and Zimbardo to answer the following question: Which of the following options is the best way to reduce the likelihood of patients experiencing unnecessary humiliating events at the hands of physicians? Choose the best answer.
a. Patients should communicate their preferences to each of their treating physicians.
b. A social environment should be created in which patients are uninhibited about communicating their preferences to each of their treating physicians.
c. Require physicians to complete at least one continuing education workshop each year which focuses on how to ensure patients’ dignity.
d. There should be a social movement designed to foster the creation of laws that punish physicians for exposing patients to humiliating events.
e. Medical students should be rigorously trained to behave in ways that would minimize the likelihood of unnecessary humiliating events experienced by patients.
f. Change physicians’ personal dispositions – such as their personalities – so that they are more amenable to avoiding the unnecessary humiliation of patients.
g. Patients should threaten physicians with murder and mayhem if they don’t behave themselves.
h. This question is irrelevant because physicians already take pains to ensure that patients are not exposed to unnecessary humiliating events.
Ray
Hex,
ignity is a moral, legal. ethical and philosophical concept that incorporates the idea that a human being has an inalienable right to be valued and to be treated ethically. In other words, to be treated with respect.
Human dignity can be violated in multiple ways. The main categories of violations are, humiliation, objectification, degradation and dehumanization.
I like that and intend to add that to my
--Banteringsdefinition of dignity.
Maurice,
(I sent this out last night but I guess it didn't go through for it is not posted.)
CONTINUATION
Now I have a confession to make. When I first began teaching college, an hour was put aside for faculty and staff to exercise together. The big wigs at the school conjured up the bright idea that formal barriers between faculty and students should be obliterated. The best way to do it, they figured, was to encourage faculty and students to exercise together, party together, defecate together, micturate together, and shower together. Now, my belief and that of many of my colleagues was, and still is, that faculty should maintain some reasonable degree of social distance between themselves and students. The level of togetherness expected by the big wigs went more than a mite too far. Apparently some students figured the same way as I and my colleagues. One of these students wrote a piece in the school newspaper about how disconcerted and shocked he was when he walked into a locker room and saw one of his professors as naked as a jay bird. The student’s chagrin was augmented when the professor called him over to speak to him while, at the same time, soaping his nether parts. He expressed great embarrassment for the professor and ended his piece with the capitalized message, “WHERE’S THE DIGNITY?”
DID I PASS THE TEST?
Now I have a multiple-choice test question for you and anyone else who would like to answer it. Answers to the question will help me formulate an argument which will serve as the next step toward accepting your January 25th at 8:21pm challenge. Here we go.
Use what you have learned from research and theories of Lewin, Asch, Milgram, Goffman, Bandura, and Zimbardo to answer the following question: Which of the following options is the best way to reduce the likelihood of patients experiencing unnecessary humiliating events at the hands of physicians? Choose the best answer.
a. Patients should communicate their preferences to each of their treating physicians.
b. A social environment should be created in which patients are uninhibited about communicating their preferences to each of their treating physicians.
c. Require physicians to complete at least one continuing education workshop each year which focuses on how to ensure patients’ dignity.
d. There should be a social movement designed to foster the creation of laws that punish physicians for exposing patients to humiliating events.
e. Medical students should be rigorously trained to behave in ways that would minimize the likelihood of unnecessary humiliating events experienced by patients.
f. Change physicians’ personal dispositions – such as their personalities – so that they are more amenable to avoiding the unnecessary humiliation of patients.
g. Patients should threaten physicians with murder and mayhem if they don’t behave themselves.
h. This question is irrelevant because physicians already take pains to ensure that patients are not exposed to unnecessary humiliating events.
Ray
Banterings,
You indicate that you are awaiting my commentary re. the concept “dignity.” Both you and Maurice provided a denotative (dictionary) definition of the concept, and I can do no better than that. I think what you want is a conceptualization of “dignity.” Denotatively defining a concept is one thing, conceptualizing it is quite another; it is a very difficult task but it is a necessary precursor for scientific research because it provides the basis for creating measures of theoretical concepts including “dignity.” It is only via a conceptualization process that one can (dare I use the word) understand a concept, for conceptualization lends to the concept precision and specificity absent from a simple dictionary definition. Back in 1989, for example, Jack Gibbs published a 10-page article in the “American Sociological Review” (one of two top sociology journals) http://ocw.uci.edu/cat/media/F06/99012/gibbs_article_1989.pdf in which he conceptualizes terrorism. He spent an entire book, published in 1979, conceptualizing, operationalizing, and recommending measures for concepts associated with deterrence theory (“Crime, Punishment, and Deterrence”).
Here’s what Earl Babbie in “The Practice of Social Research” (p. 125) writes about conceptualization.
"Day-to-day communication usually occurs through a system of vague
and general agreements about the use of terms. Although you and I
[may] not agree completely about the use of the term ‘compassionate,’
I’m probably safe in assuming that Pat won’t pull the wings off flies.
A wide range of misunderstandings and conflict – from the interpersonal
to the international – is the price we pay for our imprecision, but somehow we muddle through. Science, however, aims at more than muddling: it cannot operate in the context of such imprecision.
The process through which we specify what we mean when we use particular terms in research is called 'conceptualization. Conceptualization produces a specific, agreed-on meaning for a concept for the purposes of research." CONTINUED
Ray
I do this post in 2 parts.
Please note that I do not link to references that I have made multiple times previously, and we do not dispute such as the "hidden curriculum."
a. Patients should communicate their preferences to each of their treating physicians.
Patients who are not afraid already do and are told "I am a professional." "This is how we have always done things." OR "Goodbye."
b. A social environment should be created in which patients are uninhibited about communicating their preferences to each of their treating physicians.
Aren't we already suppose to have this? Also, see answer to "a," above.
c. Require physicians to complete at least one continuing education workshop each year which focuses on how to ensure patients’ dignity.
...and the pharmaceutical companies will sponsor these in Cancun, they may meet the criteria, but the presenter will say this is how to make the process go quicker (A.K.A. the hidden curriculum) OR providers will fall back on "that was not the way I was taught." "I can't afford to hire a male nurse," "where practicable."
d. There should be a social movement designed to foster the creation of laws that punish physicians for exposing patients to humiliating events.
A better possibility. I point to all the bad press of the Brian Persaud case and ATLAS doing a 180 on the use of the DRE, the issue of pelvic exams on anesthetized women and the ACA leading to new guidelines on pelvic exams.
e. Medical students should be rigorously trained to behave in ways that would minimize the likelihood of unnecessary humiliating events experienced by patients.
This is good. But this needs to be carried through clerkship and residency. The definition of humiliating events needs to be changed. Example: Dr. Sherman's stance that hernia exams are not necessary for sports participation.
f. Change physicians’ personal dispositions – such as their personalities – so that they are more amenable to avoiding the unnecessary humiliation of patients.
I like this, except I feel this is unrealistic and not practicable. Additionally, (just as the system is now,) there are too many loop holes that allow them to ignore patient wishes. They would also argue, they are following the guidelines as they were trained to. Look at the recent recommendations on pelvic exams, pap smears, the bad press about physicians requiring (when the law does not require) which makes a barrier to birth control, and how the healthcare community is fighting back saying the exams are necessary and forcing exams for birth control.
g. Patients should threaten physicians with murder and mayhem if they don’t behave themselves.
This would have good results, but is not moral or legal. Before you admonish me, think about this: Have you ever been driving and been cut off by some "idiot" driver? We all have been there. What is your first inclination, lay on the horn, give him the finger, cut him off? Then you think, what if he has a gun under the seat... Does it make a difference if the driver is a distinguished-looking, gray-haired gentleman in a Mercedes OR a 20-something in a 1985 honda with a shaved head and wearing a leather jacket?
h. This question is irrelevant because physicians already take pains to ensure that patients are not exposed to unnecessary humiliating events.
Some do! Some don't.
Continued...
CONTINUATION
The conceptualization of “dignity” may have already been done. If so, I’m not at this point about to take on that task and most people would probably not go through the tedium of reading it. The first thing one would have to do is review writings about dignity, focus on the indicators and dimensions of dignity used, identify any patterns in usage, and use those patterns to conceptualize the concept.
Actually you and Hex have begun the process of conceptualization. Hex, for example identified four forms of indignity. If there are four forms of indignity, then there must be four forms of dignity – personalization, humanization, glorification and elevation. Now, to be precise, one must distinguish each one of these concepts from the other. This exercise tends not to be done off the top of one’s head but by studying the literature on dignity.
I prefer the word dignity to modesty. I write in a CONTINUATION unposted contribution the story of a student whose professor, while showering in a locker room, called him over to speak to him. He writes about his experience in the school paper and ends with “WHERE’S THE DIGNITY?” rather than “WHERE’S THE MODESTY.” What disturbed the student was not that someone who needed a shower was taking one in full view of others but it was a professor (or, it could have been the school president, some administrator, or the president of the U.S.) who was doing this. It wasn’t the immodesty of the professor that bothered him it was the “indignity of it all.”
Furthermore, being treated with dignity is a human right recognized in both international ethical codes and international law. A human right is something that is accorded a human being because s/he is a human being; it is not, by definition, something that must be earned, purchased, demanded, or requested. Nor is it something that can be accorded today and taken away tomorrow. If a highly immodest person with visions of martyrdom who, when ordered by a Gestapo henchman, strips naked with alacrity and stands proudly before a tribunal of judges, that person, no matter his or her sentiments, can be said to have been subjected to indignities. In short, a person can be subjected to great indignities even though it doesn’t offend that person’s sense of modesty. Also, a focus on dignity rather than modesty can be used to parry the cynic who proclaims, “But it didn’t bother her. Why should it bother you?”
When one gets right down to it, then, “dignity” is simply a much more puissant concept and, I think, more consistent with our interests than is “modesty.”
Ray
Part 2:
Read this disturbing blog post: Doctors with a `'God' complex.
Part of the problem is how they were taught. I also think laws need to be harsher because they can too easily say "I was being thorough." We know that with our shortage of doctors, we are bringing in many foreign doctors to fill the gap. Just look at how foreign doctors are trained: India Bans 'Two Finger' Test on Rape Victims and Slideshare: Examination of a Victim of Rape (see slide #48). How can any practitioner of the healing arts possibly justify this voodoo? There is a similar issue in the US:
Medical Examination for Sexual Abuse: Have We Been Misled? (Make sure to read "The Debacle in England," 3/4 down.)
Licensing boards do nothing, Twana Sparks not only continues to practice, and perhaps the most disturbing part of this story is that now she works with children.
What about this as an approach: A change in the law so that providers who deny modesty violations go before a board (50/50 split) of providers and non-providers (this being the socially acceptable part). If found "guilty" by the board, the provider will act as the patient, so as to have the procedure (circumstances, or as close to) professionally recreated (conducted).
Obviously I am not saying cut him open, but the surgical prep for example. This will see if the the provider was trained properly, if he believes what he says, and gives both him and the other providers a chance to review the procedure for improvements.
What harm can this do if conducted properly, after all patients go through these procedures all the time...
I know, it may sound far fetched, but can anyone argue it won't improve the process?
--Banterings
To All: All the recently received Comments have been published. None have been withheld. At times there is a delay in the e-mail notification of a comment to be moderated and I apologize for the delay.
I certainly don't want to delay publication of the current batch of erudite and informative discussions which actually fit my requests for something more than "moaning and groaning" and do provide us with tools to formulate approaches for change in the education and behavior of those in the medical system (both patients and healthcare providers and the administrators.)
Again, may I suggest that an effort be made to Hex, Banterings, Ray, Charles et al to consider independently or as a group to write an essay to be published in the New York Times or other major news source proposing the issues and the necessary changes in the medical system. Philosophizing on this blog, I find, does get a tiny bit of U.S. and world-wide readers (thanks mainly to Google Search) but clearly a "drop in the bucket" compared to the distribution potential for the major news sources. So..go to it! ..Maurice.
Ray,
My first definition of dignity is my own "creation."
Dignity is: Respecting the answers (choices) that others make to the same questions that we answer as to self determine our own existence. At the very least, the questions cover basic human rights. Dignity can NEVER be negotiated, overridden, or taken away, but it can be ignored by others. We may choose to sacrifice or compromise our dignity for what WE deem a higher purpose.
Our dignity exists in the intrinsic value we have as a human being. Life is not a higher issue than dignity, it is one of the choices that we make in regards to our dignity (i.e. do not resuscitate). One person's dignity can not trample on another person's dignity, for then that is NOT an aspect of dignity in the first person. Not caring about an area or choosing not to make a choice about an aspect of one's dignity IS a legitimate option and that area must be respected in others. Source: Archie Banterings
I agree with trying to measure or quantify the abstract. That is why in my post, Patient Dignity 02: But it is Sexual... I only deal with what is observable and quantifiable; i leave all intent and motives out of it.
Let me conceptualize my definition of dignity: A Muslim Imam and Jewish Rabbi are seated next to each other on a bus. Each respects the other's right to free expression, that is to choose a religion. (Conceptually it is: human rights ==> dignity ==> freedom of expression ==> religion.) Each does not have to agree with the religion that the other chose, but they must respect that each HAS the right to choose.
With the story of the professor in the shower, I think that the student is referring more to the "dignity of the office" rather than human dignity. I am assuming that human dignity was protected in that the showers were not co-ed, there were no recording devices, etc. Let me ask this: If there were no mandate of fraternization between faculty and students (assuming that faculty had their own showers), would the student have written the same piece singling out that professor if by his choice he fraternized with students? Your argument only strengthens stratification by class which has historically led to abuses.
Perhaps that is the problem, providers confuse the dignity of their position with human dignity.
--Banterings
I apologize for so many postings, I hope that I am not monopolizing this conversation. After re-reading the posts that I responded to, I remembered this in regards to "dehumanization" after the fact. (I blame it on the ADHD.)
"Dehumanization in Medicine Causes, Solutions, and Functions," by Omar Sultan Haque and Adam Waytz, in the Journal of the Association for Psychological Science OR The Journal of the Association for Psychological Science :
“Anyone who has been admitted into a hospital or undergone a procedure, even if cared for in the most appropriate way, can feel as though they were treated like an animal or object,” says Harvard University psychologist and physician Omar Sultan Haque. Health care workers enter their professions to help people; research shows that empathic, humane care improves outcomes. Yet dehumanization is endemic.
I have stated that it is a physician's training that causes these things to happen, but the training causes a physical change in the brain of physicians. I am not making this up. This also fits in with Ray's question of making changes.
Doctors also show less empathy to patients’ pain than non-doctors do, suggesting they are not thinking of patients as having fully human feelings. A recent neuroimaging study found that, when watching a patient get pricked with a needle, physicians showed far less activation in brain areas linked to empathy. This lessening of empathy, Waytz and Haque say, likely comes from medical training. (Source: "Kellogg Insight," publication of the Kellogg School of Management at Northwestern University"A Patient, Not a Person")
So how do you fix that???
--Banterings
Banterings, please re-create the link to the Kellogg School article, as it is now it just goes to a commercial web-creating website. I would be interested to read the article you referenced. ..Maurice.
Apologies for that....
Here is the link:
"Kellogg Insight," publication of the Kellogg School of Management at Northwestern University "A Patient, Not a Person"
--Banterings
Maurice,
You recommend that Banterings and I submit a piece to the NY Times. I was unable to find out how to get an article published via the internet, or even if it is possible. I’ll have to phone.
Considerable information about patient dehumanization is in the public realm ranging from anecdotes about patients’ bad experiences to books about the participation of healthcare providers in torture and murder, but it is scattered. My first effort to be heard by the general public was in 1994 after I read a piece in Dr. Peter Gott’s syndicated column (http://askdrgottmd.com/about/) about the chaperoning of male physicians by female nurses. I responded with the following letter:
“Dear Dr. Gott: I read your piece “When Should Exams be Chaperoned?” with interest because I was speaking to a class about this very subject on the day the article was published. I and my students have questioned hundreds of patients and health care providers over the past few years. Among our many findings have been reports of sexual improprieties committed by female nurses ranging from the sexual battery of male patients to off-color comments about male and female patients’ genitalia and female breasts.” [I then gave a number of examples and commented on the expressed humiliation felt by patients. The examples came from credible sources – one a Ph.D. nurse who taught a legal/ethics course in a BS-prepared nursing program and a nurse-educator and state representative.]
Gott wrote the following response to my revelations. “I must say that I was astounded by the information contained in your letter of May 26, 1994. In fact, I was so impressed that I plan to use it as the basis for a future column,” which he did. The response to my letter that he received from his readers shocked him even more than my correspondence. In his December 12, 1994 column he confesses, “When I wrote a column about female harassment of male patients, I wasn’t prepared for the avalanche of letters from readers who had either experienced such harassment or were aware of it. In fact, I was careful to say in the original column – and in a subsequent follow-up – that I had no idea of the extent of the problem. I still don’t. But I suspect it is more prevalent than I had assumed” I wrote to Gott asking him for copies of the avalanche of letters or a sample minus the names so I could conduct a qualitative methodological technique called content analysis, but he informed me that they had all been destroyed.
Gott also received “many letters of protest from irate female nurses. In fact,” he wrote, “some nurses in our local hospital claimed that I perpetrated a gross injustice by suggesting that nurses would behave in such a manner.” One nurse was especially confrontational. Gott published her diatribe in his November 27, 1994 column.
Ray
CONTINUATION
“Dear Dr. Gott: I found your piece entitled “Readers Say Harassment by Female Doctors Common” very disturbing. It smacked of yellow journalism. I’m a registered nurse with 20 years’ experience and have never seen or heard of such behavior. In protecting your sources, you have allowed those letters to be published, which questions your credibility and motive. The majority of nurses are patient advocates who would never think of doing any of the things you mentioned. By printing such smut you damaged the physician/nurse relationship. We need to work as a team and this doesn’t seem to be in your agenda. This type of unprofessional behavior should be censored.”*
Dr. Gott pulled no punches when he responded:
“Dear Readers: I never stated that this type of harassment affects EVERY hospital, EVERY nurse or EVERY office. However, it clearly is a problem in some parts of the country. If pointing this out constitutes ‘yellow journalism,’ so be it. I willingly place myself in a class with Sinclair Lewis, the writer who first exposed unfair labor practices and was unfairly labeled a ‘yellow’ journalist for doing so. Pretending that female harassment of male patients doesn’t exist will not make the practice go away. Of course I protected my sources. This is entirely appropriate. In my view, the only unprofessional behavior to be censored in this situation is the harassment itself. Perhaps by raising the issue, I’ve been fortunate enough to begin this process.”
I was quite willing to give up my name, but it was not to be. And, of course, I’ve no evidence that anything was ever accomplished by my intervention and Gott’s support except to anger a lot of nurses and maybe drive Gott to an early grave.
In following years, I mentored students conducting research on topics pertinent to issues we’ve discussed on this blog and wrote theoretical papers, usually designed to explain deviant behavior in healthcare settings, and read them at professional meetings. If providers were present during the latter, they would invariably spit and sputter with indignation at my temerity for explaining things that don’t occur.
People outside of healthcare tend to also be disinterested in addressing the problem. “I wish you hadn’t told me that” is a frequent refrain when I make presentations or speak to people about dehumanization issues in healthcare. I have no trouble understanding where they are coming from and more often than not, I will respond, “Indeed, I myself wish I didn’t know now what I didn’t know then.” George Annas, who spent a lifetime studying the healthcare system posits an explanation for such responses. After dubbing the modern hospital as a “human rights wasteland,” he writes:
CONTINUED
Ray
CONTINUATION
“Civil libertarians have little difficulty appreciating the plight of prisoners or mental patients. But tell the average civil libertarian that there are significant and unnecessary restrictions on the individual rights and liberties of patients in general hospitals, and you are likely to encounter a blank stare. There are a number of reasons for this. One is the general misconception that the problems are minor, or that certain temporary restrictions on individual liberty are essential if hospitals are to treat sick people properly. An unconscious desire not to perceive ourselves at risk may be another reason; we seldom seriously think we will ever be either prisoners or mental patients. But almost all of us have been hospital patients at least once, and each of us will be a hospital patient an average of seven times during our life. By not dealing with the issue, perhaps we are seeking to avoid thinking about our own future hospitalization, an event which is almost always traumatic and undesired.” (“Judging Medicine,” p. 4)
* I’ve also been told by 20-year nurses that they never saw or heard of such things occurring. On the other side of the coin, there have been 20-year nurses, some of whom worked in the same facilities as the former, who informed me that it was a frequent occurrence and a 10-year RN just last year informed me that he could count on one hand the number of times he had seen patients being treated inhumanely by female nurses. Also, participants on this blog may recall the young nurse who described her co-workers, including the head nurse, allegedly lifting an unconscious patients’ sheet to admire the size of his penis. She wondered if she should report it. A 20-year self-identified nurse confessed that such things occurred in every hospital where she worked and coached the writer not to say anything but to simply continue to act professionally. This recommendation is enlightening in the sense that the nurses’ professional ethics require them to report such activities.
Ray
What has happened to our female contributors from the previous Volumes? This discussion regarding the understanding of the anatomy,physiology and pathophysiology of what the issue of "patient modesty" is all about should not be discussant gender limited. Right? ..Maurice.
WOW!
Even as cynical as I am, I am shocked by what you have written.
Thanks for taking the time to write here.
We should collaborate and publish as Maurice suggested. I have some ideas, but I need a little time before I can articulate them.
Between this blog and Joel Sherman's ... information overload ...
Maurice:
Thanks for hosting this discussion! It is important.
Choice, choice, choice.
When women breastfeed in public or wear bikinis to the beach it is THEIR CHOICE. What happens to patients in hospitals is very often against their will or without their knowledge.
Many other patients are either told or believe that if they don't strip and allow the nurses to gawk at and fondle them they won't receive treatment. Still others believe that these "angels from God" are beyond reproach and would never do anything inappropriate or unnecessary. They're fooled into trusting them and end up getting emotionally destroyed by those unethical perverts.
Mom
Welcome Mom. I don't think I have seen you post here before. Are you new?
Mom's comment got me to thinking about when the most complaints from patients are, and that is at a hospital or first time visit with a new physician. These are places where there is no relationship with the patient. Logically, you may say treat a patient badly, they are moving on until they find a provider who treats them with respect.
But why does that have to be? What about the person going in for surgery or taken to the ED? Why are they not afforded humane treatment?
I think that it goes back to the new patient or one-time patient being dehumanized by the provider. When you have a relationship with a provider, they are forced to treat you as a human being because they know you.
Speaking of dehumanization, I am surprised that I have not seen any comments to the study I posted and the finding that on a MRI, providers showed less empathy to human suffering than non-providers.
This question goes to Ray:
Since this topic has been ongoing for almost 10 years, and due to anonymous postings there is a certain lack of data validation. Bu the nature of the length of time and the consistency in the responses, what are the research implications of this as a qualitative (not necessarily a quantitative) study?
It is rare from a research perspective to see such a continuous, well documented stream of data.
--Banterings
Dr. B:
I am a female, long-time reader of this blog although I haven't commented in quite some time. I have wondered also if the other frequent female contributors have quit or are (like myself) just reading. Although I do find the current threads toward analysis of the causes of the lack of attention to patient modesty/dignity quite interesting I do think the blog has morphed into one that is addressing male concerns more frequently. And that may be understandable in light of the fact that the majority of nurses, assistants, techs, etc. are still female, although that may be slowly changing.
My general thoughts about the whole subject are that there will probably never be a system-wide solution as most people have accepted the status quo of mixed gender providers. They just don't question it and if it bothers them they either avoid care or "suck" it up. As for myself, if and when I need to seek medical care I will address my concerns and needs on an individual basis. I am no longer too timid nor do I feel embarrassed to speak up. Jean
Jean, thanks for responding. I think one value of this long running thread is to support and encourage what you are doing "speaking up" as the tool the individual patient can use in the interaction with their healthcare provider. And by the way, the "speaking up" or "speaking to" should not be limited to the patient's physician but also to the nursing and administrative staff. In a doctor-patient relationship, the patient is not "serving" the doctor, it is the doctor who should be "serving" the patient. That is what the medical profession is all about. Yes, for that relationship to be effective and come to a patient's final benefit, the patient must "cooperate" with the physician in terms of providing the necessary history and permitting a physical examination of clinical value. Nevertheless, there must be communication, each "speaking to" between the two to allow effective "cooperation" (working effectively together) to attempt to achieve the final goals. And that is where the doctor "speaking to.." will provide the basis for informed consent and patient "speaking to.." in order to set the limits for consent.
I think one problem most doctors have not included in their vocabulary or have experienced from their patients is "patient informed dissent". (I think nursing staff is a bit more aware of informed dissent than the doctors.) I think doctors, generally, make assumptions (as indeed I have in the past) that the patient's goal interacting with their doctor is only to attain relief of symptoms and cure of the illness. Doctors, in their busy practice life, cannot imagine that a patient's goal in this relationship is anything other than "get better". Yes, we doctors know there are some embarrassing issues for the patient in both history-taking and physical exam but that finally it is "relief and cure" which is utmost in the patient's mind and the patient's reaction to what is happening.
It is to reverse this "wrong assumptions and conclusions" by physicians where the patient "speaking up" is so valuable and indeed necessary.
So.. "keep up the speaking up!" ..Maurice.
Jean: I am glad to see you back. You have made excellent points about how we will probably never see a system-wide solution. The medical industry is too big. Patients who care about their modesty have to go to medical facilities / practices that accommodate their wishes. This is exactly why we have an all female ob/gyn directory and online directory of men’s clinics with all-male staff. I remember you mentioning that you had to drive about 100 miles for female care. Many women felt strongly about their modesty when they were younger, but they felt they had no choice because there were only male gynecologists in their area. It is great that you stand up for your rights to modesty.
Dr. Bernstein: I appreciate your great points about how patients must speak up. It is true that the doctor should be serving the patient. This means accommodating his/her wishes for modesty. This reminds me of how urologists should hire more male nurses and assistants to accommodate their male patients.
A number of doctors know that patients value their modesty. This is evident in the fact there are many all-female ob/gyn practices and a few men’s clinics with all-male staff in the US. I have talked to a number of all-female ob/gyn practices over the years and they are well aware that many women do not want a male gynecologist under any circumstances. It is encouraging that many women in big cities have the luxury of being guaranteed they would have a female gynecologist for emergencies. But this choice is not available in many small towns. Men’s choices are even more limited because there are not that many men’s clinics with all-male staff in the US even though some urologists have hired more male nurses and assistants.
Misty
Again, I do this in 2 parts:
On my blog I say "I will write the truth on the back of a shovel and hit you with the shovel" as a metaphor for being brutally honest. I also have saw this issue as dignity, and from day 1 on my blog addressed it as such.
In doing my research I cam across a fetish site and their forum where they discuss both things related to their fetishes and things unrelated. Some topics overlap. Medical fetish play and real life medical encounters obviously are one of them.
One thread that struck me had a couple people (one in particular) who were very modest in real life medical settings. I did not thoroughly read the thread, I am not sure what fetishes the modest people had, but I suspect that most people, especially providers would find it interesting that people who engage in such activities, sometimes in a group setting, have modesty issues.
There were also those who said they have no problem getting undressed, many prefer it because the goal is their health. They may have lower inhibitions, some even admitted a certain thrill, but they all linked it to their health. The same went for the gender issue; the modest people did not like cross gender care while the less inhibited did not care. In fact, many stated that they had an opposite gender doctor, but that was because the quality of the doctor and not gender.
Those demographics resembled those of society, some modest, some not, some in between, but all expected to be treated in a dignified manner. To me that is no surprise. I still have friends today from when I was doing research among that subculture. A few years ago I had some consumer demographic profiling (marketing research) as a favor to a friend. I was invited to the premiere party for the launch of his artistic website. I was talking to one of the performers (who also worked as an exotic dancer) at the party. It was a Saturday night and getting late. I said I was leaving soon because I had a 3 hour drive and I promised my wife I would be home to go to church in the morning.
She exclaimed OMG, you understand. Even when she dances, she does not go out to breakfast late night on Saturday because she goes to church every Sunday. I simply stated, that industry does not make people bad, not spiritual, or wanting to be treated as a human being with dignity. My friend has the typical suburban family, and is married to a very modest soccer mom. Having proclivities as such do not make you a bad person, they make you human. As such, you are entitled to human dignity as bestowed upon us by our creator.
Continued...
Part 2:
Then I saw another thread talking about school physicals. I suspect I am going to get a lot of feedback on this, especially from Dr. Sherman. There was discussion and links to images; mostly PG rated, actual school physicals, not staged, not pornographic, and most in foreign countries. One of the things that I took away from the conversation and the pictures kept in line with the conclusions of the Stamford Prison Experiment.
That was, the group of children in their underwear waiting next to be poked and probed in front of everyone, provided a support system for one another. Even though very humiliating, I noticed that the ones in line were smiling and laughing. (I cannot remember this so if anybody knows this, please contact me.) There was a study that concluded that a person was more comfortable being naked in a group of naked people, even when there were fully dressed people also present than being the only one naked.
I know that is common sense, but without a study, you can be marginalized. The 70th anniversary of Auschwitz reminded me how the prisoners of the camps supported one another. This is not to say that we should assembly-line naked patients, I am pointing out that this dynamic along with efficiency may also contribute to the paternalistic view of controlling patients. The group socializes itself and supports those roles of subservience, offering some comfort otherwise there would be a revolt.
While on the subject, this form for the Rochester NY School District physical exam parental consent. It states:
"Your child will be asked to disrobe to underclothing: boys will wear socks and underpants; girls will wear socks, underpants, and a loose shirt without a bra or undershirt. While every effort is made to preserve dignity and privacy, most health offices are too small to provide the level of privacy your child may be used to in his/her private provider’s office. Other children of the same sex may be in the changing area. Your child may need to walk small distances partially clothed to get to, from, and around the exam area. The exam includes a complete head-to-toe screening of all major organ systems, INCLUDING BREASTS/PUBIC AREA FOR GIRLS AND HERNIA/PENIS/TESTICLES/PUBIC AREA FOR BOYS, AND INGUINAL/GROIN AREA FOR PULSE EXAMINATION FOR BOTH GENDERS. The examiner will touch your child. There may or may not be an additional person as a chaperone present during the examination. THIS IS AN INTIMATE EXAM BEST DONE IN YOUR PRIVATE PHYSICIAN’S OFFICE BY A PROVIDER YOUR CHILD KNOWS AND TRUSTS."
I realize that the form is a CYA, but it almost seems to me to say "you can't trust our physicians" and "your children are going to feel like they have been raped." I wonder if a parent can cross that section out? This form seems to fly in the face of so many guidelines; earning the patient's trust, informed consent, right to refuse treatment...
Now let me take Maurice's theme of this thread one step further: Most physicians that I know tend to be conservative and modest. So based on Maurice's premise do patients with modesty concerns extend them to all members of society, then how do you explain what happens to patients at the hands of modest physicians?
If you say necessity, then I respond with my theory of Superego Repression. Even if we were Puritans, we still deserve to have our dignity and modesty respected.
--Banterings
Banterings,
The form you found about school physicals is very disturbing. I read an article last year about how a mother was upset that her 11th grader was required to have a genital exam in Buffalo. Parents / students need to fight to end those unnecessary intimate exams. Can you please give me the exact link you found this form on?
Misty
Hello Everyone. My comment is mainly directed toward Misty. First I want to make it very clear. I DO NOT agree with these exams. I agree they need to stop. But I read the form. Here are a couple of comments from that form. They made it clear that the student would be examined a minimum of 6 times through out their 13 years in school. They stated you have a right to be present. They warn you about a chaperone being present. Then they stated , this is a intimate exam best done in your private physicians office. And lastly, An examination WILL NOT be done in school without your signed consent form. Look at all the warnings you are given. If you go to the physicians office today as a adult they won't give you this many warnings. Also unlike in the past they tell you to go to a private physician and they will not do the exam with a signed consent form. I believe because of people posting here those changes where made. People spoke up and complained to the school. Sometimes change comes very slowly but I do see change. Thanks to all who work for this kind of change. My last comment. All the medical field has to do is ask. Let the patient choose what they are most comfortable with. AL
Al,
I am the one that posted the link to the form. I like your observation that the form provides more disclosure than any patient consent form.
This form is a direct result of some very egregious violations of children. Here are the big 4:
On March 19, 1996 at the J.T. Lambert Intermediate School in East Stroudsburg, Pennsylvania
The most disturbing thing about this incident is:Dr. Ramlah Vahanvaty, who performed the exams... She said, "Even a parent doesn't have the right to say what's appropriate for a physician to do when they're doing an exam."
on November 5, 1998, in Tulsa [OK]
The most disturbing thing about this incident is:They forcibly removed the clothes from numerous children between the ages of three and five--over their cries of fear and desperate attempts to resist--and proceeded to probe the genitals of the now-nude children.
on November 2009, in the School District of Lebanon [PA]
Multiple incidents in the Buffalo Public School District, the most recent March 2014
What I find most concerning is that the form violates the Federal Patients' Bill of Rights. What happens if they cross that section out?
If you read the form, no gowns or drapes are provided... So much for conducting in a professional manner with appropriate draping. That violates all ethics and guidelines. The parents are not aware of the guidelines, but you would think that a parent who is a provider would file a complaint with the state licensing board, but the white wall holds strong.
Forgive me for starting to rant. What bothers me is to see what children are subjected to. How many practices still don't provide gowns for children. Do you think these are the "let-me-explain-what-will-happen-when-you-are-still-dressed" exams, or the "drop'em" exams. What will happen (do you think) if the child refuses that part? Threaten to call the police for truancy because they are expelled for refusing?
I think that it is perhaps childhood was where many of us first learned who our bodies belong to...
--Banterings
Maurice,
I recently asked that you in particular and others in general answer a multiple choice question with several response options. Banterings was the only one to take a stab, but he did not follow directions. It is a question the answer to which requires the ability to critically think; in this case, to infer the correct answer from research findings and/or theoretical propositions.
I’ll ask the question again but this time give the respondent a greater chance of getting it correct than last time. And, I’ll change the question a little by cutting out the names of Lewin, Asch, Milgram, Goffman, and Bandura. I’ll leave Zimbardo in because he borrowed from the latter five theorists/researchers to formulate and test his theory.
QUESTION: Use what you have learned from Zimbardo’s research and theory to answer the following question: Which of the following options represents the best way to reduce the likelihood of patients experiencing unnecessary humiliating events at the hands of physicians? Choose the best answer.
a. Patients should communicate their preferences to each of their treating physicians.
b. A social environment should be created in which patients are uninhibited about communicating their preferences to each of their treating physicians.
c. Medical students should be rigorously trained to behave in ways that would minimize the likelihood of unnecessary humiliating events experienced by patients.
d. This question is irrelevant because physicians already take sufficient pains to ensure that patients are not exposed to unnecessary humiliating events.
The answer to this question or the refusal to answer it will determine the structure of my next contribution to this blog. I then hope to address the questions you asked on 12/30 --
“. . . 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 . . . blog thread? . . . What would you recommend?” Will speaking up or to “the elements of the system by patients and their families” help bring about “overall change?”
Ray
Maurice,
I came across this story about modesty. It is the reverse of what we talk about here: High-Schooler Told to Cover Up for Exposing Her Shoulder.
There is a picture of the dress, see what you think. Lone Peak High School is in a suburb of Salt Lake City which has higher standards of modesty due to the prevalence of the Mormon culture there.
I think that the relevance of this story is in relationship to another story I referenced: LDS Hospital in Salt Lake City, Utah did as part of their overhaul of healthcare delivery in 1998:
SOME PATIENTS were especially bothered to spend half the day without underwear -- for shoulder surgery, say. Ms. Lelis was convinced this longstanding practice was meaningless as a guard against infection, persisting only as the legacy of a culture that deprived patients of control. "If you're practically naked on a stretcher on your back," she says, "you're pretty subservient." The nurses persuaded an infection-control committee to scrap the no-underwear policy unless the data exposed a problem; they have not. Source: The Wall Street Journal
Could one possibly infer that higher modesty standards of the providers led to more patient protections in 1998!
--Banterings
Hello all,
I think we loose a little something important in this discussion when we focus narrowly on the most extreme cases of physician abuse. Firstly, these cases will almost always be addressed with real legal and civil consequences. In Lebanon, I could be wrong, but I think it was millions. Or maybe I am confusing this with a similar case out in Arizona (head start). I will be too lazy to dig up citations now; too tired; been sick all week. MY POINT! We have all read some horror stories; I suspect many of us have lost a little sleep for it; I KNOW I have. I think we are better served by focusing on the day in day out issues that everyone has experienced.
One idea I have: a collaborative publication .... "how to maintain respect in a medical setting", or better yet, something more simple. I imagine something short and written in simple language. It should educate the reader of his/her rights and offer some practical tips as to how to safeguards those rights. How to distribute ... no clue ... not there yet. :)
As always, feel free to laugh at me. It's just an idea, maybe good, maybe not, maybe a jump to a much better idea.
Seems like an intelligent and decent little group here. I was particularly encouraged to see Mom and Misty chime in again. As Maurice implied, the conversation became a little too male-centric.
So to this little group of iconoclasts: let us think small. A little bigger than this blog but much smaller than an act of congress. WE CAN DO SOMETHING!
I love maths. 1 + 1 = 2. Except when human beings are ivolved, 1+ 1:always seems to be something greater than 2.
Call me dumb, but I say "let's play"
Charles
Ray, I would say that the only response which has a chance of working is " b. A social environment should be created in which patients are uninhibited about communicating their preferences to each of their treating physicians."
"a." won't work if the physician is not conditioned or free to listen
"c." won't work if they turn out be doctors who are limited in their ability or time to listen. Since what is "humiliating" to one patient may be more tolerable to another. The only way to tell how a patient may feel which behavior is intolerable is for the doctor to actually listen to what the patient has to say and that means "b" should exist.
"d" doesn't exist.
That is my response. ..Maurice.
Charles,
Hope you are feeling better.
The East Stroudsburg School District settled for $7500 per child.
But you miss the entire point, even by your own words.
They only settled civilly, there was no criminal prosecution! The same with Dr. Twana Sparks and Dr. Stanley Bo-Shui Chung.
Twana Sparks is still practicing and involved with children's charities!
Many Physicians defended (and still do) the exams Dr. William Ayres preformed!
I can list abuses ad nausium...
In opening statements presented Monday, the hearing was told that Patient A underwent nine pelvic and nine breast examinations in a 10-month period when she was 17.
Another woman, Patient B, had 71 pelvic examinations over a 24-year period, 41 of which were deemed medically unnecessary by an expert witness who will take the stand Tuesday afternoon. Patient B also had 62 breast exams, 46 of which were deemed unnecessary, over the same time.
A third patient, Patient C, had 229 pelvic and 159 breast exams over a 24-year period. Of those examinations, 86 pelvic and 131 breast examinations were deemed medically unnecessary. Source:
During the cross-examination, Alice Cranker, counsel for the College, told Chung that Patient A had 18 pelvic and breast examinations in just over two years. The lawyer asked him if he now believes every examination was necessary.
“They were necessary at the time of presentation,” he said, adding that in hindsight, there may have been some that were unneeded, but there was no way of knowing that until the examination was performed.
I ask, at what point does "MEDICALLY NECESSARY become ABUSIVE?
AT what point does ABUSIVE become CRIMINAL?
How do you think the East Stroudsburg children approach healthcare now?
Dr. Ramlah Vahanvaty, who performed the exams... She said, "Even a parent doesn't have the right to say what's appropriate for a physician to do when they're doing an exam."
Many physicians defended her position when she should have been in front of the licensing board.
Again, the problem is that healthcare has granted itself rights that go unchecked!
People (patients) are fighting back. I personally do not agree with the mandatory drug testing that California physicians are facing or mandatory finger printing that Delaware physicians must go through, but these are backlashes from the lack of self-policing.
Guidelines are useless because they are only recommendations (which is good if the physician treats every patient as an individual and errs on the side of the patient's wishes), they include some "where practicable" clause, and anything can be justified as being "medically necessary."
EVERYONE, PLEASE COMMENT ON THESE QUESTIONS!
I ask, at what point does "MEDICALLY NECESSARY become ABUSIVE?
AT what point does ABUSIVE become CRIMINAL?
Please note that I did not cite sources for the above cases as I have cited them multiple times previously.
--Banterings
My answer to the QUESTION:
a. Unworkable
b. A social environment should be created in which patients are uninhibited about communicating their preferences to each of their treating physicians.
c. Worthless
d. False
BJTNT
"Twana Sparks is still practicing and involved with children's charities!"
Disgusting
Ray, I take option G
Maurice and BJTNT
Thank you for responding. You are both, of course, correct. Only “b” can be inferred from Zimbardo’s theory and from the research he and others have done.
Maurice, if “b” is correct in the “real world,” then your mantra “speak up and speak to” necessitates context. Tell me if I’m incorrect. Based on what you’ve written regarding the content of your medical student teachings, I’m guessing you recognize the importance of social environments* (or social situations) created by healthcare providers in determining how comfortable patients feel about communicating their dignity needs to those providers. I’m also guessing that you consider credible my and other bloggers’ belief that the typical social environment discourages such communication. Finally, I’m guessing you believe that where needed, a change in healthcare settings’ social milieu is primary but in the meantime the only option patients have is to “speak up and to.” Sometimes the provider will comply, sometimes the provider will refuse; sometimes the provider will couple the refusal with good explanations, sometimes with specious explanations, threats not to treat, ridicule, derisive laughter, brow beating, or worse.
You’ve written frequently about your approach to teaching students. It appears that one of your goals is to inform them regarding how to create an environment which is conducive to patients’ “speaking up and to.” You’ve also told us that you don’t know if what you trained them to do during their second year of education sticks with them in later years. Here is what Hague and Waytz writes about that: “During medical school, students report being the most empathic during the first 2 years of school, but report empathy declines as soon as significant patient contact occurs in the 3rd year of training, persisting for the final clinical year of school. A systematic review of 18 longitudinal and cross-sectional studies on changes in empathy over time in medical students and residents demonstrated that empathy decreases as education and training increases, especially as training becomes clinical and requires more direct patient interaction. This reduction of empathy likely directly contributes to increased dehumanization.”
If you take Hague and Waytz’s assessment to heart, how discouraging it must be for you to realize that much or all that you have taught students about how to humanize healthcare delivery is dismissed by many if not all of them as they face the realities of their profession. Recommendations for humanizing healthcare must include ways of dealing with whatever it is that occurs after the second year of training that contributes to maintenance of the status quo. What situations do students face that have the power to uncouple what you and others have taught them? You’ve mentioned a couple of these situations including the ungodly hours they are required to spend when in clinicals. What else goes on?
Ray
A Banterings
I would like to point out to all of our readers
that Dr. Sparks never was an employee of the
hospital, but rather acted in the capacity as a
free agent for the facility. All nursing staff are
equally culpable to allow her behavior, a non
hospital employee, to enter that medical
facility and molest, assault her patients. True,
the nurse anesthetist was terminated for bringing
the issue to administration, yet she did so after
years of observing the behavior of Dr. Sparks
which came about after some interpersonal
disagreement. Was this an isolated incident that
occurred at this facility, absolutely not. I'm
suggesting this kind of aberrant behavior occurs
every day of the week at every hospital.
PT
Ray, your "guesses" about my recognition and considerations are correct.
With regard to the instructors' frustration about the effect of the "hidden curriculum" in years 3 and 4 and beyond on the humanistic approaches we have been teaching our first and second year medical student, yes it is of concern and I do warn my students about the "hidden curriculum" and give them suggestions as to what to do about it. At our school, they have the ability to talk to program supervisors, without personal academic harm, in their clerkships if they they observe or are pressured into unethical and unhumanistic actions without having to directly challenge their supervising residents or attending staff. The facts in the literature do show that there are some students who "buck" the "hidden curriculum", despite the pressures of trying to please their supervisors and performing with more and more responsibilities, and carry out with them the ethical and humanistic behaviors we have taught them. ..Maurice.
PT,
First, Hospitals [can be] Held Liable For The Acts Of Independent Physicians See the cases were Roessler v. Novak and Malcolm v. Mount Vernon Hospital. So it doesn't matter.
Second, The Supreme Court has said that there is no definition that solves all problems relating to the employer-employee relationship under the Fair Labor Standards Act (FLSA). The Court has also said that determination of the relation cannot be based on isolated factors or upon a single characteristic, but depends upon the circumstances of the whole activity. Source:
On the federal level, there are 3 definitions used to describe the employer-employee relationship:
-- English Common Law definition of an employee. (Formerly known to the common law as servant; as in a master-servant relationship.) See: Employee Legal Definition:
-- IRS definition of an employee. See: Independent Contractor (Self-Employed) or Employee?
-- DOL (Dept. of Labor) definition of an employee. See: Employment Relationship Under the Fair Labor Standards Act (FLSA)
-- OSHA has it's own definition of an employee which slightly differs from the DOL definition. I will not include that because that deals with control of the site.
It would be very easy to prove that Twana Sparks was an employee of the hospital (especially due to the length of time she had a relationship with the hospital), OR the hospital admits gross negligence for not having the same control over its independent contractors as it would (for patient safety) over its employees. Having that control for safety, would make her an employee.
Here are a couple more articles about physicians as independent contractors:
Doctor Was Employee, Not Independent Contractor, Tax Court Says
Physician Employment and Independent Contractor Agreements
PHYSICIAN EMPLOYEE V. INDEPENDENT CONTRACTOR STATUS - WHY IT MATTERS
The problem there was the plaintiff needed a better attorney...
--Banterings
Thanks for your feedback, Maurice. Given the pulls and pressures to behave unethically and/or illegally in many social settings, it is fascinating to me that there are people who resist them, so fascinating, in fact, that I think it is far more challenging to explain why people resist temptation than to explain why others do not.
I have asked students if they had ever done something they were expected to do although they thought it didn’t seem quite right, and they simply couldn’t put their finger on the source of their uneasiness or articulate an objection. Most acknowledged that they had had such experiences. And then I would confess, so had I. Maybe, I proposed, what we were expected to do violated our sense of ethical propriety, but because we did not have a good solid ethical foundation we were unable to convince ourselves not to carry out those questionable actions expected of us.
I have asked 4-year nursing students in and after they have completed ethics courses to repeat back to me the ethical guidelines of nursing. Most of these individuals were able to give vague reference to some ethical principles but none gave any indication that they understood what they were saying. Not a single student could tell me what the very first ethical statement in the ANA’s Code of Ethics with Interpretive Statements was. I’ve wondered for some time now if having knowledge of and having a deep understanding of universal ethical guidelines would go a long way in insulating people from the urge to follow the crowd; the more solid a person’s ethical foundation, the more likely that person will resist the pulls and pressures to engage in ethically questionable behaviors. Zimbardo and some others of his ilk, however, believe that having a solid ethical foundation would not make a difference. Zimbardo writes in “Pathology of Imprisonment,” “Many people, perhaps the majority, can be made to do almost anything when put into psychologically compelling situations – regardless of their morals [and] ethics . . .” But he makes this assertion without evidence. So, I wonder.
Ray
Ray and maurice:
You are both WRONG!
Option b is just more happy horse shit.
Option g is the correct answer.
This IS not about ethics. It is about POWER.
Top down:
Better laws and better law enforcement.
Bottom up:
Speak up! lol
When I threaten my provider with violence, it conforms to my wishes immediately and without question.
I do use this technique. IT works!
Dah?
Maurice,
On 12/30, you asked me the questions, “. . . 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 . . . blog thread? . . . What would you recommend?” I will postpone my response to these questions and reply first to your next question, “Is formal and specific research (sociological, psychological, legal, ethical, etc.) the only method for establishing the approach to change?”
By way of response, I know of no studies in the “hard sciences” (e.g., biology, physiology, chemistry, etc.) or in psychology (a discipline which has its origins in biology) that give us a hint as to how to best foster systemic changes in social institutions (e.g., family, marriage, the polity, the economy, healthcare, etc.). If you know of any, please inform my ignorance by referencing them. It appears to me that if one wishes to consult science for ideas regarding how to best foster institutional changes, s/he must necessarily look to the relevant social-psychological and sociological/anthropological studies that have been done.
The second question you asked on 12/30 (‘“ Speaking up’ or ‘Speaking to’ the elements of the system by the patients and their families would be of no overall benefit for change?”) does not seem to follow seamlessly from the first question because “speaking up” for one’s rights, needs, and/or preferences (which I assume is a reasonable interpretation of what you mean) is an approach to change rather than a “method for establishing the approach to change.” However, I can address your second question with some degree of facility if your intention is to ask about “two methods for establishing the approach to change,” one being consulting with science and the other being the use of common sense, individual initiative or some other construct that can be categorized as a “method for establishing the approach to change.” One of many approaches that can be subsumed beneath this heretofore unlabeled method includes speaking up for one’s rights, needs, or preferences.
Ray
I do this in 2 parts:
Maurice et al,
Ray makes an extremely valid point about the disconnect between hard science and social institutions/systems. When we apply hard science, ANYTHING can be justified (the Holocaust, Guantanamo Bay, Bo-Shui Chung's unnecessary exams, NSA gathering cell phone data).
That was the downfall of Communism: The capitalist and communist models may be compared in terms of the principle of utility which demands the greatest satisfaction of human needs. Communism used hard science and defined justice as such. What lacked was the humanist perspective that shows (I hate like hell quoting Rush Limbaugh) "you cannot spread prosperity equally, but you can spread misery equally."
The communist model further fails to account for human emotion in response to the model. If one can never achieve upperclass wealth and the privileges that it brings, then there is no incentive to be super productive, in fact, just has been argued of our welfare system in the US, there is incentive to NOT be productive. Many of the human rights violations under communist regimes can be traced to hard science. The ultimate goal is the preservation of the society and the moral values of the solutions have always been excluded trumped by hard numbers and efficiency rates. Examples include Stalin's Gulags, prison labor in China, (even ) slavery in the US.
Perhaps the best example in healthcare is the old school physical exam with the patient naked throughout the whole process. A model of efficiency, but healthcare failed to realize that it is uncomfortable for the patient being the only one naked in the room. The civil rights movement is truly the basis of many reforms of patient dignity by raising awareness of human rights and human dignity, and empowering people to fight for them.
While I do NOT agree with Charles's solution, it does illustrate the imbalance of power in negotiations (or speaking up) between the physician and patient. Historically, healthcare has played the "saving lives" card. Who would dispute saving human lives, especially your own? The civil rights movement has focused on quality of life (as seen by the saying "Better to die a free man than live a slave"). All guidelines say "my way" or let the patient seek out another provider. Many times this is not practicable if not impossible.
Charles's implication of threats (the health, well being, and life of the provider) gives the patient on equal bargaining power with the provider; a "life for a life" if you will.
There have been some theories that suggest that increased power and abuses by law enforcement have led to increased violence against them and a reduction in respect for them as a whole. One such theory dealt with African American conviction rates vs non-African American. The thinking is that if you are African American, and you are arrested for a crime, you are facing a higher chance of conviction and a stiffer sentence. Couple that with profiling and from a purely scientific risk analysis, a gun fight seems logical.
I do not have citations on hand for these theories, I am sure that Ray is aware of what I speak and can cite them. I think the plight that LEOs are facing is very similar to the situation with physicians. I also think there is a certain arrogance of the profession, just as pelvic exams being required by most physicians for oral contraceptives despite guidelines stating the opposite, and the police turning their backs to the NYC mayor at the funerals of the slain officers.
Here is a good editorial that sheds light on the NYC police example (via the AP): Serving The True Call Of Duty
Continued...
Part 2:
I believe that we have not seen that here in the US because of "ambulance chasing" lawyers. The public takes some satisfaction in (ate least the appearance) that offending providers face some punishment. I believe that with the ACA and states limiting torts against providers, the "white wall," and the impotence of licensing boards, when one is left crippled and has no recourse, facing an unpleasant life, what is left for them to do? How can they get justice for themselves?
Even in recognition of patient autonomy, the humanistic concept is discounted by the hard science: When does a patient have the right to refuse lifesaving medical treatment? and Autonomy, religious values, and refusal of lifesaving medical treatment.
Here is a disturbing trend in healthcare that is justified by science, but is contradictory to social an ethical values: Refusing to treat smokers is unethical and a dangerous precedent
As to Ray's question of hard science addressing changing the system, I think this article comes closest in the acknowledgement of the patients would choose to refuse life saving treatments. I gave a copy of this to my physician and his reaction was the same as Maurice's reaction; almost a disbelief that this can occur. Tomophobia, the phobic fear caused by an invasive medical procedure - an emerging anxiety disorder: a case report
--Banterings
In a follow up to my previous 2 part comment that expanded on Ray's concept of "hard science vs humanism, let me demonstrate another current (August 2013) example where science defies common sense: Russian Military Recruits to Undergo ‘Gay Tattoo’ Checks in New Kremlin Clampdown on Homosexuality.
Granted that some tattoos may be indicative of homosexuality (two male symbols of the arrow and circle interlocked), but this is basically absurd.
--Banterings
Maurice,
When first I read your second 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?”), I considered it a rhetorical one since you’ve answered it many times throughout the years, the last time on 1/27. Your consistent refrain has been “speak up or to.” It has become your signature recommendation to patients for humanizing healthcare delivery. It appears clear that you believe that the best way for patients to foster changes of the sort we’d like is: 1) by each patient letting a treating or caring provider know how to best preserve his or her dignity before that dignity is compromised; 2) by challenging, politely but frankly, what s/he believes to be inappropriate, dehumanizing, degrading, etc. behavior by healthcare providers; and 3) if the provider is intransigent, vent “directly to the objects of the profession who have created the ‘bad’, to their superiors and to the medical or nursing boards or to law enforcement if a crime has occurred.” (from your 1/18 post)
I use your response to my “test question” and your intermittent descriptions of the training you provide students to assume that you have an honest interest in seeing that a social environment is created in which patients are uninhibited about communicating their preferences to each of their treating physicians (and any others who provide them healthcare services). I personally find this interest to be rare among physicians and, consequently, I have on occasion been compelled to move from one primary physician to another until I find one who demonstrates this interest.
When I’ve asked physicians what can be done to humanize healthcare settings (or some similar question), they tend to express one of the following beliefs (from most to least extreme): 1) healthcare settings should not be humanized (e.g., Doctors must maintain an aloof and detached demeanor.); 2) healthcare settings are already sufficiently humanized (e.g., option “h” on the test question – Doctors already take pains to ensure that patients are not exposed to unnecessary humiliating events.); and 3) it’s up to patients to humanize healthcare settings (e.g. option “a” on the test question – Patients should communicate their preferences to the physician).
Given that the belief, independent of context, that it is incumbent on patients’ to speak up is the most oft given recommendation, presented as a panacea, for humanizing healthcare, I’d like to spend some time debunking it on both logical and practical grounds, those grounds being: 1) it ignores the fact that in many cases, neither patients nor their family members can speak up; 2) it ignores the influence or “power” of the situation typical of healthcare settings that discourages patients and their families from speaking up; 3) it is a refrain that itself dehumanizes patients because it is based on the assumption that patients cause their own dehumanization by not speaking up; 4) when taught in medical school, it is part of a hidden curriculum that may foster rather than discourage the dehumanization of patients; 5) it is founded on an informal logical fallacy, the fallacy of wishful thinking; and 6) it is founded more on ideology than on fact. I will conclude that any recommendation that places the onus for change onto the shoulders of patients is designed whether intentionally or not, to maintain the status quo.
Since we’ve already covered the first two, ad nauseam, I’ll provide arguments to support the remaining four in a later post.
Ray
I want to thank Banterings, Ray and the others who are adding a major degree of thoughtful and documented analysis to this ongoing issue of patient modesty and how it is dealt with by the medical profession. If patients want to change the medical system, such analysis is the first step into deciding what appropriate and most effective approaches are going to be required to effect such a change. In treating a medical condition, knowledge of the patho-physiology and anatomy of a disease is necessary to provide the best chance of a resolution of the patient's illness and concerns. To change a building structure beyond just "blowing it up", one needs to know how it was originally constructed and on what foundations it is currently standing. Changing the medical system, in my opinion, requires the same type of knowledge and understanding. ..Maurice.
Ray, "speaking up and to the physician" is the final responsibility of the patient (not the physician nor the medical system). That "speaking" is called "informed consent" or the opposite "informed dissent". It is this "speaking up" which separates professional medical management from criminal battery.
By the way, this happened to be the precise statement I gave to my 6 first year medical students today after they had completed their 2nd practice on each other of the abdominal exam and in 2 weeks are going to "practice" the exam on real patients on the hospital ward. Yes, I told them exactly what I wrote above and I did use the word "battery". Nevertheless, I expect they will get their necessary practice on real patients since, in my experience, the vast majority of patients are comfortable with the student learning with the consented use of the patient's body. Yes, and it is only with the patient speaking up and to the student and giving their consent. ..Maurice.
Maurice ,
Let me use a blunt example to illustrate Ray's point about speaking up and the system;
Does one not think that the victims of the Holocaust did not speak up and request humane treatment? I am sure that detainees at Guantanamo spoke up. The system is designed to ignore those requests.
Look at the case of Brian Persaud at NewYork-Presbyterian Hospital; He walked into the ED, he was NOT of an altered mental state, but when they cut his clothes off and threatened a rectal exam, he fought back (the human defense mechanism of fight or flight). The system said that being combative was symptomatic of an altered mental state. The system failed to recognize that was a normal response for someone unaltered.
Note Mr. Persaud's civil suit and charges against the physician were dismissed ONLY because Mr. Persaud could not prove that a rectal exam occurred.
If anything, the case of Brian Persaud (seemingly) supports Charles's solution. Again, I am not advocating the use of violence.
I know that this blog has taken a turn into some very deep, abstract thinking. I too find myself rereading posts five times, looking up terms in dictionary.com, and looking up concepts, theories, and researchers in Wikipedia. I am sure that we all want to continue to be engaged here, so using some of Ray's own words, let me update everyone with my "Cliffs Notes" version of where we are at:
Ray asserts that it is the healthcare system (a social institution) that allows the dehumanization to take place. There is no research in the "hard sciences” (e.g., biology, physiology, chemistry, etc.) or in psychology (a discipline which has its origins in biology) that show how to change social institutions (e.g., family, marriage, the polity, the economy, healthcare, etc.).
Maurice and all scientists, were trained in and relies on hard science which believes the truth of observable phenomena is by hard science and quantitative analysis (using, for example, experimentation, multivariate statistical analysis from survey data, etc.).
It was very difficult to move from hard science to think in a more humanistic understanding of the observable world. Humanism assumes that the only way to get to the truth of human issues is via "walking a mile in the shoes of another" and qualitative analysis (using, for example, the participant observation method).
"Reality" to the hard scientist constitutes facts gleaned from science; "reality" to the humanist is people's definition of the situation, their perceptions and understandings of life. To fully understand human behavior and social conditions, the observer must recognize that both approaches to "reality" are important.
Here is an example to illustrate the limitations of hard science; If one followed the scientific method to the "letter of the law," technically, one would question the color of the sky unless one saw a study that concluded it was blue and the reasons for it. The humanist simply looks up and says blue sky. That is NOT to say that humanism does not have limitations either. Humanism cannot explain why the sky is blue (atmospheric molecules appearing on the blue spectrum and the reflection/absorbtion of that light).
--Banterings
Banterings, battery is a legal issue and as virtually all behavior which requires a court decision as to criminality, there will be isolated cases where the proof of criminality fails. The important point to make is regardless of the outcome, the patient did "speak up". Perhaps he needed a more effective lawyer. This one case does not change my advice to my students that to perform any exam without the patient's (or legal surrogate's) informed consent can represent a legal definition of battery. ..Maurice.
Maurice,
I appreciate your point of view. I also agree that most physicians respect their patients.
My goal is to illustrate the point that Ray made: the system is designed to nullify the patient's speaking up if the physician so wishes. The ED is just one example how the system does this.
I am not even looking at tort or criminal law. I included that tid-bit to preempt anyone noting the case being dropped and no criminal charges pressed.
--Banterings
Maurice,
You suggest that “battery is a legal issue.” It is indeed a legal issue, but, as are all crimes, it is also, among other things, a political, social, economic, and empirical issue. I’ve spent a lifetime studying the latter. Descriptive research and research that tests causal theories of crime, including battery, have relied on three sources of data – official reports, self-reports, and victim-reports. Without going into detail, were one to limit the operational definition of battery (or any other crime) to only those cases which have resulted in conviction, I’d wager that over 90% of these studies would be called into question.
Banterings,
The Persaud case did, in fact, end up in civil court. It appears to me, based on a blog contribution of one of the jurors, that the jury may have used its power of nullification to decide against Persaud. This decision must have come as a surprise to Persaud’s attorney. I had e-mailed him prior to the trial; his evidence was convincing and his assurance of a win was high. I tried to contact him after the decision to find out what he thought went wrong, but he did not respond. (I suspect the problem originated during the process of voir dire.) The media reported that Persaud’s attorney was considering an appeal, but I’ve found no evidence that an appeal was ever made.
Ray
IMPLICATIONS OF THE FUNDAMENTAL ATTRIBUTION ERROR
Argument #1: The “speak up” mantra is a refrain that itself dehumanizes patients.
The “speak up” proposal is founded on the assumption that the cause of patient dehumanization by healthcare providers is that patients (and/or patients’ families) do not speak up for themselves. The reasoning behind this proposal takes the following form: 1) There is a problem of dehumanization of patients in the healthcare system; 2) The problem can be solved if patients just speak up; 3) If patients don’t speak up, then they will be dehumanized; 4) It follows that if patients don’t speak up, then they have only themselves to blame for their dehumanization.
Those who assert that the dehumanization of patients is attributable to patients’ failure to “speak up” commit the fundamental attribution error, the tendency to attribute human behavior or social conditions to the dispositions, qualities, characteristics, or idiosyncrasies of individuals while ignoring or minimizing the importance of situational and structural factors. Attributing patient dehumanization solely or primarily to the failure of patients to speak up or to other individualistic factors ignores the ecosystem within which providers and patients interact – the non-democratic asymmetrical relationship between provider and patient along with the conveyed symbols which discourage patients from speaking up.
A consequence of the fundamental attribution error is, in the present case, to place the responsibility for the dehumanization of patients squarely on the shoulder of the dehumanized patient. The victim of dehumanization becomes responsible for his or her own victimization. You might recall that David Matza refers to this phenomenon as “denial of the victim,” one form of neutralization technique. Albert Bandura suggests that “blaming the victim” is a “cognitive mechanism” that alters one’s view of the victim thereby opening the way for the commission of reprehensible conduct. Matza, and Bandura along with Zimbardo and others recognize that “blaming the victim” or “denial of the victim” is a way of dehumanizing the victim, thereby absolving offenders of responsibility for their acts. In essence, then, to recommend that patients assume the responsibility for preventing their own dehumanization is a recommendation that dehumanizes patients and absolves offenders for their wrong doings. It also absolves from responsibility for humanizing healthcare experiences other providers who encourage or who say or do little to nothing to stop offenders, accrediting agencies that permit the dehumanization to take place free of effective deterring sanctions, provider organizations that lobby against changes, and lackadaisical legislators who are influenced by lobbyists’ pleadings.
Ray
Ray, I have, as you know, presented the argument to use "speak to.." rather than the "speak up..", the latter suggesting a power differential.
I don't look at the doctor-patient or patient-doctor relationship in "power" terms and I certainly don't practice medicine or teach my students that there is "power" on one side and "weakness or powerless" on the other.
What the public might be uneducated about is in virtually every doctor and patient relationship, the doctor needs the cooperation and contribution of the patient as the patient needs that of the doctor. Diagnosis and treatment becomes "guesswork" without the input and help of the patient. Yes, in the past history of medicine there was a lot of "guesswork" going on which extended to the paternalistic behavior of the doctor's "I know it all" attitude. Fortunately, understanding disease and treatment through advancements in medical science and the active participation of the patient and the move to patient autonomy in recent decades has removed much of the inequality.
Yes, it is the patient whose sickness is a burden but it is the doctor who has the burden to diagnose and get the patient well. To me, that latter burden is a heavy one too. And to lift the burdens, both patient and doctor need each other. ..Maurice.
I do this in 2 parts:
Maurice,
I must argue with your assertion:
I don't look at the doctor-patient or patient-doctor relationship in "power" terms and I certainly don't practice medicine or teach my students that there is "power" on one side and "weakness or powerless" on the other.
How can one NOT know there is a power differential? By being a patient a person has relinquished at least some power. If I have to ask a physician for a prescription, I relinquished power. If I could write my own prescriptions, then there is equal footing.
What really needs to happen is physicians need to learn to relinquish power to the patient. Granted, some do relinquish some power to the patient. When the system does not, then the patient seeks to balance that power outside the healthcare system and in the legal system. By your exposure to this issue over the past 10 years it would be expected that you are more sensitive to the issue in regards to how you train your students. You are the EXCEPTION, not the rule.
Continued...
Part 2:
Ray,
From The NY Times, "In the Hospital, a Degrading Shift From Person to Patient": The psychological dynamics of this identity change have evolved little since the 1950's, when the sociologist Erving Goffman detailed the depredations of life inside a mental institution in his classic book, "Asylums."
In normal life, people can keep intimate things like ailments, thoughts and their bodies to themselves. In an institution like a hospital, "these territories of the self are violated," he wrote. "The boundary that the individual places between his being and the environment is invaded and the embodiments of the self profaned."
Here is a great article on KevinMD, "The patient experience can be dehumanizing". Too bad the article finishes just as it begins to expose the dehumanizing practices.
... humanizing a patient's suffering positively predicted symptoms of burnout especially for those participants that had higher levels of direct contact with patients. Source:NIH PubMed, "Defensive dehumanization in the medical practice: a cross-sectional study from a health care worker's perspective."
Eight coping mechanisms were identified, including medicalization, dehumanizing the patient, anger directed at the patient, use of euphemisms, use of humor, denial of the lack of skill, going numb, and talking to others. Source:APA PsychNet, "Coping mechanisms of physicians who routinely work with dying patients."
A June 2014 study found, Nurses who viewed their patients as less human reported experiencing less stress. This was especially true for nurses who were more emotionally attached to their employer, the hospital, and to their patients. Source:Research Digest, "Committed nurses cope with stress by dehumanising themselves and their patients - Italian study"
Here are 2 consistent accounts of what it’s like to be a patient in a US hospital. Both accounts were from minors, so these patients had even less power than adult (non-elderly) hospitalized patients. These patients’ accounts bring to my mind the Stanford Prison Experiment, and how psychologically vulnerable we are when stripped of our individuality, power, voice, and control over our environment and even our bodies. "This 15-Year-Old Absolutely Nails What 'Patient Centered' Is - And Isn't" (Forbes) and "Powerless"
Here is a solution (from October 2013, Feldman says that when he brings trainees into a patient room on rounds, he has everyone introduce themselves. Even if it's unlikely the patient will remember everyone, it creates a better relationship, he says, adding that modeling appropriate behavior for interns is a good place to start. Source:Johns Hopkins Medicine News Release, "'Common Courtesy' Lacking Among Doctors-in-Training"
Here is some hard science on the topic of dehumanization, "Dehumanization in organizational settings: Reassessing our beliefs in view of the scientific evidence"
--Banterings
Chad, wrote the following comment to, of course, closed Volume 66. I am publishing it here because I think it brings up, to me, an important point regarding informed consent of an anticipated surgery. I think that discussing the pros and cons of the surgery with the patient is hardly enough "information" for consent. What is missing, I think, to all consents is an education about the operating room itself, who is or comes into the room and how the patient is specifically treated by the staff before, during and immediately after the surgery with regard to bodily exposure, draping, undraping and other "routine" manipulations including catheterization of the urinary tract.
What effect all this information to the patient would make and whether hospitals would change operating room protocols in response to now an educated patient's request is an unknown. ..Maurice.
When you say you "awoke" To being catheterized, Do you mean you still had the catheter or could tell you had one?
I've been wondering if you would be able to tell after an operation if a catheter had been inserted or not if you were not told.
I recently had an abdominoplasty (26 yrs old) My surgeon had told me after the surgery my operation took a little over 3 hours and I read on another forum that if a surgery takes longer than 2 hours then a catheter would most likely be needed. My incision went almost all the way around my back to about midline . When I asked him how he got the incision so far back he said "we had to turn you over." thus why I am now thinking how much do they do during surgery that they don't tell you?
When I walked into the operating room there were just 4 people - the surgeon, the male anesthesiologist and 2 female nurses. I had assumed the nurses would be seeing me naked, as the one who met me on arrival (who was also who walked with me into the operating room) first told me to "take everything off" and put on the gown. Which made me self conscious enough, but if a catheter was inserted then was it most likely one of the female nurses who put it in? It seems like something they would tell you before hand. And it seems that so many people speak of having one with just about every surgery.
Maurice,
You are absolutely correct in pointing this out. The problem though, is you can NOT say providers are unaware of the issue.
Simply put, I am sure that at some point with your 1st/2nd year students (probably when you go over the syllabus, grading rubric, etc.), you cover the topic of labs and exams. You (probably include) assurance of professional setting/draping/etc., exemptions from participation, what exams will AND what exams will NOTbe preform on each other. You probably say something "need not worry" because they will not do intimate procedures.
Hospital consent forms do not explicitly mention catheterization, because that is considered routine (so explicit consent is not required). The point of Jason and so many others here is that if these are so routine and innocuous, there should no problem with medical students preforming them on each other. You stop short of saying that these would be psychologically traumatic on the students although the implication is there.
So why are they not traumatic for the patient? Why is this NOT explained and there NO explicit consent? The answer is then would come the conversation about patient's wishes and preferences. Beyond that, providers would need to justify practices beyond "ritual" or "the way we have always done it".
In Vol 68, I pointed out what LDS Hospital in Salt Lake City, Utah did as part of their overhaul of healthcare delivery in 1998:
SOME PATIENTS were especially bothered to spend half the day without underwear -- for shoulder surgery, say. Ms. Lelis was convinced this longstanding practice was meaningless as a guard against infection, persisting only as the legacy of a culture that deprived patients of control. "If you're practically naked on a stretcher on your back," she says, "you're pretty subservient." The nurses persuaded an infection-control committee to scrap the no-underwear policy unless the data exposed a problem; they have not. Source: The Wall Street Journal
Again, let me point out a few obvious problems that relate to providers here:
1.) This was done as part of a marketing campaign to increase revenue by attracting more patients, NOT because of any ethics or regard for the patient. Technically, patients were and still are at many institutions forced to needlessly undress which is not only an ethical violation, a violation of the Patient Bill of Rights, but may be criminal.
2.) Why do LDS and other institutions that implemented these changes fail to apologize or acknowledge a history of patient abuse? What most do is make it sound like they are the ones sacrificing, especially in situations like LDS where it is initiated for marketing purposes.
3.) How is it that providers NOT know that undressing is a major source of anxiety for a patient, OR is the patient dehumanized to the point that the patient's feelings are inconsequential?
4.) I am also sure that you point out that your students should expect patient reluctance to disrobing and how to convince patients to do it (ethically, professionally, and when necessary).
5.) Millions of people live with catheters every day under their clothing. A patient can go into surgery with surgical pants, be catheterized (opening the front of the pants), and wake up with both a catheter and surgical pants. This is never offered because it takes time and is inconvenient.
This is what happens if the healthcare system were left to their own devices to design what an institution would look like: "Bodily Practices as Vehicles for Dehumanization in an Institution for Mental Defectives".
I am sorry if this seems like a rant, but my next post will contain some solutions.
--Banterings
Maurice,
Can you tell me what I wrote that precipitated your February 4th response?
You write, “I have, as you know, presented the argument to use ‘speak to..’ rather than the ‘speak up..’, the latter suggesting a power differential.” I returned to this blog on Dec. 16 and have read every post in Volume 70 and 71 and cannot find where you made a conceptual distinction between “speaking to” and “speaking up.” Indeed, the use of “or” in your 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?” suggests, by definition, that both may be necessary in the sense that each is an alternative to the other. Make no mistake about it, were a physician to attempt to browbeat me for not truckling to his or her demand that I serve as a teaching tool or visual aid to his students under the threat of withdrawing needed healthcare (as occurred to a former nurse-colleague of mine), I would “speak up” in a blink of an eye and in no uncertain terms (just as my nurse-colleague did).
When you write, “I don’t look at the doctor-patient or patient-doctor relationship in ‘power’ terms,” you appear not to recognize that there tends to be power differentials that exist between physicians and patients; you appear to deny the wealth of anecdotal and scholarly evidence that differential power does, in fact, exist.
To increase the humanization of the healthcare system requires a movement toward the democratization (reducing the power differentials) of patient-physician interactions. If this is so, and if you truly believe that the relationship already tends to be democratic, that power differentials tend not to exist, or that the typical interaction between physician and patient is symmetrical rather than asymmetrical, then it follows, you must also believe there is little is any need to institute changes in the system that would improve patients’ chances of not being dehumanized.
You next assert, “I certainly don’t practice medicine or teach my students that there is ‘power’ on one side and ‘weakness or powerless’ (sic) on the other.” I submit that were you to ask your students the following question, the largest percent would respond “physician”:
“In a formal medical setting, who tends to have the greater power? (check only one option)
[ ] the patient [ ] the physician [ ] neither, the power is equal [ ] don’t know
CONTUNUED
Ray
CONTINUATION
If I am correct, then from where does their knowledge come, if not from you? Their impression was probably formulated long before they applied to medical school, from their own experiences, experiences of others whom they know, or studying about the subject in high school and college. If so, neither you nor anyone else has to teach them about power differentials in medicine; they already know. If the healthcare system is to be more fully humanized, what students must be convinced of is the desirability of breaking down power differentials that do exist and how to do it. It would be counterproductive to do otherwise.
I do not see the relevance of the remainder of your post to my first argument; the truisms you introduce seem to beg the issues I address. For example, you remind me that “the doctor needs the cooperation and contribution of the patient as the patient needs that of the doctor” and that “diagnosis and treatment becomes ‘guesswork’ without the input and help of the patient.” If my post suggested something different, then your exhortations are apropos. But it did not.
You suggest that “the public might be uneducated about” the need for patient-physician inter-cooperation. I think you underestimate “the public.” I and others who participate on this blog are part of “the public” and I bet we and just about every sound-minded adult member of “the public” who has visited a physician already knows that inter-cooperation between physician and patient is needed to “get things done” and don’t need to be reminded of it. If healthcare is to be more fully humanized, it is the typical physician who must be educated to recognize the barriers that discourage inter-cooperation and who must be convinced that it is desirable that these barriers be expunged. Again, to deny that these barriers exist is counterproductive to that goal.
You end your paragraph with, “Fortunately, understanding disease and treatment through advancements in medical science and the active participation of the patient and the move to patient autonomy in recent decades has removed much of the inequality.” Even were I inclined to agree with this statement, as a scientist I would not be so bold as to state it as fact. You have written in the past that you and other physicians need evidence before making diagnostic judgments. You and people in your profession are not alone; social scientists, too, demand evidence, gleaned from systematically gathered data, before they draw conclusions about social phenomenon. So to your statement of “fact,” I’m from Missouri – Show me!
Your last paragraph is a homily reminiscent of what is written on the cover of Edward Rosenbaum’s “A Taste of My Own Medicine” – “We place our faith in their skill. We lay our lives in their hands. But sooner or later we realize that they are only human. And we hope that they notice. . . we are too.”
Ray
Argument #2: When taught in medical school, the “just speak up or to model” becomes part of a hidden curriculum that may foster rather than discourage the dehumanization of patients.
It is unlikely that any program designed to train individuals to be healthcare providers includes only messages that lend themselves to dehumanizing patients or only messages that invariably foster the humane treatment of patients. The reality is more likely to be that students receive messages that encourage and messages that discourage patient dehumanization. Borrowing from and adapting Edwin Sutherland’s differential association theory, it can be reasonably hypothesized that the greater the frequency, duration, and intensity of definitions (messages) favorable to the dehumanization of patients compared to definitions unfavorable to the dehumanization of patients, the greater the likelihood that patients will be dehumanized. The “just speak up or to” model is a model that lends itself to the dehumanization of patients, unless it is coupled with the recognition that this model can only be deployed if healthcare providers create a social environment that invites patients to “speak up or to.” That is, it is incumbent on providers, not patients, to first foster a “speak up or to” milieu before it can reasonably be expected that patients will “speak up or to.” This means that to take the dehumanization message out of the “just speak up or to model” it is necessary that instruction take the following form: “Don’t expect patients to tell you what their dignity and privacy needs are unless you first create a social environment which invites them to do so, a milieu in which they are uninhibited about communicating their dignity and privacy needs.”
A cautionary note to our hypothesis borrowed from Sutherland is in order. To the extent that students are exposed to both definitions that favor and definitions that do not favor the dehumanization of patients is the extent to which a double bind occurs. Inconsistent messages that cause double binds have been shown, since the phenomenon was first identified and studied by Gregory Bateson, to cause cognitive dissonance along with undesirable emotions such as confusion, frustration, and uncertainty in those people exposed to them.
These undesirable emotions are hardly conducive to the compassionate treatment by people in superordinate statuses (e.g., physicians) compared to those in subordinate statuses (e.g., patients). In fact, the theories and research to which I have alluded in earlier posts suggest just the opposite is likely to be the case; they increase the likelihood of dehumanization. More specifically, the greater students’ frequency, duration, and intensity of exposure to double messages regarding dehumanization, the greater the frustration, confusion, and uncertainty of the recipients, and, consequently, the greater the likelihood of dehumanization. This double bind theory may help explain why, in students’ third and fourth years of medical school, they tend to exhibit a significant diminution of empathy.
Ray
The Source for this post is: Stanford Encyclopedia of Philosophy, "Mill's Moral and Political Philosophy".
I fully support Ray's statement; To increase the humanization of the healthcare system requires a movement toward the democratization (reducing the power differentials) of patient-physician interactions.
I think that John Stewart Mill provides a good rational and how to change the system with his concept of Utilitarianism:
We can reconcile self-interested motivation and promotion of the common good if we make rulers democratically accountable to (all) those whom they govern, for this tends to make the interest of the governed and the interest of the governors coincide. Bentham's argument, elaborated by James Mill in his Essay on Government, is something like this.
1. Each person acts only (or predominantly) to promote his own interests.
2. The proper object of government is the interest of the governed.
3. Hence, rulers will pursue the proper object of government if and only if their interests coincide with those of the governed.
4. A ruler's interest will coincide with those of the governed if and only if he is politically accountable to the governed.
5. Hence, rulers must be democratically accountable.
Just as Mill argues against paternalism in government, the same holds true in healthcare:
Insofar as Mill insists that preventing harm to others is the only legitimate basis for restricting individual liberty, he is committed to a blanket prohibition on paternalism. Why? Mill offers two explicit reasons.
First, state power is liable to abuse. Politicians are self-interested and corruptible and will use a paternalistic license to limit the freedom of citizens in ways that promote their own interests and not those of the citizens whose liberty they restrict.
Second, even well intentioned rulers will misidentify the good of citizens. Because an agent is a more reliable judge of his own good, even well intentioned rulers will promote the good of the citizens less well than would the citizens themselves.
For if a person's happiness depends on her exercise of the capacities that make her a responsible agent, then a principal ingredient of her own good must include opportunities for responsible choice and self-determination. But then it becomes clear how autonomy is an important part of a person's good and how paternalism undercuts her good in important and predictable ways. Mill may still not have an argument against successful paternalism, but his perfectionism gives him an argument that successful paternalism is much harder to achieve than one might have thought, because it is very hard to benefit an autonomous agent in ways that bypass her agency.
--Banterings
Ray, my last argument in favor of "speak to" instead of "speak up" was my introduction presentation and even the graphic for Volume 69.
As for who has the "power",comparing the patient and physician, as I have written I practice and teach equality. Yes, the patient has the sickness but the physician has the responsibility of diagnosis, treatment and curing the sickness. As the patient is dependent on the knowledge and skill of the doctor, the doctor is dependent on the participation of the patient to provide the necessary history, to allow a proper examination and workup and to, with education, understand the nature of the illness and treatment and to follow through with the agreed upon treatment. Failure for the physician to satisfactorily complete his or her responsibilities to the patient is a personal injury and repeated such injuries lead to physician "burnout".
If I was on the admitting committee for the medical school, I would never want to accept a student whose attitude is that the physician and only the physician is the one with the power in the doctor-patient relationship. That attitude on starting medical school and continued would lead to all the terrible stories written about here on this thread.
In summary, a question: how can a physician or medical system be humanistic when the physician or the system have decided that it is only they who are the "humans" and the others are simply the objects of the profession? This is what is needed to be taught to students, physicians and the system if they look at the practice of medicine otherwise. ..Maurice.
Maurice,
Please do not take this as a personal attack, but rather for the inquiry and debate that it is meant to be.
I do not find your position plausible as you have stated:
As the patient is dependent on the knowledge and skill of the doctor, the doctor is dependent on the participation of the patient to provide the necessary history, to allow a proper examination and workup and to, with education, understand the nature of the illness and treatment and to follow through with the agreed upon treatment.
The best example of this is a trauma patient; unconscious. Furthermore, informed consent is not required. Another example is Dr. Joel Sherman's recommendations on the hernia exams for sports physicals. Although NCAA and many other other governing bodies do not require them, Dr. Sherman has demonstrated why they are NOT necessary, yet many physicians require them as medically necessary. In the case of pelvic exams required for oral contraceptives, the 50%+ that require them would be (and are) guilty of battery except they deemed the exam "medically necessary." (Reference: "Time Magazine, Are Doctors’ Exams a Barrier to Birth Control?" AND "NIH: Pelvic examinations and access to oral hormonal contraception.")
Even physicians acknowledge that paternalism exists in healthcare still, some even argue that it is good. Paternalism is the imbalance of power in the doctor-patient relationship. Many say the patient's power lies in finding a new provider. I am sure that you are aware that with many providers dropping Medicare/Medicaid, and even insurance companies, practices not taking new patients, networks, etc., that only increases the provider's power because the patient may realistically NOT have alternatives.
Yes we have made some progress with Patients' Bill of Rights, the proliferation of civil cases, but ultimately the patient's needs are more urgent than the physician's. The fact that your medical students practice intimate exams on standardized patients and real patients is indicative of this power differential. Further proof is the prohibitions of physicians having relationships with patients.
Yes you may train your students to be more democratic, but the fact remains that that differential exists. Where I see the change to balance the power coming in is when what may seem medically necessary at the time becomes medically preformed, that is the procedure was not necessary but preformed in a professional manner and that is prosecuted as fraud. May seem extreme, but this would balance the power.
--Banterings
Hello all,
Firstly, I would like to clarify my own stance.
To my own embarrassment, I did write,
"When I threaten my provider with violence, it conforms to my wishes immediately and without question."
Please do not take my words literally.
I learned early in life that in a medical setting, "no" is often interpreted as an invitation to further discussion, coercion, and manipulative dishonesty. In my late teens or early twenties, I learned to say "no" firmly, with dissernable anger in my tone of voice and choice of words, and a matching physical posture (body language". "Speak up; speak to" is rarely effective. Asserting personal power is often, but not always, much more likely to achieve the desired result: to be treated with respect and dignity. I have also walked out of offices with out paying, after unleashing truly cruel verbal abuse. I have also been in medical settings where such radical attitudes were simply unnecessary. I was treated with dignity and respect without having to say or do anyhing exceptional.
Secondly,
I can now see where Ray was going, although unnecessarily in my opinion. The system CAN NOT self-reform without MUCH MORE vigorous effort. I argue that it CAN NOT self-reform in any but the must trivial and superficial ways. Reform MUST be imposed!
Bottom up:
Education (evidence based care; existing rights; concept of "informed consent/assent")
Encourage rebellion against status quo
Encourage the exercise of power in all forms (personal interactions, civil litigation, criminal complaint, dissemination of propaganda)
Top down:
Better laws
Better law enforcement
BTW:
Diagnostcs, policies and procedures that can not be scientifically justified should be grounds for criminal prosecution, however trivial the infraction.
It is about the exercise of power!
Charles
OK.. I agree with Charles OX. If the solution turns out of be politics (politics creating the new laws) then what should the visitors of this blog thread who agree do to create the changes desired? What is the next step?
I am truly pleased with all the current detailed and referenced discussion of he "patho-physiology" of this medical system problem but just discussion is insufficient to start a change. The folks here have to move on to some things which could be called "activistic". This means "action". So the planning now should start and "what's next" should be answered. ..Maurice.
Charles,
Diagnostcs, policies and procedures that can not be scientifically justified should be grounds for criminal prosecution, however trivial the infraction.
This is called mail fraud. Because billing. receipt of, explanation of benefits, results, etc. are all sent by mail. Whether paid for totally by the patient, insurance, social program, or combination of, this constitutes fraud, specifically mail fraud. Mail fraud is handled on a federal level by the regional postal inspector.
I am not a lawyer, but I am well aware of the intricacies of mail fraud. (No, I was NEVER involved with mail fraud either.) I have not seen this strategy used in terms of unnecessary medical procedures, yet.
That leads to my second point:
Maurice,
You ask what we are doing? My answer is that I am producing a document that a patient can use to secure their dignity. It gives the rational for patient requests and shows strategies like the mail fraud example above. Some of these strategies are traditional like "battery." Many are unique like mail fraud.
I bet nobody has ever heard of using this strategy (except possibly Ray as he is a professor of criminology.) I avoid state licensing boards, in my opinion they are useless. They are either made up of industry insiders appointed by, or the politicians who take billions in campaign contributions from the medical industrial complex lobbyists. Postal inspectors are beholden to no one.
I have spoken to a couple participants here off-blog about my work. I am 85% complete in my first draft. Upon completion, I am going to ask everyone here to review it. I have a distribution plan that is as equally cutting edge.
I have been alluding to this for some time. The concept evolved from an open letter to it's third iteration (where I am at now). I want to finish it on a positive note, so my final recommendation is to find a good provider that you can build mutual trust and respect with.
--Banterings
Maurice,
You write: “As for who has the "power",comparing the patient and physician, as I have written I practice and teach equality. Yes, the patient has the sickness but the physician has the responsibility of diagnosis, treatment and curing the sickness. As the patient is dependent on the knowledge and skill of the doctor, the doctor is dependent on the participation of the patient to provide the necessary history, to allow a proper examination and workup and to, with education, understand the nature of the illness and treatment and to follow through with the agreed upon treatment.”
The concept “equality” or its obverse “inequality,” like most concepts, is not unidimensional but multidimensional. One dimension of equality, among many, is educational equality. Your paragraph deals with this dimension of equality. Physicians almost always have more education than patients when it comes to diagnosis, prognosis, treatment, and cure. I and every person I know recognizes the superior knowledge that physicians have in these areas as compared to the typical patient; that’s why we visit physicians. When physicians diagnose, prognosticate, treat, and/or cure, they are conforming to the roles we expect of them.
Again, what was it that I wrote that precipitated your paragraph cited above? As far as I can tell, the physician’s formal roles as a diagnostician, prognosticator, treatment-giver, and curer has not been presented as controversial issues by me or anyone else who has contributed to this blog. Can you specify my words, sentences, or paragraphs that precipitated your discussion of physician’s knowledge and skills? In the future, when you address what I’ve written, will you at least give me the courtesy of quoting me and giving me your interpretation of what I’ve written before writing your reply based on your understanding or misunderstanding of what I’ve written? Better yet, confusion can best be reduced were you to test out your understanding of what I’ve written thereby giving me the opportunity to confirm, deny, clarify, or qualify your impression.
A second dimension of equality is social equality. The research is clear, the greater the social equality between physician and patient, the less likely the dehumanization. By the same token, the greater the social inequality between physician and patient, the greater the likelihood of dehumanization. Ethnic minorities, racial minorities, people with little education, people who occupy low prestige occupations, and the poor are more likely than others to be dehumanized in healthcare settings. However, I’ve not seen where this has consistently been at issue on this blog.
What has been at issue in this blog, it seems to me, is a third dimension of equality; viz., interpersonal equality. I and every person I know is quite willing, indeed we are happy, to permit physicians to diagnose, prognosticate, treat, and cure – that is, employ their technical knowledge to do what is expected of them. What is at issue on his blog, it seems to me, is the behavior of some providers, including physicians, that deviate from their expected roles when it comes to interpersonal relationships with patients including a whole slue of actions that undermine the dignity of patients including, but not limited to, inviting film crews to film patients without their consent, exploiting patients by using them as teaching tools and visual aides without their consent, browbeating patients when they refuse to truckle to the unreasonable demands of providers, unnecessarily undermining patients’ bodily integrity, allowing people who are not directly participating in patients’ healthcare to intrude on their privacy, and so on. I and other patients may not have the technical knowledge possessed when it comes to diagnosis and treatment, but we do tend have the ability to judge the quality of their interpersonal interactions with us. That’s the crux of the matter. CONTINUED
Ray
CONTINUATION
Also at issue is a fourth dimension of equality; viz., power equality. It was clear from day one that you do not believe that power inequality should exist between patients and physicians; that you try to teach students ways to minimize or prevent the emergence of power inequality; that you strive to prevent unequal power in your interactions with patients; and that you can infer from the writings of scholars that before many patients will “speak to” their modesty concerns, patient-physician power differentials need to be broken down. What is not clear is weather or not you believe that power inequality between physicians and patients does, in fact, tend to exist. You have not clearly presented your position on the issue. Your statement, “I certainly don’t . . . teach my students that there is ‘power’ on one side and ‘weakness or powerless’ (sic) on the other” suggests that you may believe a power differential does tend to define patient-physician relationships and, for some unexpressed reason, choose not to discuss it with students or that you may believe that a power differential does not exist and is, therefore, unworthy of discussion. Can you clearly articulate what your belief is? An answer to this question is pivotal for proceeding to a discussion of what can be done to more completely humanize healthcare delivery, because many ameliorative recommendations, including those in the publication by Hague and Waytz (which Banterings shared with us) assume that unequal power does, in fact, exist. CONTINUED
Ray
CONTINUATION
Whether or not you believe power inequality between physicians and patients exists in healthcare settings, there are physicians who deny its existence, so I’ll again argue against their position. To deny that power inequality between physicians and patients exists is to reject the credibility of every author of every textbook ever written in the sociology, psychology, and anthropology of health, medicine, and illness, all of which address power differentials in healthcare organizations, especially those between physicians and patients. It also requires that one reject the credibility of the mass of studies on physician-patient power inequality cited in these books including those by Erving Goffman, Thomas Sheff, Thomas Szasz, George Annas, Rodney Coe, John McKinlay, Paul Starr and even by physicians including Edward Rosenbaum, Peter Conrad, and Melvin Konner. Hague and Waytz (in the publication provided by Banterings) recognize the validity of these scholars’ findings when they write the following: “Dissimilarity in power between doctor and patient can have . . . specific effects on dehumanization. The doctor-patient relationship is typically a relationship between superior and subordinate. . . The control and power afforded to doctors in this relationship constitute a major determinant of dehumanization – mastery – which can then facilitate dehumanization of patients.”
While I’m at it, let me add a thought. The interest in “bedside manner” training, which got going in earnest in medicine circa the late-‘80s or early-‘90s was not based wholly on altruism, a desire to meet patients’ needs for self respect and dignity; it was also justified pragmatically, a desire to minimize the likelihood of lawsuits. The training was, in effect, part of the “defensive medicine” movement. The movement was born from the results of research which showed a clear link between physician-patient rapport and the likelihood of lawsuits, controlling for other causal variables. The following link is to a 1987 publication by Ann Kellet, which I came across fortuitously in 1991, “Healing Angry Wounds: The Roles of Apology and Mediation in Disputes between Physicians and Patients” published in the Journal of Dispute Resolution. Kellett does an excellent job reviewing the studies that found inverse relationships between “bedside manners” and likelihood of law suits, results that helped precipitate “bedside manners” training in medicine. http://scholarship.law.missouri.edu/cgi/viewcontent.cgi?article=1157&context=jdr
Another publication on this topic is by Ellen Annandale (1989), “The Malpractice Crisis and the Doctor-Patient Relationship” published in the Sociology of Health & Illness. This publication is also available on line but has no URL.
Ray
Maurice,
You write, “If I was on the admitting committee for the medical school, I would never want to accept a student whose attitude is that the physician and only the physician is the one with the power in the doctor-patient relationship.” That attitude on starting medical school and continued would lead to all the terrible stories written about here on this thread.
I should hope so, if by “is” you mean “should be”. Is there anything written on this blog that gives you the impression that I or any other blogger would think otherwise?
However, again, your use of “is” is ambiguous. Let’s do a little Einsteinian thought experiment. Let’s say there is only one medical-student slot and two applicants for that slot who are equivalent in all ways except for their answer to the following open-ended question. “What is your opinion about physician-patient inequality or equality in the hospital or medical clinic?”
Applicant #1: “I think an egalitarian relationship should define patient-physician interactions. The patient has the sickness but the physician has the responsibility of diagnosis, treatment and curing the sickness. As the patient is dependent on the knowledge and skill of the doctor, the doctor is dependent on the participation of the patient to provide the necessary history, to allow a proper examination and workup and to, with education, understand the nature of the illness and treatment and to follow through with the agreed upon treatment. In short, the patient and the physician are interdependent; they must be equal partners in achieving the goal of health and wellness of the patient with both the physician and the patient performing their respective roles as I have described them.”
Applicant #2: “That depends on the dimension of equality to which you are referring. We hope that physicians enter a social exchange with patients with a greater knowledge of diagnosis, treatment, and cure. Patients are dependent on the physician to use this knowledge to help them attain health and wellness. I believe this knowledge inequality is desirable for if it did not exist, the physician’s competence would surely be subject to question.
There are also two dimensions of patient-physician equality that I believe are desirable including interpersonal equality and power equality. Interpersonal and power inequalities in a patient-physician relationship are counterproductive. It is true that just as the patient is dependent on the knowledge and skill of the doctor to diagnose, prognosticate, treat and cure, the doctor is dependent on the participation of the patient to provide the necessary history, to allow a proper examination and workup and to, with education, understand the nature of the illness and treatment and to follow through with the agreed upon treatment. In short, the patient and the physician are interdependent; they must be equal partners in achieving the goal of health and wellness of the patient with both the physician and the patient performing their respective roles as I have described them. However, the interpersonal and power inequities that have been shown to exist in many patient-physician interactions tend to create barriers that discourage some patients from performing their roles as expected. Consequently, once I begin working with patients, I intend to do all I can to prevent the emergence of these inequalities in my dealings with patients, thereby creating the social environment most conducive to patient-physician inter-cooperation and for improving patients’ health and wellness. I have some knowledge about how to do this from life experiences and from my undergraduate studies in the liberal arts. However, I suspect that medical school educators will instruct me in other equality-producing techniques in the specific contexts of carrying out different diagnostics, treatments, and cures.
Which of the two would you admit to medical school?
Ray
Maurice
You write, “In summary, a question: how can a physician or medical system be humanistic when the physician or the system have decided that it is only they who are the ‘humans’ and the others are simply the objects of the profession?”
Is this another one of your rhetorical questions? I’ll assume it is not and answer it. A physician or medical system cannot, by definition, be humanistic, at least in thought, when the “physician or the system have decided that it is only they who are the ‘humans’ and the others are simply the objects of the profession.” But, why do you ask the question? I did not imply otherwise.
If I were to take your question literally, I could point out that just because a person has decided that s/he and people similarly situated are humans and others are not does not mean that their behaviors will necessarily be consistent with what they believe. For example, it has been found that only 9% to 16% of the variation in racial/ethnic discrimination (behavior) is attributable to racial/ethnic prejudice (a belief or attitude). Many people who are prejudiced toward racial/ethnic groups do not discriminate against them because of any number of reasons – e.g., fear of suit, fear of peer/parental reproval, fear of losing business. Robert Merton classified these people as “timid bigots” (prejudiced non-discriminators). Similarly, we may find that many dehumanizers at the cognitive level are not dehumanizers at the behavioral level as a result of similar fears characteristic of prejudiced non-discriminators.
I’ve a not altogether irrelevant side observation to make. You frequently anthropomorphize non-human entities. In this case you attribute human characteristics (being humanistic and having a decision-making capacity) to a non-human entity – the medical system. In your 12/30 post you attributed the capacity to be “aware” to the medical system. I don’t think you do this deliberately nor do I believe you have devious motives for doing so. You could defend it by proclaiming, “Well, you know what I mean,” which I think I do. You could argue that it is a stylistic thing, which is also true, and that everyone has done it at one time or another, which may be correct, at least among English speakers. But the anthropomorphizing of non-human entities is done deliberately and with devious intent by some. Also, when it is embraced as a legitimate way of defining reality by people in social positions endowed with great power and by the social masses, it can undercut the integrity of an entire nation.
I’ll not elaborate here, but the issue may arise later.
Ray
Ray, I don't believe we are too far apart on our definition of "patient-doctor, doctor-patient" relationship (note even the orientation of the names can set an impression to the reader of a non-equal interpersonal relationship.) Of course, with what Applicant #2 stated, that applicant would be the one I would accept.
And for my first and second year students, I have always emphasized to them that the inequality of medical education and medical/surgical skills and, of course, also the sickness and physical and emotional stress and uncertainty of the patient already sets a difference between patient and physician--and that this difference and personal difference (knowledge and health) between the physician and patient should not be taken to the physician's advantage but such awareness by the student and later as a doctor be utilized to direct and provide the patient both education and hopefully comfort and finally cure.
Ray, I can tell you and my other visitors honestly that in my entire medical career "superiority" over the patient was never in my mind..never! I always felt I was in an exercise which amounted to a "fight with each set of symptoms" presented to me by the patient to attain a diagnosis along with a treatment I could report to the patient and provide a successful conclusion. I have always had the attitude that it was the patient who was challenging me. Therefore, before starting and reading this thread I never considered that my patients or the patients of other physicians would look at the profession with such fear and anger. Yes, I read about the occasional "bad apples" in the profession but they were not me or the physicians in my professional neighborhood.
So, as I have repeatedly mentioned in the past, this thread has been an education for me and look forward to read about approaches to make the changes in the medical system to resolve the concerns written here. ..Maurice.
Ray, with regard to your conclusion that I am creating an anthropomorphic image of the "medical system". Remember, the "medical system" is not analogous to a rock or a tree but is an organization of human beings setting criteria of behavior and function among many other activities. Therefore, I look at the "medical system" as human as the individual humans who participate in the system as physicians, nurses, techs and administrators are human and yes, if the system looks at themselves as the only the "humans" the system thus degrades the patients to the category of "objects" only, the system, whose duty is primarily to care for patients and not their own self-inteest, would not be said to apply that attention to patients in a humanistic manner. ..Maurice.
Argument #3: The belief that the healthcare system can be changed and made more humanistic by individuals telling physicians and other “elements of the [healthcare] system” what their dignity needs are is founded on an informal fallacy, the fallacy of wishful or fanciful thinking or what I call the pie in the sky fallacy. In other words, it is a recommendation that might be pleasing to imagine but doesn’t follow from available evidence. It ignores all the knowledge that scholars have accumulated at least since the writings of Plato regarding how to best make systemic changes in social institutions. It also ignores what we have studied on this blog, viz., what Zimbardo calls the “power of the situation.” Since I’ve already written at length about this concept, I’ll spare the reader the monotony of reading it again. Suffice it to say that the situations in which patients tend to find themselves discourage them from “speaking up” and, in some cases (as with Anne), instill within them the fear of retribution, a fear which is not always unreasonable under the circumstances (or situations).
The simplistic view that it is incumbent on individuals to change the healthcare system by speaking to providers and to “elements of the [healthcare] system” harkens back to the “Just Say No” to drugs initiative led by Nancy Reagan in the 1980s which, true to form, focused on individual responsibility. Those who evaluated the program failed to find a significant effect on young people’s use of drugs. Any changes in the rate of drug use by young citizens occurred in spite of rather than because of Reagan’s initiative. CONTINUED
Ray
CONTINUATION
Argument #4: The recommendation that to humanize health care delivery necessitates only or primarily that patients “speak to” providers and other “elements of the [healthcare] system” is founded more on ideology – the ideology of individualism – than fact.. Zimbardo in “The Situationist Perspective on the Psychology of Evil” apes the ideas of scores of other scholars when he writes: “Our legal, medical, educational, and religious systems all are founded on principles of individualism.” One is unlikely to find in any other nation around the world the focus on individualism that characterizes the United States. The general sentiment here is that our social problems – crime, discrimination, poverty, violence, drug addiction, etc. – are due solely or primarily to dispositional factors such as character defects inherent in individuals (the fundamental attribution error). This belief continues to persist in the face of overwhelming evidence against it.
In other high-income nations, collectivism rather than individualism is the prevailing ideology. Consequently, one would expect that the citizens of these nations would be more likely than U.S. citizens to recognize that collective action rather than individual action is necessary before structural changes can be made in social institutions. The rub is, our European, Scandinavians, and Asian allies are correct; collective action has been shown to be more effective than individual action for bringing about social change and a concomitant diminution of social problems. Consequently, among high income nations, which has the greatest or amongst the greatest rates of social problems including poverty, illiteracy, violence, crime, morbidity, mortality, inequality, drug addiction, incarceration, mental illness, etc.?
The source of the focus on individualism can be found, according to the 19th century writings of Max Weber, in the “protestant ethic and the spirit of capitalism” (the title of Weber’s most famous publication). Contemporary reactionaries ethnocentrically brag about “American exceptionalism,” with it stress on individual responsibility and individual initiative, and proudly advocate changes in the dispositions of individuals to solve all our social problems, from poverty to corporate miscreancy. Trying to tackle social problems by changing individuals is both inefficient and ineffective. Systemic institutional changes can be most efficaciously achieved via collective action in the form of social movements. I will later address the factors that are necessary for the successful implementation and success of a social movement designed to more fully humanize healthcare delivery.
Ray
If patient modesty is only a sub-issue with regard to patient dignity then
let's create a list of issues which represent the medical profession's ignorance and lack of attention to their patients' need for DIGNITY. And for each, let's set a plan or goal as to how each issue could practically (not theoretically) be resolved.
I suppose we should first describe what is meant by "dignity". My attempt at that would be that in the way "dignity" has been used on this blog thread is one dictionary definition: "a sign or token of respect". Is that "respect" the response of others or are we talking about dignity as "self-respect". What do you think? ..Maurice.
Dr. B,
I'll restate what I said earlier in this volume:
Dignity is more than a simple definition, it is a moral, legal. ethical and philosophical concept that incorporates the idea that a human being has an inalienable right to be valued and to be treated ethically. In other words, to be treated with respect.
Human dignity can be violated in multiple ways. The main categories of violations are, humiliation, objectification, degradation and dehumanization.
Hex
Banterings,
Thanks for posting your Feb. 4 articles and impressions. The Carey article does a good job identifying the situations that contribute to the dehumanization of patients and the obsequiousness of patients. As I’ve written on past blogs, Erving Goffman’s publications are excellent sources for understanding the dynamics of bureaucracies (including hospitals), especially those he dubs “total institutions.”
I’ve read just about everything Goffman has published. I prefer his book “Stigma” over “Asylums.” In the former, he conceptualizes for us what he means by “total institution.” He also defines and gives examples of what he calls the “mortification of the self” whereby people are stripped of their self identities and compelled to adopt new, more adaptive, identities.
Mortification of the self is most likely to occur in prisons, concentration camps, inpatient hospitals, mental hospitals, the military, nursing homes and other “total institutions.” Research published by Zimbardo and others inform us that those who adapt to their new environments the most are those who truckle to all the demands made of them by those in authority. The only thing researchers found that distinguished between those who adapted well and those who did not was that those who adapted well tended to score higher on Adorno, et al.s F-scale which measures the personality syndrome level of fascism or, more euphemistically, authoritarianism.
Ray
Hex, I fully understand and agree with your definition of dignity. And it should apply to all patients but also, I must say, to the medical profession itself. With regard to each of the violations you identified (humiliation, objectification, degradation and dehumanization), over the years, the writers here have been commenting in ways accusing and painting the medical profession with the results of these terms. For example looking at the medical system as an non-human entity represents to me objectification and dehumanization of a system made up of and functioning by humans.
Therefore dignity should be applied to the humans who make up the profession of medicine and the medical system itself as well as the patients (who, by the way, can be looked upon as a main component of the system.)
So, now, how do we assure the components of dignity are applied to all? ..Maurice.
Maurice, et al,
I apologize having lost a thought to ADHD again. Let me finish that thought.
I do not find your position Maurice, plausible as you have stated:
As the patient is dependent on the knowledge and skill of the doctor, the doctor is dependent on the participation of the patient to provide the necessary history, to allow a proper examination and workup and to, with education, understand the nature of the illness and treatment and to follow through with the agreed upon treatment.
The best example of this is a unconscious patient, found laying on a sidewalk.
In this situation the patient provides no history, it is solely up to the physician to diagnose and treat. Consent in this situation is waived. So if the participation of the patient necessary, and the patient cannot participate, does that mean the physician cannot diagnose or treat?
Yes it is much harder to diagnose and treat, many times they get the patient conscious to get a history or they miss the correct diagnosis and the patient does not recover. This is an extreme example, but it is the extreme that tests our theories and postulates.
Another article by Richard C. Senelick, M.D., "Little Privacy in Health Care -- Shame on Us" (via The Huffington Post), from December 2011 is about a physician who lets his wife's dignity be violated in a healthcare setting.
I still hold the position that healthcare does not know what is acceptable by societal standards or what is excessive. Here are two examples:
Pediatric Abdominal Pain This is a Power Point presentation saved as a PDF file. Note on page (slide) number 7, under "History and Physical [exam]" it states:
Rectal may not be necessary, but if surgical [option of the] abdomen is present[ed,] should do.
– Teaching institutions…LIMIT number
Why does one have to say this? Why are there NO guidelines that say this? Again, if left up to healthcare there would be (and have been ) students in long lines waiting for their turn. (Reference: News.com Australia "Medical students are performing intrusive exams on unconscious patients")
This example, "How hospitals waste the patient's money", talks about how the patient must have the same tests repeated. There is no regard given to the dangers of repeated testing such as radiation exposure.
--Banterings
I will speak to Maurice's definition of dignity.
It may he hard to define dignity since it is an abstract concept, what is clear is that people know when they have not been treated with dignity and respect, OR when their dignity has been violated.
Dignity is a right granted to us by the nature of being human and ascribed to God. It cannot be given to us or rationed, it is always there and must always be respected. One area that has been greatly debated, and which Beauchamp and Childress have also addressed is patient dignity.
Dignity was not included in Beauchamp's and Childress's principals because it is too hard to define.
Dignity is: Respecting the answers (choices) that others make to the same questions that we answer as to self determine our own existence. At the very least, the questions cover basic human rights. Dignity can NEVER be negotiated, overridden, or taken away, but it can be ignored by others. We may choose to sacrifice or compromise our dignity for what WE deem a higher purpose.
Our dignity exists in the intrinsic value we have as a human being. Life is not a higher issue than dignity, it is one of the choices that we make in regard to our dignity (i.e. do not resuscitate). One person's dignity cannot trample on another person's dignity, for then that is NOT an aspect of dignity in the first person. Not caring about an area or choosing not to make a choice about an aspect of one's dignity IS a legitimate option and that area must be respected in others.
Dignity also has a set lower limit: that is a societal consensus on human dignity, most notably illustrated in the United Nations' "Universal Declaration of Human Rights"
Dignity is best defined by illustration, so let me illustrate; Society holds killing another human being is wrong except in some instances such as self defense, war, or capital punishment. This is the lower limit, thus genocide is never acceptable even if a group tries to make it so. If an individual believes all homicide is wrong, they may be exempt from military service as a "conscientious objector."
As for a prisoner on death row, my definition of dignity would not allow the person not to be executed, but rather executed in a humane way. If anyone had to die, then they would choose the most painless way. That is why as a society we do not extract revenge. That is also part of the debate over lethal injection and many moratoriums in the US.
--Banterings
I must do this in 2 parts:
Medical students are taught a number of ways to desexualize patient exposure. One of them goes along with the teaching of looking at the body in terms of systems, and that is focus on the body part and not the whole body. It is a vagina, not a person. Unfortunately, this is objectification of the person. "Dehumanization in Medicine Causes, Solutions, and Functions," by Omar Sultan Haque and Adam Waytz, and "NOT JUST BODIES: Strategies for Desexualizing the Physical Examination of Patients," by P. A. Giuffre and C. L. Williams are just two of many sources that validate this.
The 20th-century philosopher Martin Buber labelled such human associations an objectified person (patient) as "I-It" relationships. (Source: The Physician-Patient Relationship; A patient-physician's view) There are some other benefits too, such as allowing the physician to diagnose and treat based on science and not emotion. A physcian's training concentrates on the skills of diagnosis and treatment, often objectifying the patient as a set of symptoms to be treated.
Haque and Waytz note: Diagnosis and treatment often necessitates "mechanization"— breaking the body into organs and systems. Scaling back empathy can curtail staff burnout. Even moral disengagement can be helpful, the researcher notes. From giving a shot to slicing into the body to perform surgery, medical care often requires inflicting pain or invading the boundaries of the body.
Medical students first objectify patients when dissecting their cadaver in their first year(Source: A Patient So Dead: American Medical Students and Their Cadavers)
This reminds me of my immature junior high years, when I learned (probably) the most degrading word in the english language. It was the "C" word (referring to a woman by her genitals). If you want to see the most self controlled woman erupt in to an uncontrollable violent rage, call her that. When I hear providers focus on just the body part, even in appropriate scientific terms, I hear the "C" word. That is the result of objectification of the patient.
--Banterings
Continued....
Part 2:
Providers view themselves as human and patients as objects. Here is proof: Lately I have been reading many threads where providers state that they view genitalia as any other body part, just like an elbow. (That is the same as saying "I am a professional" or "have seen it all before."This statement is absolutely false. What they are saying is that "I do not view you as a person deserving of any dignity." If you don't believe me, ask them to shoe you their "elbow."
If providers view the genitals like an elbow, then they should have no problem showing you theirs as proof of their training and honesty, AND as educating the patient that it is just another body part. Most will get angry and defensive, "how dare you (the object)?" They expect their modesty respected, but that is because they are the only humans in the room.
Along with the risks of objectifying the patient to the status of a bowl of sugar on the table that one casually exposes by removing the lid, other traits (such as sexuality) may be read into the encounter when in fact they do not exist. This "perception" may induce anger towards the patient resulting in further dehumanization, embarrassment, and harsh treatment. I believe this is the source of female providers' towards male patients and their dismissive attitude. Here is what the study reveals:
"According to models of objectification, viewing someone as a body induces de-mentalization, stripping away their psychological traits. Here evidence is presented for an alternative account, where a body focus does not diminish the attribution of all mental capacities but, instead, leads perceivers to infer a different kind of mind. Drawing on the distinction in mind perception between agency and experience, it is found that focusing on someone's body reduces perceptions of agency (self-control and action) but increases perceptions of experience (emotion and sensation)." (Source: More Than a Body: Mind Perception and the Nature of Objectification)
Objectification benefits the providers more than the patient. It prevents burnout, allows them to efficiently invade a patient's body and inflict pain, help deal with death, prevent depression, etc. As demonstrated by Zimbardo, Milgram, Ubel, and others, objectification dehumanizes the patient, and allows providers to abuse and traumatize patients (whether they are cognizant or not).
Here is a podcast of a doctor speaking to the objectification of patients in reference to Figure One, an app/website that is like Instagram for doctors: The Secret, Gruesome Internet For Doctors
Maurice, could you speak to how students are trained to deal with dealing with exposure, death, dissecting a cadaver, preforming painful treatments, etc. I assume objectification (as per research cited above). Please do not take this as an indictment of your teaching or the profession, but rather to see all the tools available to providers. Do you (your school) teach that chaperones are one of the tools?
--Banterings
I would like to add this to my previous 2 part post:
This paper ("The Fabrication of Nurse-patient Relationships") shows nursing attempting to recognize the patient as a person in the late 1970's/early 1980's.
The main point to take away from that is prior to that, the patient was NOT a person. I do not think that has been fully integrated into healthcare yet, which explains the pelvic exams of anesthetized patients. What has changed is healthcare wanting to avoid lawsuits spurred from such actions, not the perception that the patient is a person.
“If you don’t want to be sued, don’t be rude.” (Helm, 2003)
Finally, here is an article that focuses on the gender bias on healthcare delivery towards women: "Eyes Wide Shut: Erasing Women's Experiences From the Clinic to the Courtroom," via the Harvard Journal of Law & Gender.
Although the pernicious effect of gender bias on healthcare delivery is well-known, less attention has been paid to its secondary effects. Disinterest in or hostility to the female experience leads to an informational vacuum that allows for the development of ideas, theories, and assumptions founded on cognitive bias, rationalization, and wishful thinking rather than empirically-based knowledge. These biases, then, are imported into the legal field where they undergird juridical movements that serve to disadvantage women.
This essay explores how, in the medical context, the stunted development of knowledge about women, becomes, in the legal context, a dangerous thing. In examining the interplay between medical and social science information and legal dogma, this essay will discuss how bodies of knowledge are selectively pursued, exploited, or ignored in the service of patriarchal assumptions that achieve expression in legal responses to emerging social dilemmas. Selective information flows between the medical and legal professions result in untoward consequences in a wide variety of settings.
I feel that what is being described here is the objectification (dehumanization) of the female patient. The effects apply to both male and female patients. Sexuality as a trained discipline is lacking in the medical education. (There are many articles that discuss the shortcomings of healthcare for gay, lesbian, bisexual, and transgendered individuals). Sexuality seems to be left to the social sciences. A better understanding of sexuality would help with the issue of patient dignity. (See: "Patient Dignity 02: But it is Sexual..."
In reference to the issue of LBGT healthcare, let me say this with great pride; we are making progress here. Our new Governor, Tom Wolf Names Transgender Woman Physician General.
--Banterings
Banterings, we don't teach and I am sure elsewhere in the first and second year students' academic learning they are not taught to "objectify" any patient including the ones alive and the ones who are already deceased. We are always and I mean always describing patients as human beings and that each patient regardless of being human are also individuals and are to be considered as both. So it is absolute fallacy regarding "objectification" and is most likely described by an individual who knows nothing about and is not engaged in the direct teaching of medical students.
And with regard to the deceased. Another lie. These bodies are accepted by medical students as former humans who by one means or another have been made available for the student's anatomical education.
Please read my blog thread on the subject "A Medical Student’s Anatomic Gift: There is More Involved than Dissection" and Boston University's "Parting Gifts" program.
Also read my blog thread from 2008 "Humanism and Pathology: Anatomy Lesson" which includes a beautiful description of the subject of the anatomy lesson, the body of a person who has died. It was written by a physician Steve Miles.
I have more written on this blog about the humanistic teachings that we present to our students. The response is not just made up by me now as some response to Batternings or others.
Again, those who write otherwise are not medical school instructors. ..Maurice.
Maurice,
Thank you for the clarification. I did not want to make ANY assumptions WITHOUT validation, that is why I asked.
I hope I did not offend you, and if I did, I do apologize.
I know that you teach them proper draping, as evidence of offering a cape for cardiac auscultation.
I have no doubt that the deceased human body is respected, draped, and afforded every consideration a live one would be, but I ask;
What (or how) are students taught in regards of the mental stresses and apprehensions that most human beings have around the deceased (I am sure that many have never handled a deceased individual before)?
What are they taught about dealing with the emotions of losing a patient?
What do you teach them to help them deal with exposures and the embarrassment that they have?
Is there any prep for them in years 1 and 2 for dealing with their emotions, or is that years 3 and 4?
--Banterings
Banterings, no need to apologize, we each learn from each other.
Of course, the initial hours (even minutes) of experience in the anatomy lab is taxing to an occasional student, perhaps reacting to the emotions with a vaso-vagal reaction (fainting) but the average student deals with the experience as a necessary learning experience on a formerly living human being. Nothing more..nothing less. And, I am sure, they all find a difference between learning anatomy from a previously living person as compared with simulated objects or human organs and tissues presented in plastic blocks.
There is no confusion as to which of these teaching tools are "objects" and which are not.
With regard to teaching students about losing their patient to death, they are warned (as I did just recently with my own group) that this will happen even despite their own attention to proper care. Obviously, mechanisms need be instituted for personal emotional resolution just as such is needed by the family.
Medical student embarrassment is understandable and is direct evidence that the student is not ignoring the bodily exposure of the patient. The most prominent embarrassment I have observed was watching both male and female students performing genital examination on male subject-teachers.
In no way, do the students appear to be looking at what they are doing as acts upon an object. And it is my opinion that they carry the same emotional reaction (but to a lesser degree) and as I do even when they become physicians later in their career. This personal emotional reaction identifies that the student or doctor doesn't look at the patient like a naked statue in a museum but as a living human who should be considered and attended to.
Of course, students in year 1 and 2 are monitored by us as they interview and examine their patients and we go over the clinical history, physical findings and the student/patient interaction and the student's feelings about what has occurred.
I think that students "dealing with their emotions" does not mean making all attempts to ignore or "bury" them.
More about medical education as it pertains to this thread later. ..Maurice.
Maurice,
Here is a follow up to a study you referenced in one of your past volumes asking your readers' reaction to. It was New York-Presbyterian Hospital and Weill Cornell Medical Center of Cornell University (WCMC), under the direction of Dr. Dix P. Poppas the follow-up tests used for assessing clitoral sensitivity in the young girls who received “nerve sparing ventral clitoroplasty."
It is a letter from Advocates for Informed Choice (AIC), a non- profit organization that advocates for the legal and human rights of children born with disorders of sex development (DSD) expressing concern over possible non-IRB-approved clinical research on children. (link: AIC letter over Dr. Dix P. Poppas “nerve sparing ventral clitoroplasty."
Beyond the obvious apparent issues (mainly no clear that the patients stood to benefit from either treatment or follow-up, since a larger-than-average clitoris presents no documented risk of harm,) the letter goes on to state (and footnote the reference for):
Given the well-documented psychological harm that can come to girls with DSD as a result of excessive visual genital exams,3 it seems likely that Poppas’s far more invasive tests pose substantial risk of psychological harm to young girls.
This only further supports how patients are objectified, but also how the system as described by Zimbardo brings the parents in to it where they objectify their children (evidence by Dr. Poppas in the 2007 Journal of Urology where he details the procedure of stimulating the girls’ clitorises in the presence of their parents).
In an article I previously referenced, "Little Privacy in Health Care -- Shame on Us" , a physician was unable to protect his wife's dignity.
I am becoming more and more convinced that the only solution is that the patient decides what is acceptable and the physician has to work with that.
--Banterings
Banterings, you write "I am becoming more and more convinced that the only solution is that the patient decides what is acceptable and the physician has to work with that." And I am quite comfortable with that since the results will be "informed consent" on the part of the patient and "informed dissent" on the part of the physician if the physician is not satisfied with the efficacy or the safety of the final decision and requirements as posed by the patient. Both are striving for the best for the patient but within their own decisional requirements..Maurice.
Maurice,
So by your statement you agree that patients do not have that power now.
The problem that I have, is that someone like Twana Sparks can do a an unnecessary genital exam and it is not criminal as long as it is conducted according guidelines. That is called the "medical exception." (For more on the medical exception, see: "Rape by Fraud and Rape by Coercion" by Patricia J. Falk) It does not matter if it was needed or not. Her response was that she was doing it (specifically to Hispanic males) because she felt that they did not have access to regular exams.
The "medical exception" allows for abuse through legitimate procedures. Here is an example from the TV show, House M.D.. "House MD Season 3 Episode 5 Fools for Love," from time 4:10 to 6:06. House leaves a stubborn patient (police detective Michael Tritter) in an exam room with a thermometer in his rectum. Granted leaving him WAS abusive, but also taking his temperature was unnecessary and abusive too. I know that this is fictional, but it is a good graphic illustration at how a procedure that is performed correctly, is NOT medically necessary, it is NOT criminal.
Until the medical exception is removed, patients are NOT safe and at risk for abuse.
--Banterings
A. Banterings
I assure you there never was any mention of
a genital exam on any surgical consent presented
to Dr. Spark's patients. Those surgical consents are
english on one side, spanish on the other, her medical
license should have been revoked. Every nurse involved in her surgical cases that witnessed her antics and said nothing should have appeared before the BON. This speaks volumes about the administration of that hospital, they are not in any
way transparent. I'd be interested who still works
there after the events came to light.
PT
A. Banterings
I believe what you are referring to is something
called the emergency medical exception and is
based on the premise that informed consent or
any consent for that matter is not required to save
someones life or to prevent permanent disability.
Hardly does a genital exam fall into this realm
for that matter and as far as Dr Sparks is concerned
regarding her patients, I doubt any were notified by
the hospital. How many years did this go on?
PT
PT,
Under certain circumstances, consent obtained by fraud will be considered ineffective and the intercourse will be considered rape.
First, if the defendant tricks the victim into thinking that the act is something other than intercourse, the consent will be ineffective. So, for example, if a doctor tells a female patient that it will be necessary to insert an instrument into her genitalia as part of an examination and, after she consents to the examination, he has sexual intercourse with her, her consent will be considered ineffective and the doctor can be convicted of rape. These situations, where the defendant tricks the victim into thinking that the act is something other than sexual intercourse, is referred to as fraud in the factum.
However, if the defendant does not trick the victim as to the nature of the act but lies to her as the medical value of the act, he cannot be convicted of rape. So, for example, if the doctor tells a female patient that it is medically beneficial for her to lose her virginity and the patient consents to the doctor having sexual intercourse with her, the doctor will not be convicted of rape even if the reasons he gave the patient as to the medical necessity of the intercourse are fraudulent. Situations where the defendant is straightforward with the victim as to the nature of the act, but lies about the necessity of the act, are called fraud in the inducement. (Source: National Paralegal College / National Juris University)
Some more examples where assault is claimed to be a medical procedure are the cases of Dr. James Bressi, Dr. James Bressi (again), Dr. Robert Martin Kevess, Dr. Robert Martin Kevess (again), Dr. Charles Gosling, and using "medically necessary" to torture prisoners in Guantanamo.
Here is an account of a woman that likens a transvaginal ultrasound to rape: Woman Sues Over Transvaginal Ultrasound: 'It Felt Like I Was Being Raped',
Perhaps one of the worst incidences are the state laws requiring (medically unnecessary) transvaginal ultrasounds prior to abortions. These laws have been described as "State-Sanctioned Rape": via NY Times, via RH Reality Check, and via slate.com.
--Banterings
Maurice,
Thanks for answering my question re. who you would admit. It was instructive.
Regarding my use of the concept “anthropomorphism,” as I suggested in an earlier post, concepts (such as equality/inequality) generally have a number of dimensions. The understanding you have of the concept “anthropomorphism” (e.g., describing a rock or tree in human terms) represents the literary dimension of anthropomorphism. If one goes to a dictionary, the definition of anthropomorphism one is most likely to find is consistent with the literary dimension of the concept.
When I read poetry, I expect and frequently encounter anthropomorphic verse used metaphorically and am usually impressed with the author’s skill at manipulating images of inanimate objects. However, just as is true of many concepts, the meaning of anthropomorphism has been expanded to encompass a number of dimensions which allows it to be used in different contexts. Among the several dimensions of anthropomorphism, the one that is most intriguing to me is the sociological dimension.
One of my interests has to do with how and why people use words and phrases the way they do, the symbolic meanings associated with them, and the effects that their use have. I have found that, among other things and contrary to what my mother taught me as a child, it sometimes does hurt to ask and that words can, in fact, hurt, sometimes worse than sticks and stones. More to the point, the anthropomorphizing of social constructs seems to be increasing in frequency, although I’ve no empirical evidence for it. But my impression, whether accurate or not, pricked my interest in finding out the contexts in which social construct anthropomorphisms are used and the possible effects of this phenomenon.
Sociologically speaking, when people attribute human qualities to social constructs, they are anthropomorphizing those constructs. I suspect we all do this at one time or another; I know I do. It tends to be used as a figure of speech that simplifies communication and may sometimes simplify a complicated world. We generally assume that when we attribute human attributes to social constructs that people know we are speaking of some or all of the elements (e.g., human beings) subsumed within those constructs. So, we hear folks proclaim that the government did this to us or the government did that to us, the Catholic Church did this or the Catholic Church did that, a gang did this or a gang did that, organized crime did this or organized crime did that, and so on. Unless we’re, say, a Netsilik or Inuit Eskimo, who historically have not thought in these terms, we probably all know that the speaker or writer is speaking/writing metaphorically and really referring to people that we imagine are part of these social constructs not to the constructs per se. CONTINUED
Ray
CONTINUATION
Anthropomorphizing inanimate objects or social constructs in order to simplify a complicated world can sometimes involve the error or fallacy of reification. Earl Babbie writes about this phenomenon: “Regarding constructs as real [or concrete] is called reification. The reification of concepts in day-to-day life is quite common. . . [Most of us, at one time or another, have fallen] into the trap of believing that terms for constructs do have intrinsic meaning, that they name real entities in the world. That danger seems to grow stronger when we begin to take terms seriously and attempt to use them precisely. Further, the danger is all the greater in the presence of experts who appear to know more than we do about what the terms really mean: It’s easy to yield to authority in such a situation.” One frequent manifestation of reification is confusing a model of some phenomenon with reality. For example, I have been told, that some high school physics teachers speak about the formula for Newton’s law of universal gravitation (F = G m1m2/r²) as though it were real. I’m getting out of my area of expertise here, but I was taught early in life that the formula for this law is not the law of gravitation but a representation of that law. To have considered the formula as something real, as actually being the law of gravity, could have resulted in a premature closure of scientific inquiry which may have stymied movement from the Newtonian paradigm of physics to the Einsteinian paradigm. In the social sciences, as I assume is the case for the “harder” sciences, we recognize that there is no one-to-one correspondence between our social constructs and the way we measure them. Consequently, when we test the measures of our theoretical constructs for their levels of validity (which refers to the degree to which our tools or instruments measure what we want them to measure), we know we will not find perfect validity. Indeed, according to Carmines and Zeller in “Reliability and Validity Assessment,” error-free measurement is infeasible; validity and reliability are relative and never reach unity. Both are “always present to at least a limited extent.”
So, treating constructs as real can have insidious effects on science by interfering with its progress. It can also have social, economic, religious, legal, and political effects that have the potential of changing the course of history. By way of illustration, five members of the U.S. Supreme Court in Citizen’s United v FEC reportedly overturned more than one hundred years of precedence by concluding that corporations are American citizens with First Amendment rights to free speech. Those five justices, in effect, assumed that corporations are as real as people. Another example is the approach used by authorities in the FEC, other regulatory agencies, and law enforcement bodies when it comes to arresting people who commit crimes while carrying out responsibilities associated with their corporate jobs. With few exceptions, they don’t; they don’t arrest and jail any of the criminals but instead levy fines against the corporations, or, more specifically, the corporation owners – i.e., stock holders. Even the president of the U.S. has jumped into the fray by dismissing the demands of millions of Americans that he compel authorities at the Justice Department to take legal action against corporate miscreants who helped bring down the U.S. and world economies. Instead, he proclaimed that “Wall Street is too big to fail.” They are also too big (or amorphous or anonymous) to jail. CONTINUED
Ray
Ray
CONTINUATION
This preliminary behind us, I’ll get to the crux of the matter. Use of social constructs as though they were real, just like the use of the amorphous “they,” may have the effect of giving the “bad guys” anonymity; they are able to remain hidden from public view so that we can’t attribute to them the problems they cause. It, in effect if not intent, may absolve them of any wrongdoing by diverting people’s attention to a non-human construct thereby preventing an effective deterrent from being implemented and ensuring a high likelihood that the wrongdoings will be repeated. One example can be found in the reaction of the president of the AMA*, among other physicians, to a 1999 publication out of the Institute of Medicine (“To Err is Human”) where it was estimated from the so-called Harvard Medical Practice Study and other publications that between 44,000 and 98,000 patients unnecessarily died each year due to mistakes made in hospitals. Healthcare providers, they proclaimed, are not to blame, they should not be held accountable; the healthcare system is to blame and should be held accountable, as though healthcare providers were not part of the system.** These people with medical authority, in effect, turned an explanation (aspects of the healthcare system cause medical errors) into an excuse for medical errors by healthcare providers. By diverting attention away from the killers and onto the system, the killers remained anonymous and unaccountable for their errors. CONTINUED
Although healthcare providers to whom I’ve spoken and some who have published their opinions in various media sources insist that things have improved, a 2010 report out of the Office of Inspector General for Health and Human Services estimated that as many as 180,000 Medicare patients unnecessarily die per year as a consequence of hospital mistakes. Even more recently, John James published a piece in the September, 2013 edition of the “Journal of Patient Safety” in which he inferred from various studies an estimated range of unnecessary yearly hospital deaths from between 210,000 and 440,000 due to medical errors of commission and omission (e.g., failure to follow standard protocol), diagnostic errors, and communication errors, thereby making hospital deaths the third most frequent cause of mortality behind heart disease and cancer. And, the World Health Organization (which, using several criteria, ranks the U.S. 37th in quality of healthcare) concluded that, ironically, both the rate of deaths resulting from not receiving necessary healthcare and the rate of unnecessary deaths due to healthcare delivery errors were greater than rates found in any other high-income nation.
Knowing whether the rate of unnecessary hospital deaths has increased, decreased, or not changed is not as important, it seems, as why it occurs as frequently as it does. One reason may be that those who are responsible for its occurrence are able to operate with relative anonymity. Researchers who were part of the Harvard Medical Practices Study found that patients and their families tended not to know when they had been victims of medical errors because they were not told or medical records were doctored. Until recently, patients in some states were not given access to their own records. Today, few hospitals provide patients with error reports and some state laws protect providers from giving up to patients’ attorneys notes taken at risk management meetings which occur following health delivery errors. These are indeed aspects of the “system” that help ensure the anonymity of the “bad guys” but they are not created and maintained by the system but by those who operate within the system, including the “bad guys.” CONTINUED
Ray
CONTINUATION
Anonymity is enhanced when people wear uniforms, especially uniforms that include masks; when their anonymity is protected by law; when they orchestrate their “evil” from a distance; when their identity is unknown or they are known by a number rather than a name; when they operate in groups; and when they operate in bureaucracies. A mass of research by people such as Edward Diener and his colleagues, Leon Festinger and his colleagues, Les Downing and his colleagues, Albert Bandura and his colleagues, and Philip Zimbardo confirms the hypothisis, the greater people’s anonymity, the more likely they will engage in antisocial and harmful behaviors (which would include the disturbing behaviors committed by providers described in this blog)
Even more to the point, after a review of relevant research, Hague and Waytz conclude that deindividuation of the sort that makes people who have the power to commit “evil” acts anonymous “can lead people toward antisocial behavior such as interpersonal aggression through diminishing feelings of personal responsibility for these actions.” When the anonymity of the potential victimizer is coupled with the anonymity of the potential victim, victimization is made all the more likely. “The deindividuation of caregivers leads them to dehumanize, and the deindividuation of patients leads them to become dehumanized. Just as soldiers’ matching uniforms in battle diminish feelings of personal culpability of action, caregivers in hospitals become anonymized amid a sea of white coats, which subtly diffuses their individual responsibility toward patients. Patients, meanwhile, can become subsumed into the mass of barely dressed entities seeking help, appearing as faceless bodies rather than individual agents requiring empathy.”
Most of us use social construct anthropomorphisms as a figure of speech. But beware, there are people in positions of authority and trust who deliberately use them to divert the public’s attention away from “culprits” and onto abstractions, thereby providing “culprits” with a degree of anonymity that may insure repetition of the behavior and maintenance of the status quo. This is a proposition that, as far as I know, has not been tested.
There have been many studies conducted by the researchers I’ve mentioned above and by others which have confirmed the proposition that the more anonymous an actor, the more likely the actor will harm others or otherwise engage in antisocial behavior. But, I know of no study which tests the proposition that when antisocial actors are made anonymous by people in authority, members of the public are less likely to harshly judge these actors than when the actors are not made anonymous by authorities. Given the truth of this proposition, if the use of construct anthropomorphisms by authorities makes antisocial actors anonymous, then it should be found that antisocial actors should be less harshly judged by the public when authorities attribute their behaviors to a social system than when they do not. The following hypothesis can be derived from this latter proposition: When physicians attribute the deviant, antisocial, or criminal behaviors of healthcare providers to the healthcare system, laypeople will recommend less punitive actions be taken against the perpetrators than when physicians do not attribute the behavior to the healthcare system. If I had the resources I once had while working in the academy, I would subject this hypothesis to the test using an elegantly simple experimental design called Fisher’s design. Alas, however, I can only hope that someone has or will do it for me.
Ray
Again, I do this in 2 parts:
A sad commentary is that NBC News takes the trust of the people they serve more seriously than that of the Gila Regional Medical Center in Silver City, NM.
NBC News anchor Brian Williams has been suspended without pay for six months after admitting last week that a story he told about coming under fire on a helicopter during the Iraq war was not true.
(Source: The Washington Post, How can NBC News’s Brian Williams ‘win back everyone’s trust’ from the beach? )
In a separate statement on the decision, Steve Burke, the chief executive of NBCUniversal, pronounced himself happy with the penalty: “By his actions, Brian has jeopardized the trust millions of Americans place in NBC News. His actions are inexcusable and this suspension is severe and appropriate.”
Shamefully, the health insurance carriers were the first to take action dropping Dr. Sparks from their networks. Her license has never been removed.
This month's AMA Journal of Ethics (February 2015, Volume 17, Number 2), has some interesting and overlapping articles. This month's theme is Describing a Culture from Within:
--Banterings
Continued...
Part 2:
This month's AMA Journal of Ethics (February 2015, Volume 17, Number 2), has some interesting and overlapping articles. This month's theme is Describing a Culture from Within:
The culture of medicine is an elusive concept; it can at once evoke images of benevolent men and women offering themselves in service of the sick and vulnerable and images of a patriarchal institution marred by elitism and the abuse of power...
The culture of medicine is not only defined by what doctors do, say, feel, and think, but also by what they do not do, say, feel, or think. What one is expected to read between the lines, or to “pick up on,” without being explicitly told is very much a part of medical—indeed any—culture; the norms and expectations that lie just beneath the surface can be as influential as anything codified. Thus, there can be a disconnect between what the medical field purports to do and what actually happens on the wards or in the classroom.
The Role of the Hidden Curriculum in “On Doctoring” Courses (Yes, it STILL is around and a problem.)
...the more complex the organizational setting the more likely there will be disjunctures between official statements about what is happening (“This is how we do medical education.” “This is how we do patient care.”) and what actually takes place on the clinical shop floor.
...When the routines of daily activity unfold in their typically routine and predictable ways, the values they convey are often invisible because they are taken for granted. They remain assumed and unnoticed until something unexpected happens, something outside the norm/rule/usual, or until these routines are looked at by someone new to them. And, all of a sudden, the invisible becomes visible.
Professionalism and Appropriate Expression of Empathy When Breaking Bad News
Just teaching the physician to further themselves from the patient, and dare I say objectify the patient.
Derogatory Slang in the Hospital Setting
...it would be better to address the use of derogatory slang in a nonpunitive way. Instead of merely condemning disrespectful talk, it might be more effective for medical educators to pay attention to it and use it to confront the issues it points to.
Professional Socialization in Medicine
...what some call the “hidden curriculum” [11-13]. In medicine, the hidden curriculum can undermine formal goals of professional socialization, contributing to “ethical erosion” among medical students [14, 15] and raising important questions about how curricular and institutional reform should proceed [12, 16].
If—as research suggests [43, 44]—students believe that their personal values about empathy or other aspects of moral life are at odds with those held by their peers and superiors, their moral commitments may be further weakened. This can become a self-fulfilling prophecy when they, in turn, discourage others from developing or expressing those values [45].
The duration and significance of this ethical decline is unclear. Scholars have long recognized that the professional culture of medical students is not the same as that of practicing physicians
This month's issue is an excellent read and I highly recommend it. I will finish by repeating the following line. No one doubts Maurice's attention to patient modesty and dignity, but in the scheme of a medical education, that is not good enough.
Scholars have long recognized that the professional culture of medical students is not the same as that of practicing physicians
--Banterings
Ray, Banterings, Hex et al, I am absolutely pleased with the erudite but yet understandable concepts which are now being introduced into the deliberations which obviously are required to come to some solution of what we have been calling the "patient modesty" issues and which apparently (and I agree) needs resolution. I want you all to know that I am reading every word you all write and trying to educate myself and understand.
You know, as a physician and medical school instructor I have been looking for ways to "spread the word" that any inertia regarding solution of these issues should be overcome. So.. as I have previously numerous times written, I have had published 2 articles in the AMA News (the second with Doug Capra). Well, I just thought of another way and this way might get down to the "birth of physician behaviors" and that is to present your dissertations to an audience other than those visiting this blog thread. That audience is a world wide wide read and written to listserv of medical educators from basic instructors such as myself to all different levels in the hierarchy of medical school education. If one or some of you could write an essay in just a few hundred words which describes clearly what is the issues presented by the patients or potential patients here and what is your understanding is of the etiology of the issues as applied to the medical system or their relationship specifically to early medical education, that might start a valuable education "in both directions" about these issues. You could write your piece first to this blog for review or just go ahead and send me an e-mail with the text. I will put it up on the listserv identifying you only as a visitor and the responses from the listserv which I hope to copy to this blog also will be totally anonymous. For those who don't look at the introduction to this bioethics blog, my e-mail address is: doktormo@aol.com ..Maurice.
Banterings, your link to the AMA Journal of Ethics (Formerly "Virtual Mentor") goes nowhere. The correct address is
http://journalofethics.ama-assn.org/
..Maurice.
Apologies again...
It is the way I create the links. In the immortal words of Homer Simpson, "D'oh!"
Here is the correct link: AMA Journal of Ethics (February 2015, Volume 17, Number 2)
--Banterings
Maurice writes: I just thought of another way and this way might get down to the "birth of physician behaviors" and that is to present your dissertations to an audience other than those visiting this blog thread. That audience is a world wide wide read and written to listserv of medical educators from basic instructors such as myself to all different levels in the hierarchy of medical school education.
I don't post, but I do follow this discussion. I'm extremely impressed with what Ray and Banterings publish here. Problem is -- you're preaching to the choir, and the material is extremely academic yet tremendously important. I agree with Maurice's comment above. I think Maurice and Banterings (and Ray) should do some writing together. With Maurice's name behind you, you can publish in some important medical journals. Years ago on this blog, I cover some of the material Banterings is covering now -- but not in the detailed way Banterings is covering it. I'm impressed with his learning. But this stuff needs to be written to an audience of medical professionals.
Many of them are aware of this material -- but it needs to be summarized and referenced specifically.
SUMMARY AND CONCLUSION
On an earlier post, I introduced four criticisms of the proposition that the best way to effect a change in the healthcare system of the sort that would protect the dignity and humanity of patients is for each patient to inform providers about what they need to do to best insure their dignity and humanity, to challenge providers when they go over the line, and to report intransigent providers to higher authorities.
One criticism is that the recommendation in question has its foundation in ideology rather than fact. To expect individual patients to independently take action to protect their humanity might help the individual but it is likely do little to change aspects of the healthcare system that foster the dehumanization of patients. Related to this criticism is the recognition that the proposed “solution” has its foundation in what I call the “pie-in-the-sky” fallacy; recommended as the sole solution for a complicated problem, it is a simpleminded and wrongheaded recommendation that may be pleasing to imagine and may be consistent with conventional wisdom but it doesn’t follow from available evidence. A third criticism is that the proposed “solution” ignores the “power of the situation.” The healthcare provider-patient relationship tends not to be a democratic one; power is most likely asymmetrical and the social milieu in which provider-patient interaction occurs dictates against patients taking affirmative action to protect their dignity. A fourth criticism is that some patients and their families, for one reason or another, simply cannot speak up. The final criticism is that the proposed “solution” assumes that the cause of patients’ dehumanization is that they are not sufficiently proactive in their efforts to protect their dignity. This assumption amounts to blaming the victims of dehumanization for their own dehumanization thereby absolving from responsibility offending providers, other providers who encourage or who say or do little to nothing to stop them, accrediting agencies that permit the dehumanization to take place free of deterring sanctions, provider organizations that lobby against changes, and lackadaisical legislators who are influenced by the lobbyists. To blame patients for their own dehumanization itself dehumanizes patients.
In one of the contributions to this blog, it was asked how providers are to know what a patient’s needs are unless patients tell them. The answer is their parents should have taught them, their teachers should have taught them, the media should have taught them, their training in healthcare should have taught them. After all, what are we asking here? We’re asking that providers recognize the virtue of American folkways, the common rules of polite society in the U.S. and many other nations including rules of common courtesy, decency, and etiquette. We’re also asking that the legitimacy of social mores and laws be recognized by providers. Why must the rules of common decency (folkways), rules governing moral behavior (mores), and/or rules of law be systematically violated with impunity or near impunity by some healthcare providers in some healthcare facilities in the process of meeting our healthcare needs? It is a strange doctrine indeed that would require a person to submit to unnecessary violations of these rules by virtue of the misfortune of falling ill and having to enter a healthcare facility. What is it that we’re asking healthcare providers? We’re asking them to do, inter alia, the following:
CONTINUED
Ray
CONTINUATION
1. knock and wait for our reply before entering hospital or clinic rooms that we occupy;
2. secure our affirmative consent or, preferably, our authorization before allowing someone who is not directly participating in our care into an examination or surgery room;
3. secure our affirmative consent or, preferably, our authorization (and, I’ll add, offer of remuneration for services rendered) before allowing students to practice on us or use us as visual aids or teaching tools;
4. secure our affirmative consent or, preferably, our authorization before allowing students to conduct intimate exams on us while we are unconscious;
5. turn down requests of the media to film us in emergency rooms and only with our authorization in other locations that will not intrude on the privacy of other patients;
6. complete 2, 3, and 4 without use of written (e.g., on consent to treat forms) or verbal (e.g., description of contents of consent to treat forms) duplicity;
7. inform us if any of our rights under the law or requests to ensure our dignity were violated while we were unconscious and offer remuneration for the violation of our trust;
8. report to pertinent authorities any violations of our rights and any violations of laws committed by providers against us;
9. avoid use of deception on hospital forms (e.g., consent to treat forms) and in verbal explanations intended to get patient compliance to hospital practices;
10. drape us as much as possible when intimate procedures are performed and use the technique of successive exposure when possible;
11. explain to us in detail and in layman’s terms the protocol for the procedures we will undergo and why the protocol is necessary, solicit from us and answer any questions we might have about the protocol;
12. tell us who will be involved in our treatment, the role they will play in meeting our healthcare needs, and allow us to meet and speak to each of them;
13. before an intimate healthcare procedure is performed, offer us the option of having a same-sex provider or providers and if none will be available, provide us with alternatives (e.g., visit when one is available or refer us to a facility in which this dignity need can be accommodated);
14. avoid use of vulgar or gallows humor or jargon that denigrates us;
15. avoid speaking to others about our physical attributes not pertinent to our medical care;
16. avoid sexual contact of any sort with us for any reason;
17. avoid performing unnecessary procedures, especially intimate procedures;
18. avoid battering us, sexually or otherwise; and
19. apologize when something goes awry and offer remuneration if warranted.
We can view the above as desirable objectives. I’ve listed only 19; other contributors may want to add some more. Please do. Achievement of these objectives will not only help insure the dignity of patients but may also reduce the likelihood of law suits when a patient is injured. This hypothesis may be inferred from an excellent article by Ann Kellett published in the Journal of Dispute Resolution (“Healing Angry Wounds: The Roles of Apology and Mediation in Disputes between Physicians and Patients”)
http://scholarship.law.missouri.edu/cgi/viewcontent.cgi?article=1157&context=jdr
http://scholarship.law.missouri.edu/jdr/vol1987/iss/10
My mother used to say about people who violate the social norms implicit in the above list, “They must have been brought up in barns.” Of course they weren’t brought up in barns and they probably do know (or knew at one time) that violations of the things I have listed are verboten. But some providers violate them anyway, others find even the most egregious violations funny or dismiss the actions as unimportant, some are bothered by them but say nothing, the few whistleblowers who file complaints are more likely than not to become pariahs and may face retribution, professional organizations defy efforts to curtail their commission, and legislators consider them to be unworthy of legislation.
CONTINUED
Ray
CONTINUATION
The bottom line is this: It is morally obligatory for healthcare providers, not patients, to clean up their own “barns.” To blithely dismiss this obligation and redirect the responsibility for change onto the shoulders of the victims of healthcare providers is not a solution for change; it is a solution for maintaining the status quo. And, it is unconscionable, the moral equivalent of expecting the victims of crime to “deal with it.” Apparently, “deal with it” we must.
I will end my piece with an anecdote. I once knew an aging gentleman who had some significant problems in daily living. By his own admission, his forte was tormenting people who occupied positions of power. “Biff Rufus” was a reincarnation of Mort Walker’s Beetle Bailey of the past. “I behave this way to create change in the system,” Biff told me. Some of the changes he wanted to make were, in my opinion, needed; his cause was noble. He would dedicate each day to achieving his goals, but his progress on a scale from zero to ten was zero. Finally, I said to him, “‘Biff’, you can’t make the changes you want to make by yourself. These changes require collective action; it’s highly unlikely that one person, or two, or three, or even a hundred scattered people could make them, no matter how dedicated they were.” He thought about what I said, returned to my office a few days later, and exclaimed excitedly, “I figured it out, Ray. I’m creating an organization and calling it “Rufus’ Raiders.’” “Thinking up a name for your social change organization is a good first step,” I replied. Unfortunately “Rufus’ Raiders” never had more than one member and “Biff’s” efforts continued to fall somewhere between flat and counterproductive.
So, to your question, Maurice – Will speaking up or to “the elements of the system by patients and their families” help bring about “overall change”? – my answer is, “it depends.” If the agents of change constitute a smattering of individuals and families bent on improving healthcare delivery for themselves, the hope for significant social change is probably a chimera – a pipe dream worthy of a Walter Mitty who spends his or her time seeped in reveries, whimsical musings, and Pollyannaland, the latter being one of the single-occupant departments of “Rufus’ Raiders.” If change does occur, it is most likely to be cosmetic rather than systemic. However, if the agents of change are individuals and families who 1) are part of a social movement, 2) are connected by a desire to foster significant social changes in a social institution or one or more of its constituent parts, and 3) participate in systematic efforts to bring about change, then the hope for such change is greatly enhanced.
Ray
Doug,
I have been toying with a couple solutions in the back of my mind, and even by my standards I consider them extreme.
It will be an advertising piece highlighting current medical guidelines such as every person in the United States is expected to get an annual physical, undressed, with a genital exam. I will show how the use of medically necessary shields one from criminal proceedings.
I will aim this at sociopaths, sexual predators, and serial rapists.
Why risk imprisonment when you can legally do it and get paid for it?
Perhaps the fear, panic, and outrage may finally push for meaningful reform.
--Banterings
To get started on "spreading the word" to the professionals, assuming Ray would approve, and without the writer's identification, I had posted on the medical education listserv to potentially 2000 teachers, Rays comment followed by his list of 19 requests to providers. Now we will see what responses we get. ..Maurice.
==================================
Today, one of my visitors presented and challenged the physicians, nurses and the entire medical system with the following seemingly rational request. Are we, as teachers of future physicians, taking all the necessary educational steps to see to it that our students understand this philosophy of patients, perhaps to varying degree by all patients, and are provided with education that will stick with them and which they can apply to each patient later in their careers? ..Maurice.
From Bioethics Discussion Blog thread "Patient Modesty: Volume 71"
http://bioethicsdiscussion.blogspot.com/2015/01/patient-modesty-volume-71.html
In one of the contributions to this blog, it was asked how providers are to know what a patient’s needs are unless patients tell them. The answer is their parents should have taught them, their teachers should have taught them, the media should have taught them, their training in healthcare should have taught them. After all, what are we asking here? We’re asking that providers recognize the virtue of American folkways, the common rules of polite society in the U.S. and many other nations including rules of common courtesy, decency, and etiquette. We’re also asking that the legitimacy of social mores and laws be recognized by providers. Why must the rules of common decency (folkways), rules governing moral behavior (mores), and/or rules of law be systematically violated with impunity or near impunity by some healthcare providers in some healthcare facilities in the process of meeting our healthcare needs? It is a strange doctrine indeed that would require a person to submit to unnecessary violations of these rules by virtue of the misfortune of falling ill and having to enter a healthcare facility. What is it that we’re asking healthcare providers? We’re asking them to do, inter alia, the following:
Maurice,
On 12/30, you asked me the questions, “. . . 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 . . . blog thread? . . . What would you recommend?” On 2/7, you suggested that we “create a list of issues which represent the medical profession’s ignorance and lack of attention to their patients’ need for DIGNITY. And for each, let’s set a plan or goal as to how each issue could practically (not theoretically) be resolved.”
I’ll begin with the assumption in your last sentence that what is practical is independent of what is theoretical. In fact, I would venture a guess that behind every social change program is one or more explicit or implicit theories. For example, the Provo Delinquency Rehabilitation Program was explicitly based on structural-functional theories of delinquency which had been empirically confirmed. Deterrence theory or rational choice theory was the implicit basis for the “Scared Straight” program which began at the Rahway N.J. State Prison. It continues to be the theory that justifies the current programs the workings which we see on A&E’s “Beyond Scared Straight.” And, it is scientifically confirmed theory that is the foundation for the recommendations made by Hague and Waytz’s in “Dehumanization in Medicine: Causes, Solutions, and Functions.” These latter authors begin by conceptualizing and operationalizing the concept “dehumanization.” They move logically from there to a discussion of dehumanization theories. They use these theories to ground practical recommendations regarding how to humanize healthcare delivery. Given your position as a healthcare educator and practitioner, you are better situated than I to assess the level of practicality of the authors’ recommendations.
I believe that I, you, and other contributors to this blog thread could add plenty to Hague and Waytz’s list. I also believe that you and other contributors to this blog thread could add plenty to my list of objectives specified in my last contribution. We can use our understanding of the concepts dehumanization, dignity and other relevant concepts; our knowledge of what causes dehumanization, attacks on patients’ dignity, and other undesirable phenomena that concern us here; our knowledge of how patients’ humanity and dignity are violated in healthcare settings; and our knowledge of possible solutions to the problems to come up with a set of goals, objectives, procedures methods for achieving the latter, and the theoretical/empirical defenses for these goals, objectives, and methods.
Let’s take a simple example and use your perspicacious observation that dignity “should apply to all patients but also . . . to the medical profession itself” and to the individuals who work within it. As I’ve suggested in an earlier post, patients are most likely to be objectified, dehumanized, humiliated or deindividualized when providers are objectified, dehumanized, humiliated or deindividualized. If I recall, you pointed out in a Volume 70 post that residents in some hospitals are expected to work ungodly hours and be alert at all times and implied that this was undesirable. One might consider this a dehumanizing (or, maybe, superhumanizing) aspect of the “system.” But, of course, it’s not the system that created and maintained this requirement; it was or is individuals within the system who are responsible. CONTINUED
Ray
CONTINUATION
Some years ago, Ann Landers was asked about the wisdom of requiring residents to work until they were frazzled. Landers consulted with some famous physician whose last name, I recall, was Shumway. Shumway was fully in favor of maintaining this dehumanizing aspect of the system and gave a number of specious arguments in favor the necessity of doing so. Landers swallowed the man’s sophistry hook, line, and stringer.
By way of illustrating what I’m writing about, we could create a goal statements, objective statements, and method statements to deal with the dehumanization of patients by reducing the dehumanization of residents.
The Goal: reduce the dehumanizing aspects of training providers
Objective #1: reduce the demands placed on residents by reducing the hours of work
Method #1: (You’re most competent, Maurice, to address methods within healthcare settings.)
Method #2: challenge the sophistry used to defend hours of work required;
Method #3: review literature having to do with the harmful effects on residents and patients of resident overload;
Method #4: use our knowledge to appeal to influential legislators who support our cause;
Method #5: use our knowledge to publish the result of our work in popular and professional sources; etc.
Objective #2: (Fill in the blank)
At the end of every chapter and every book about social problems are recommendations for ameliorating the problems based on knowledge of theory and research. Hague and Waytz and we can list all kind of changes to healthcare delivery systems that we’d like to see. It’s all well and good to recommend that resident overloads be eliminated, but how do we buck the Shumways who are interested in maintaining the status quo. How do we get to where we want to go? As I said in my last post, the best evidence suggests that it takes collective action and collective action is most effective when it takes the form of a social movement.
SOCIAL MOVEMENTS
Social movements are on-going, goal-directed efforts to change social institutions. Social movements are not successful unless significant and long-lasting structural changes in social institutions occur. Most scholars focus on national social movements. But, the principles governing successful national movements can be mimicked by organizations bent on bringing about changes at the international, the state, and the local levels.
The experiences of Faith Myers is an example of change that has taken place as a result of collective action. She along with several other women in Anchorage psychiatric hospitals combined forces with attorneys, mental health workers, media personalities, and political leaders to do battle with the very powerful Alaska Psychiatric Institute (API). They compelled its top administrators and board of directors to change its policy regarding cross-gender intimate treatment. But knowing that as soon as the furor died down, hospitals would return to their old ways of doing things, they forced the issue, over the lobby efforts of API officials, resulting in the passage of a law that increased psychiatric patients’ protection from the humiliation that often occurred when patients’ bodily integrity was violated by opposite-sex healthcare workers. Myers and her team continue to work to increase the likelihood that other basic rights of psychiatric patients, heretofore denied them, will be recognized via the passage of state laws. The sum total of their success may take the form of significant structural changes and practices in Alaskan psychiatric hospitals. The process used by Myers and others leading to the desired changes would be an interesting study.
Research on social movements by scores of scholars suggests that there are certain conditions that must be operative before these movements can get started and, ultimately, be successful. CONTINUED
Ray
CONTINUATION
Some years ago, Ann Landers was asked about the wisdom of requiring residents to work until they were frazzled. Landers consulted with some famous physician whose last name, I recall, was Shumway. Shumway was fully in favor of maintaining this dehumanizing aspect of the system and gave a number of specious arguments in favor the necessity of doing so. Landers swallowed the man’s sophistry hook, line, and stringer.
By way of illustrating what I’m writing about, we could create a goal statements, objective statements, and method statements to deal with the dehumanization of patients by reducing the dehumanization of residents.
The Goal: reduce the dehumanizing aspects of training providers
Objective #1: reduce the demands placed on residents by reducing the hours of work
Method #1: (You’re most competent, Maurice, to address methods within healthcare settings.)
Method #2: challenge the sophistry used to defend hours of work required;
Method #3: review literature having to do with the harmful effects on residents and patients of resident overload;
Method #4: use our knowledge to appeal to influential legislators who support our cause;
Method #5: use our knowledge to publish the result of our work in popular and professional sources; etc.
Objective #2: (Fill in the blank)
At the end of every chapter and every book about social problems are recommendations for ameliorating the problems based on knowledge of theory and research. Hague and Waytz and we can list all kind of changes to healthcare delivery systems that we’d like to see. It’s all well and good to recommend that resident overloads be eliminated, but how do we buck the Shumways who are interested in maintaining the status quo. How do we get to where we want to go? As I said in my last post, the best evidence suggests that it takes collective action and collective action is most effective when it takes the form of a social movement.
SOCIAL MOVEMENTS
Social movements are on-going, goal-directed efforts to change social institutions. Social movements are not successful unless significant and long-lasting structural changes in social institutions occur. Most scholars focus on national social movements. But, the principles governing successful national movements can be mimicked by organizations bent on bringing about changes at the international, the state, and the local levels.
The experiences of Faith Myers is an example of change that has taken place as a result of collective action. She along with several other women in Anchorage psychiatric hospitals combined forces with attorneys, mental health workers, media personalities, and political leaders to do battle with the very powerful Alaska Psychiatric Institute (API). They compelled its top administrators and board of directors to change its policy regarding cross-gender intimate treatment. But knowing that as soon as the furor died down, hospitals would return to their old ways of doing things, they forced the issue, over the lobby efforts of API officials, resulting in the passage of a law that increased psychiatric patients’ protection from the humiliation that often occurred when patients’ bodily integrity was violated by opposite-sex healthcare workers. Myers and her team continue to work to increase the likelihood that other basic rights of psychiatric patients, heretofore denied them, will be recognized via the passage of state laws. The sum total of their success may take the form of significant structural changes and practices in Alaskan psychiatric hospitals. The process used by Myers and others leading to the desired changes would be an interesting study.
Research on social movements by scores of scholars suggests that there are certain conditions that must be operative before these movements can get started and, ultimately, be successful. CONTINUED
Ray
CONTINUATION
DISSATISFACTION: First, members of some segment of a population must collectively experience a sense of dissatisfaction. Dissatisfaction may take the form of relative deprivation which refers to a person’s sense that s/he is deprived of what is customary in society or, according to John Macionis, “a perceived disadvantage arising from some specific comparison” *
An example of relative deprivation can be found in the courts’ decisions in Backus v. Baptist Health and EEOC v. Mercy Health. Although the judges never used the term relative deprivation, they nevertheless recognized its existence when they concluded that it is a strange doctrine indeed that would require a person who enjoys certain rights in the general population to relinquish those rights by virtue of the misfortune of falling ill and entering a healthcare facility.** In other words, the right to protect one’s bodily integrity (which was at issue) is customary in society. To strip people of that right in healthcare facilities puts them at a disadvantage compared to those who are fortunate enough to be healthy. I have found no legal doctrine in American jurisprudence that sanctions such a thing.
The best method for finding out the extent to which relative deprivation exists and to what extent there is dissatisfaction with healthcare facilities’ protection of patients’ privacy rights is to conduct a survey or, if resources are available, to employ a polling organization (e.g., Gallup Poll, Harris Poll) to conduct a survey. Given what George Annas in Judging Medicine recognizes as the covert nature of privacy right violations in hospitals and other healthcare facilities, it may very well be that survey subjects will express little concern with their commission and view offenders as “bad apples” or rogue providers rather than attributing their commission to aspects of medicine’s social structure. Such information is useful as it provides the basis for using the media for informing the public and opening their eyes to the problem. By way of illustration, one of the things that proved to be so disconcerting to physicians involved in the Tuskegee Syphilis Experiment was their perception that the African American survivors were “content” to live their lives absent of any knowledge of how unethically they had been treated. It wasn’t until a bunch of “upstarts” (which included physician whistleblowers, attorneys, and people in the media) told black participants that what happened to them was wrong that they became disgruntled. For example, one physician condemned his condemners by exhorting, “They [black participants] weren’t at all disturbed about what happened to them until the media and lawyers got hold of them.” Another physician expressed a similar complaint on the video about the Tuskegee experiment I cited on an earlier post. CONTINUED
Ray
CONTINUATION
COMMUNICATION NETWORK: In order to successfully implement a social movement it is not enough for people to be dissatisfied; they also must be able to communicate that sense of dissatisfaction. John Farley in Majority/Minority Relations says it well: “It does not matter how dissatisfied people are if they cannot communicate with one another. Without communication, they cannot act collectively. To form a movement, dissatisfied people must be able to share their dissatisfaction, develop a group consciousness, and decide what they are going to do to change the source of their dissatisfaction. Communication also helps in the formation of a collective identity that supports movement participation.” Numerous media are available today that were not available in the past for communicating one’s concerns. Disgruntled consumers of healthcare have, of course, been using this blog for years. But, I’d guess that more contributors have dropped out than are participating today. If so, why? What are the reasons people stopped participating and what do you suppose the most important reason is?
People who benefit from the status quo will, of course, do what they can to prevent communication networks among dissatisfied people from developing. For example, plantation owners prevented slaves on their plantations from visiting slaves on other plantations. During the Great Depression, city ordinances were passed that outlawed assembly in order to prevent the unionization of workers. And, during the 1960s the FBI planted agent provocateurs in civil rights organizations and anti-war organizations to, among other things, disrupt communication networks and provoke violence with the intention of discrediting the organizations and their leaders. One can only imagine what healthcare interests will do to disrupt communication among disillusioned consumers of healthcare who are vociferous about their wish to make providers more accountable than they presently are for privacy-right violations once these consumers are perceived as threats to the status quo. Participants probably won’t have to worry about being shot down in the streets, but they can expect to be slandered, libeled, ridiculed, and sued.
RESOURCE MOBILIZATION: The third condition that must exist before a social movement can get started and be successful is resource mobilization. One resource, of course, is access to communication networks that allow disgruntled people to communicate their dissatisfaction. Access to money and time and capturing the ears of accreditation organizations (e.g., JCAHO), watchdog organizations (e.g., HIPAA), political leaders, and professionals, can be helpful. Access to the mass media can be a real boon to those interested in starting social movements. According to John Farley, “Modern mass media can be used both to facilitate communication among potential movement participants and to generate bad publicity about the groups or institutions that the movement opposes.” Participants who are part of a social movement to humanize healthcare organizations may pressure legislators, the executives of JCAHO and HIPAA, and other authorities to expand their protections of patients. Communication technology can be used to identify providers who violate their own standards, local standards, state standards, or federal standards; the violations can be reported to the authorities in each; and pressure can, in any number of ways, be brought to bear on their directors to take action against the offenders.
Ray
CONTINUATION
Let’s use the example of Gila Regional Medical Center in Silver City, N.M. This hospital has been in the national news as a place where Twana Sparks and her cohorts got her jollies and where an innocent man was abused and battered by healthcare providers at the command of the police after a physician at a Deming hospital refused to accommodate them for ethical reasons. Hospital authorities have arrogantly refused to be forthcoming about specifics, apparently have not fired anyone but a whistle blower, and continue to allow Sparks and other abusive physicians unabated hospital privileges. One might think that the hospital’s accreditation might be in jeopardy. It appears that nothing could be further from the truth. As a matter of fact those responsible for Gila Regional’s website brag about the hospital having received the “Joint Commission Gold Seal of Approval.” Here is how the hospital’s website reads:
“Joint Commission Gold Seal of Approval
At GRMC, we are committed to patient centered care which includes communication with patients and families and a model transparency with our quality data. That means being open with our patients and communities about our efforts to improve performance in safety, quality and patient outcomes.
Access to this information allows you to feel confident in our organization and our commitment to you. We use the data to help us set and meet improvement goals. See our Quality Indicator scores.
Gila Regional Medical Center and its related health care entities are accredited by The Joint Commission.”
In the ‘70s, I worked at a job which required that I help healthcare organizations prepare for accreditation by what was then the Joint Commission of the Accreditation of Hospitals (JCAH). I found the organization, which was run primarily by physicians, to be unusually lax. The same may be true today. If it is true that Gila Regional’s accreditation was not jeopardized in any way (e.g., either pulled or made provisional), then resources could be mobilized to generate bad publicity against both the hospital and JCAHO in order to effect change in the hospital and in JCAHO’s laxity, especially if research revealed a pattern of laxity by JCAHO officials.
CONTINUED
Ray
CONTINUATION
SENSE OF EFFICACY: There must be a sense of efficacy among potential social movement participants. That is, people must believe that the gains of participation will outweigh the costs to themselves. When civil rights workers who were part of “Freedom Summer” visited Mississippi in the summer of 1964 to register African Americans to vote, they found that although most of the residents wanted to vote, many of them did not have a sense of efficacy; they were afraid that they would be beaten or even lynched if they registered to vote and, especially, if they went to the polls. Some workers themselves dropped out of the movement because of the difficultly they had achieving their goals (including convincing African Americans to register), the violence (including murder) to which many workers were exposed, and the refusal of the U.S. government to protect them. And, given the experience of some people who have contributed to this blog, it is easy to understand why people might be reticent to exercise their rights to privacy in healthcare organizations (Anne, for example) by communicating their dignity needs to the defenders of the status quo. Paternalistic cajoling, refusal to treat, and retribution in the form of ridicule, assault, battery, and browbeating are among the responses that patients have been forced to weather. According to Philip Zimbardo in “The Psychology of Evil,” those who adapt best to evil are those who consent and don’t dissent. His research showed that the only factor that differentiated between them and those who did not consent or did dissent was that they tended to score higher on Adorno, et al.’s F-Scale (a measure of authoritarianism or fascism). Patients who speak out, who inform providers of what it takes to ensure their dignity, who protest when their dignity is compromised, or who inform authorities when the rules are violated are the patients who experience the greatest stress. Speaking up, to, or out is not an easy thing to do; there are consequences that may be none too pretty.
LEADERSHIP: Finally, there must be leadership before a social movement will get started and be effective in achieving its goals. This leadership is not infrequently charismatic, as in the case of Martin Luther King. To be most effective, physicians and other healthcare providers must be among the leaders of a social movement designed to humanize healthcare. It is also desirable that among the leaders there are those who have not experienced indignities at the hands of providers, who do not perceive themselves as being at risk of experiences indignities, but who are part of the movement solely because of their interest in justice. Such was the case of the white folks who joined Martin Luther King and others in the civil rights movement of the ‘50s and ‘60s. CONTINUED
Ray
CONTINUATION
Macro-level social forces also come into play in determining whether or not a social movement will get off the ground. For example, some people attribute the emergence and the success of the civil rights movement in the 1950s and ‘60s to the charismatic personality of Martin Luther King and the good-hearted people in Congress who were horrified by the treatment of people of color in southern states. Yet, there were good-hearted people in Washington and charismatic civil rights leaders, such as Philip Randolph and W.E.B. Dubois, before the 1950s. If this is so, then what precipitated the civil rights movement in the 1950s? Azza Layton, in “Mobilizing International Pressure: A Strategy of U.S. Civil Rights Leaders,” provides his readers with an historical/structural explanation. He notes that following World War II, two things occurred which insured that the time was right for implementing a civil rights movement. First, the United States and the Soviet Union became embroiled in the “Cold War” and second, the United Nations was formed. An analysis of congressional records showed that political leaders in the U.S. were convinced that the only way we would win the “Cold War” was to curry the support of low-income and developing nations the leaders and citizens of which were primarily people of color. We could hardly hope to engender support from these nations if we didn’t change the way we treated U.S. citizens who were of color. Indeed, Layton reports that when the U.S. offered to broker a truce between India and Great Britain over conflict they were having, “Gandhi and Nehru rejected the offer ‘because the Indian people [had] no faith in American democracy as it applie[d] to colored people.” Furthermore, some people in the U.S. government were embarrassed when several civil rights organizations – including the National Negro Congress, NAACP, and the Civil Rights Congress – filed complaints with the United Nations about the treatment black Americans were receiving here at home.
To be successful, the leaders in a social movement designed to humanize healthcare must necessarily be opportunistic, just as Martin Luther King and other civil rights leaders were in the past. For example, they could take advantage of especially egregious behaviors of healthcare providers soon after they become public knowledge, as in the incidents at Gila Regional, and use the resources available to them to take corrective action.
The civil rights movement to improve the situation of people of color had the cold war. We don’t have anything comparable. What we need is a widely read publication that reveals the pattern of abuses that occur in healthcare. The civil rights movement had the United Nations with which to file complaints. We have only HIPAA, JCAHO, and other sanctioning bodies the members of which, without constant urging and pressure, are unlikely to be proactive in their efforts to increase the humanization of healthcare delivery.
Ray
Ray, thank you so much for the pathophysiology which leads to the medical system behavior but also the factors that can alter or prevent a therapeutic cure. So .. now...as physicians are always challenged with this question:
What is your prognosis for cure? ..Maurice.
Maurice,
You ask about my “prognosis for cure.” If the patient is fully compliant, follows the regimen and all that, then the prognosis, at least for significant amelioration if not cure, is good.
Ray
Ray, I am pleased with your prognosis and thanks for your post
Maurice,
Regarding “spreading the word” and my “approval,” I’m all for it., which was accidentally deleted. ..Maurice.
Maurice and Doug,
Can we somehow get copies of the 2 articles you published in the AMA News? I did a search but couldn’t find them. However, I did find one publication about i-Human which is an innovative approach to student learning that involves students using “a computer-animated patient.” Nothing in the article indicates that students will learn how to objectify patients, but if that is not an effect of using i-Human, at least as described in the piece, I’ll eat my hat.
http://www.ama-assn.org/ama/pub/news/news/2014/2014-11-20-i-human-partners-with-ama-clincial-skills-training.page
I would like to collaborate with Maurice and Banterings and/or other interested parties in writing an article and submitting it for publication or put it onto the “listserv of medical educators” that you mention, Maurice. Right now, I find organization and specificity difficult because much of my professional stuff is packed away and is in disarray and there probably won’t be a day when it’s all in array. I don’t have access to a library which will help me get the most current publications and I don’t, at this time, have access to a statistical package (e.g., SAS or SPSS) which would allow me to conduct an analyses of pertinent data I’d like to collect.
I would also be interested in collaborating on a research paper if we can gather data at sites such as allnuses.com and/or the listserve of up to 2000 educators that you mention, Maurice. We could come up with some research questions that can be investigated on pertinent sites and then conduct surveys on these sites. I might be able to get access to SPSS at the university at which I once taught so that I could do statistical analyses on the data collected.
Maurice, you mention Steven Miles in your Feb. 9th post. Maybe this is the same Steven Miles who wrote “Oath Betrayed: Torture, Medical Complicity, and the War of Terror.”
Ray
Ray, yes, same Steve Miles, physician ethicist and a physician leader against torture and particularly governmental ignorance in identifying and penalizing those physicians who participate in torture. ..Maurice.
Ray
If you yahoo Gila Regional Medical center on
yelp review, there is a picture of three extraterrestrials with the caption, "Anal Probe, you're gonna get one." Re: the suspect who was evaluated for 14 hours after he was suspected of hiding drugs in his rectum and after numerous rectal exams, x-rays and finally a colonoscopy, none were found. One would think the episode with Dr Sparks would have awoke those in risk management, obviously not.
This is how this hospital, along with the other
4,999 other hospitals around the country treat their
male patients, criminal or not!
PT
So far, no response to Ray's list of "to do's" to be considered by the medical providers which I put up on a medical educators listserv. ..Maurice.
I feel that providers are unable to make any sort of changes because by the nature of them perpetrating procedures and even abuses (PE on anesthetized women), they have demonstrated they are incapable of distinguishing what is socially acceptable or excessive. This is not all providers.
I also believe these abuses are more likely to occur where there is no relationship with the provider (such as ED, outpatient services, imaging, etc.) and where there is a strong corporate structure (hospitals). I think that even those good providers also contribute to the "white wall of silence."
Please do not insult me by defending the 2 following examples as "medically necessary."
I am talking about legislation requiring transvaginal ultrasounds for women seeking abortions and the rectal feedings at Guantanamo Bay. Why no outrage from the medical community?
There is no denial that TVAs are a ploy by conservatives to make access to abortions more difficult. Ref: "How Republicans Quietly Mandate Transvaginal Probes", "State Requirements for Ultrasound", "What We Are Missing in the Trans-vaginal Ultrasound Debate".
To protest a bill that would require women to undergo an ultrasound before having an abortion, Virginia State Sen. Janet Howell (D-Fairfax) on Monday attached an amendment that would require men to have a rectal exam and a cardiac stress test before obtaining a prescription for erectile dysfunction medication. Source: The Huffington Post
Our bodies are not political battlefields. The medical community has been largely silent on this issue. They have not spoken with a collective voice. Are they just willing to invade our bodies in another way when unnecessary???
When the CIA 'torture report' was finally declassified, waterboarding, sleep deprivation, abuse. But there was at least one newly-surfaced atrocity revealed in the report, too. Interrogators had subjected at least 5 detainees to 'rectal feeding' and 'rectal rehydration,' often against their will.
The CIA had administered rectal feedings and hydration both to counteract prisoner hunger strikes and to exercise "behavioral control". "Rectal Feeding: The Antiquated Medical Practice the CIA Used for Torture"
But leading human rights groups, including the United Nations Committee Against Torture, International Committee of the Red Cross and the World Medical Association, have accused the Obama administration of continuing a similar practice at the U.S. military prison at Guantanamo Bay. Note it is the WORLD Medical Association, NOT any US medical association. Source: ABC News "Former CIA Director Hayden: Rectal Feeding Not Torture, 'A Medical Procedure" See: "Is rectal feeding an actual modern medical practice?"
I guess just like the healthcare system, we can take SILENCE as CONSENT (approval)
Banterings
Here is another problem that patients face against the healthcare system, and that is a few deviants can infect the whole industry in the same way the actions of a few led to the Holocaust. In healthcare the actions of a few led to the systematic victimization of patients.
Dr. James Marion Sims, considered the father of modern gynecology, carried out human experiments on female slaves and Irish women in the mid-1800s. (Note: the Irish were of the status as Africian-Americans and slaves. See: Irish need not apply) Read about his a human experimentation here: The medical ethics of the 'Father of Gynaecology', Dr J Marion Sims and Slaves, Experiments & Dr. Marion Sims's Statue: Should It Stay or Go?. His perversions led to what is know today as the "annual well woman exam" (which has been described as more of a ritual than science based).
Convicted pedophile psychiatrist Dr. William Ayres, was president of the American Academy of Child and Adolescent Psychiatry and co-author of "Practice Parameters for the Forensic Evaluation of Children and Adolescents Who May Have Been Physically or Sexually Abused" which is now an accepted guideline. Many of the egregious acts he used to groom the victims, give him access to their bodies, and allowed him to molest he had written into those guidelines. This has turned abuse into medical procedures.
The genital examinations of patients of William Ayres appeared to have "very specific” reasons and follow the general consensus of researchers who not only approve of but encourage such methods, a psychotherapist with a medical degree told jurors yesterday.
...Dr. Gilbert Kliman, who belongs to the American Academy of Child and Adolescent Psychiatry [Ayres once was president], differed from prosecution witness, Dr. Lynn Ponton, who told jurors there was little if any reason for the genital exams described by 10 former patients who testified.
…Kliman disagreed. He called one patient’s file a "delightful psychotherapeutic interaction” and praised Ayres’ methods. …the wider realm of psychiatry which allows — and sometimes proactively supports — the idea of physical and genital exams performed in conjunction with treatment.
Some researchers believe physical exams provide more comprehensive care and "increase rapport” between doctor and patient, Kliman said.
Kliman conceded he’d likely seek parental consent before performing a physical and genital exam on a minor patient but that it isn’t an industry standard. Source:Doctor defends physical exams in molestation trial
Ayres also said there is nothing inappropriate about a psychiatrist giving physical exams. He said every full pediatric exam should include an inspection of the genitals. Source:Dr. William Ayres defends practices in molestation trial testimony
Yet when common sense prevails, it is denounced because it goes against guidelines:
"My training was very strict on that," said Hugh Wilson Ridlehuber, a retired child psychiatrist who said he was present for Ayres' presentation and once worked out of the same group practice as Ayres. "Even if it's done innocently, there is a very high risk of a patient sexualizing it and affecting your relationship with the patient."Source: Doctor says boys were not molested
--Banterings
Banterings: It is very disturbing about how Dr. Ayres abused a number of children. There was no reason for him to do genital exams. Parents need to be educated about how to protect their children. I encourage you to check out this article I wrote about how parents can protect their children.
On another subject, I wanted to share a very interesting discussion that was started by a male technician on AllNurses with everyone. He talked about how he has had female patients who requested / demanded a female technician and how he worked to honor them. He talked about how he is a modest patient himself and how he has had many bad experiences with female nurses. He had a horrible experience with a female office manager who did not respond favorably to his wishes for male intimate care. This tech has so many amazing points.
You all will notice that there are some encouraging comments by nurses who agree that patients have the rights to same gender intimate care. I was especially encouraged by the female nurse who worked with soldiers and how she honored the wishes of male patients who preferred a male nurse. It is encouraging there are some medical professionals who are sensitive to patient modesty.
Misty
Misty,
I have read that article before. There is one thing that is lacking.
I know that I am probably going to get a lot of negative feed back, but bear with me.
You need to encourage patients/parents to report (even perceived) inappropriate behavior/procedures/exams to the authorities (not licensing boards). If a provider is following guidelines, then they have nothing to worry about. One or two reports will not cause a problem, but a pattern of inappropriate behavior/procedures/exams is a problem and potentially abuse.
Simply finding another doctor only allows perpetrators of abuse to continue abusing.
--Banterings
PT,
Regarding your comment, “This is how this hospital, along with 4,999 other hospitals around the country treat their male patients,” there was reportedly at least one physician at one hospital (probably Mimbres Memorial in Deming, NM) who refused, for ethical reasons, to submit to the demands of law enforcement to coerce a suspect to undergo rectal and colonoscopy exams. I wish I knew this physician’s name and address so I could send him a congratulatory note. Not knowing who s/he is, I’ll instead send a message to the hospital at the following link:
http://www.mimbresmemorial.com/Mimbres-Memorial-Hospital/ContactUs.aspx
Ray
I want to inform the visitors here that what is being discussed here in terms of modesty and dignity of the patient is being taught to our medical students. Yesterday, the entire 2nd year class heard lectures on how to perform rectal and genital exams on their future patients. They were taught that the physician should first attend to the patient before any exam by explaining to the patient what and how the exam will be carried out and then to allow and consider a response by the patient regarding the patients own concerns regarding the exam. During the afternoon yesterday while supervising 4 groups of 6 students, each group examining plastic male models, I re-emphasized the need for disclosure but also the need to listen to the patient's response and to attempt to mitigate the patient's concerns. Will they later on in their careers remember and respond to what they were taught today? I hope so. ..Maurice.
All, we have reviewed most aspects of patient modesty and abuse but one element I would like to put on the docket beyond standing up for your rights is how to go about handling the damage that has already been done. After no response and multiple tries in contacting the offending practice, I have tried to seek professional counseling for my own peace of mind. It has been my experience that seeking professional help for the associated medical PTSD is very difficult. In trying to deal with the long term effects, I find it frustrating that I have yet to find a professional in my area prepared to deal with this specific kind of trauma. Even those that specifically state on their web sites that PTSD is an area covered by their practice, unless you are a veteran or a rape victim, their expertise does not apply. The referrals have been many and all have led to dead ends. The clinical psychologist will point you to a social worker and the social worker will point you to a clinical psychologist. Round and round it goes.
The end result is that one gets nowhere fast and that this specific area is simply not recognized or taken seriously in professional circles. I live in a major metropolitan area in Texas with abundant medical facilities but have come up with zero success in finding someone to talk too.
Has anyone else hit this wall?
Ed T.
I do this in 2 parts:
Maurice,
Are your students warned of the hidden curriculum at this level?
IMHO it would seem prudent as a teacher in you having discussions of "the proper way" to perform the procedure you prepare them for potential pressures that they may face in their clerkships "shortcuts" and of the hidden curriculum.
Do you discuss cases (usually in the media) that even though (the physician involved's opinion was) "medically necessary", the question of the necessity along with what is considered excessive (Dr. Stanley Bo-Shui Chung), socially unacceptable (Dr. Twana Sparks), or criminal (Dr. William Ayres) deemed the exams/procedures inappropriate and unnecessary?
Again, I would believe that part of learning how to, is knowing when not to.
The reason for my curiosity is to understand the inner workings of the system. Let me illustrate with Dr. Bo-Shui Chung and the system had failed in his case:
[In Chung's testimony to the College of Physicians and Surgeons of Ontario:] We were told that breast and pelvic examinations are part of the physical examination of the body,” he testified.
During the hearing, he read from a variety of medical textbooks that he said he used while attending medical school in Wisconsin in the late 1960s and early 1970s.
“Neglect of the pelvic examination often leads to serious errors in diagnosis,” he read out from one of the books, Bedside Diagnostic Examination by DeGowin and DeGowin. Source: Metro News Canada
He never talked about when omit them (even if he felt they were probably needed. Further he failed to realize that he was being excessive. I suspect that for fear of not doing those exams, his professors only focused on doing them. The assumption was (probably) there was no harm in doing them (as opposed to an MRI or a biopsy). Yet today we recognized that there can be harm in them even when indicated; PTSD/emotional trauma (as I have previously demonstrated), false positives, etc.
I believed that the system failed Dr. Chung in its failure to recognize the psychological aspects of healthcare and teaching him temperance.
Continued...
Part 2:
Maslow's Hierarchy of Needs 1943 ("A Theory of Human Motivation" in Psychological Review - 1943), parallel many other theories of human developmental psychology, some of which focus on describing the stages of growth in humans. Maslow used the terms "physiological", "safety", "belongingness and love", "esteem", and "self-actualization".
One of the biggest shortcomings in "The Four Principles," originally devised by Beauchamp and Childress in their textbook Principles of Biomedical Ethics, (considered the standard framework of medical ethics) is their failure to address the higher needs. In discussions of The Four Principles," the expression "the patient choosing health" is used. This expression allows for whatever the physician deems necessary to preserve the patient's health.
If the patient's goal is not health, then Biomedical Ethics do not apply [sic: and the patient is free to seek another provider...] Choosing health is only the bottom 2 needs in the hierarchy; physiological and safety. Belongingness/love and esteem are higher than the physical needs, these are the emotional/psychological needs AND where PTSD and mental trauma occur. The Hierarchy of Needs demonstrates why a patient would willingly choose (prefer) dignity over preservation of life.
--Banterings
I wanted to encourage you all to check out an interesting article, The Male Nurse Debate. I thought that this article did an excellent job addressing patient modesty. It was encouraging to read that a charge nurse encouraged a male nurse who was upset that a female patient refused to let him care for her to think about how he would feel if his role was reversed. It made him become more sensitive to patient modesty. I am glad there are some medical professionals who understand that you should respect patients’ wishes for modesty. I think that this article should be read by every medical professional.
Misty
Banterings, in perhaps partial answer to your question, in the "Introduction to Medicine" (ICM) course in which I participate, we teach "how to do" both history taking and physical examination (provide the students with the skills of performing) but it is up to the other clinical courses and in the students 3rd and 4th year clerkships and beyond into residency and later practice to provide the accepted standards for what conditions require what actions both in terms of procedures and treatments. Are the some procedures thought to be necessary in the past now unnecessary? Of course. Are there some procedures unknown or thought to be unneeded in the past and now necessary? Yes. But it isn't our teaching role in this course to make the distinctions of what to do for what and under what circumstances. These issues must be presented by those who detail the great number of medical conditions, their pathology, diagnosis and treatment approaches. And it is not those of us in ICM.
Physician defending themselves for their advice or actions must provide evidence in the form of accepted current standards of care both clinical and ethical if they are challenged by patients, family, medical boards or the law. ..Maurice.
Misty
I think the article on the male nurse was to the
point and appropriate, however, the article made no
mention as to the gender of his charge nurse. Was
that coincidence or by choice and my second point
I'll make is show me a comparable article where the
nurse is female.
PT
Maurice,
This morning you mentioned that “yesterday, the entire 2nd year class heard lectures on how to perform rectal and genital exams on their future patients.” In the past, physicians have given me both of these exams. However, not all have performed them in the same manner. Some have conducted them in ways that I would consider to be less demeaning than others; they permit the patient some dignity when performing what I consider an inherently undignifying procedure. I pointed this out in response to a piece written by you in 2012 on Joel Sherman’s blog but received no response. Can you give me a response now? Here’s what I wrote.
May 13, 2012 Dr. Maurice Bernstein in “Teaching Medical Students about Patient Modesty,” writes the following: “Male genitalia exams for an ambulatory patient is done standing and rectal examination with the patient bending over a table.” The internist with whom I did business for sixteen years never had me “bend over a table” when he performed a transrectal prostate examination. A nurse would ask that I replace my clothing with a gown. The nurse would leave and the physician would enter the examination room and have me lie on my left side with my legs bent at the knees. He then draped me before performing the examination. This was not my experience with a female urologist whom I visited. She had me undress in front of her and bend over a table, as described by Dr. Bernstein. In an ice-cold voice she proclaimed, “You have a lump” and when I asked her what that meant, she responded, “Cancer!” This shocked me, given I had just had a PSA and prostate exam with the internist a couple of months earlier. So, I went back to him and asked if bending over a table would make it easier than lying on one’s side to detect a lump on the prostate. His response was, “Absolutely not. But in case you are concerned, I’ll do it her way.” He did so and felt nothing out of the ordinary. After speaking to a number of physicians and patients, I came to the following conclusions: Requiring patients to bend over a table to conduct a transrectal prostate examination unnecessarily adds to the indignity of an already undignifying procedure. It is done in lieu of draping patients and asking them to lie on their side because the latter is less convenient for the physician than asking patients to bend over the table. Furthermore, according to social constructionists, the bent-over patient with a physician behind him sticking a finger up his rectum carries a more powerful symbolic meaning than treating a patient with greater dignity. This symbolic meaning, which I am sure is clear to all of us, reinforces the asymmetrical power relationship that exists between doctor and patient. If my assessment is correct, it would follow that those who give instructions to medical students and are concerned about patients’ dignity should themselves be taught how to perform a transrectal examination that minimizes the indignity of an inherently undignifying procedure and be encouraged to transmit what they have learned to their students.
Ray
Ray, physicians as well as the patient are aware of the need not to prolong the male genitalia followed by rectal exam. In addition, the male genital exam including hernia detection is best performed standing. Therefore, after the examination in the frontal position, the patient turns, remains standing, and the rectal exam is performed and the patient then raises his shorts and then re-dresses. The exam can be quick and more accurate than if performed with the patient laying on his back on a table for the genital exam, with the physician bending over and then on his side for the rectal.
Also standing, beyond permitting a inguinal hernia to be more readily discovered (in part due to gravity) also the anatomic relationships on both genital and rectal exams are more easily defined if the patient is standing.
Now, if the informed patient doesn't want to have any part of the exam done standing and wants to get up on the table and lie down, covering himself and tells this to the physician after the physician has informed the patient that standing is performed more quickly and accurately standing, hopefully the physician will follow the patient's request.
Another way I can illustrate this issue is that for a male exam, unless the patient is bedridden and unable to stand, examining the patient supine and then in a lateral position makes for a "sloppy" exam. But if that is what the patient desires after education, as I said, the physician should follow that request.
..Maurice.
I do this in 2 parts:
Maurice,
You stated: in the "Introduction to Medicine" (ICM) course in which I participate, we teach "how to do" both history taking and physical examination (provide the students with the skills of performing) but it is up to the other clinical courses and in the students 3rd and 4th year clerkships and beyond into residency and later practice to provide the accepted standards for what conditions require what actions both in terms of procedures and treatments.
I can only hope that in "other clinical courses" the students are taught temperance. It seems that physicians practice for their comfort and not the patients because they feel that they are being thorough. What is missing from the medical education is a course called "the patient experience." Teaching students draping, the guidelines, etc. is totally different than teaching them how the patient feels.
Just as patients are told that they do not understand the providers' point of view, because the patients do NOT work in the healthcare setting, they do not see bodies all day long, etc., I argue that providers do not see the patients' point of view. The providers that speak to the indignities of healthcare almost always discover them when they become a patient. Yet, healthcare makes no attempt to train in the understanding. Simply teaching students how-to's, such as proper draping methods is totally different than being exposed and draped.
This is NOT me trying to justify students practicing on each other.
I have never found any course that teaches the patient's perspective. You reminding your students about the dignity of patients as human beings is not the same as a complete course focussed on that. Further, the course will have to look at Maslow's Hierarchy of Needs and explain the rational why a patient may choose the preservation of dignity over the preservation of life/health.
If you ask a physician to explain a patient's choice of preservation of dignity, they almost always answer along the lines of mental illness. You even had trouble grasping this concept when I presented it to you until I cited research affirming it. I think that it is a deficit on the provider's part NOT to recognize it. I realize that the physiological needs are lower than the psychological needs, but when the patient perceives the preservation of health not as psychological (emergency room vs. annual physical) the two are weighed equally in terms of cost/benefit.
Getting back to teaching the patient perspective, students take an "On Doctoring" course, but again, viewing from the receiving end is totally different. I do not know what the class would look like exactly, but I imagine that the labs may be a bit uncomfortable... I point to practices such as the pelvic exams on anesthetized women. Again, I ask, how could providers not realize how wrong this practice is?
In all seriousness I ask, would that practice have existed if there was a "Patients' View" course, and students were told that you will be put under and examined?
What is even more disturbing is the people who defended the practice, and there were many. The main reasoning was patients had an "obligation" to do so.
Continued...
Part 2:
Thank you Maurice for explaining ICM. Perhaps you are aware of other courses that address the issues that you bring up.
These issues must be presented by those who detail the great number of medical conditions, their pathology, diagnosis and treatment approaches.
Again, nothing strikes me here as temperance. Over-medicalization is a big problem today. Over-medicalization has caused preventative procedures to do more harm than good. Prostate and pelvic exams are 2 examples, and I do not mean the psychological trauma, I refer to biopsies, false positives, aggressive treatments, etc.
What may be scientifically justifiable and/or medically necessary is limited by many other factors such as social acceptability, excessiveness, and (Constitutional) Law. It is easier to have a patient fully undressed for the complete exam (as once was the practice), but it is socially unacceptable. Medical marijuana may be medically necessary, but prohibited by federal law, Granted I am sure that students learn the law, but not other temperances.
Physician defending themselves for their advice or actions must provide evidence in the form of accepted current standards of care both clinical and ethical if they are challenged by patients, family, medical boards or the law.
Standards are ignored. Look at pelvic exams and oral contraceptives.
Maurice, I ask you; what are students taught at your school in regards to pelvic exams and oral contraceptives? If this is something that you do not teach, perhaps you can find out the answer.
I also ask that you do not answer that they are taught the guidelines, because there are conflictive. Your school may have it's own guidelines too. Despite which guidelines are used/taught, there are three possible answers: The school (or professor) teaches they SHOULD do the PE for OC, they should NOT, or it is entirely at their discretion. (Regardless of what is taught, the individual can always choose not to follow.)
I know that the focus of the education is the physiological, and the social aspect is expected to be learned in clerkships and residencies, my entire point is that may be the problem. Ubel demonstrated what is really learned.
--Banterings
I know that I have been hard on healthcare and providers for shortcomings and transgressions, but I also praise the good. Here is a blog post about A Doctor on Transvaginal Ultrasounds.
This keeps in line with the theme of "speaking up/speaking out." What is really interesting is that this was written 3 years ago, and this is the first that I have seen a physician addressing the issue (and not just interviewed as part of a story on the subject).
I especially applaud his call for civil disobedience in the name of protecting the patient and I fully support it.
Near the end of the comments, one contributor disputes what another has said. This is also very relevant to our discussions here:
However the use of the word “rape” to describe an ultrasound obscures that fact that it is an important part of making abortions safer, and will likely create additional fear for women who are already going through an anxiety-provoking ordeal.
A medically necessarily or medically advised TVU is a completely different thing from a legally mandated one. The issue is simply one of consent. With consent, TVU is a useful, if very unpleasant, procedure. Without it, it is rape. That does not obscure anything, it points out exactly how evil the law is.
in point of fact an abortion is “not medically indicated” for someone’s biological health either. (Yes, there are exceptions, I concede that) So then, if neither are medically necessary and both invade the vagina any arguments using “rape” as a basis for their outrage is nothing more than “the politics of healing.” I would argue more politics than healing.
Oh, BS. An elective abortion is necessary, and is once again not rape because the woman is consenting to it. Consent, consent, CONSENT. Every single person who dismisses the importance of consent in all of this, I worry deeply about. Because if you don’t think consent is important, then what have you done to people without their consent?
I don’t see this big deal about these type of ultrasounds.
CONSENT. The big deal is CONSENT. And if there’s coercion, including legal coercion, then there is no consent.
However, I am disgusted about this article calling a transvaginal ultrasound “rape”. This is NOT rape.
Rape is the nonconsensual insertion of a penis or object into the vagina, anus or mouth. You cannot have consent where there is coercion. How is it not rape to be coerced into having something inserted into your vagina?
The woman can choose to leave the clinic (true, you may argue that she won’t be able to have her abortion in that part of the country). If the woman decides to have the abortion and understands that she has to have an US, she would be giving consent.
IT IS COERCION. To deny someone medical treatment unless they undergo this procedure is COERCION. Where there is coercion, there is no true consent. Without consent, that insertion is rape. If my boyfriend threatens to not let me see a doctor when I need to unless I have sex with him, that is ALSO rape.
--Banterings
Banterings, "how a patient feels" is transferred to the doctor or the medical student by observing the patient's behavior and listening to the words of the patient express their feelings. Though one might assume that on reading on this thread regarding the reactions to the behavior of professionals, every patient feels the same way, that, based on my own observations and simple logic, is the wrong assumption. Each patient is different from the other in their behavior and expression to medical diagnostic procedures and treatment. It is wrong to generalize "how a patient feels".
So yes, for first and second year medical students we teach to observe and listen to the patient and particularly when more intimate examinations or procedures are about to be done.
With regard to your question about what students are instructed regarding any relationship between prescribing oral contraceptives and associated pelvic examinations, I don't know since this may be taught in the clerkship period. Certainly, a physical examination including a pelvic exam would be appropriate prior to prescribing the first dose of a contraceptive. Beyond that, I would think repeated routine pelvic exams, without symptoms, is unnecessary. Banterings, why don't you write to the Ob-Gyn department of a number of medical schools and see how they answer your concern? ..Maurice.
Dr. B.,
You wrote "Certainly, a physical examination including a pelvic exam would be appropriate prior to prescribing the first dose of a contraceptive."
Based on what justification?
A number of organizations, including the WHO and ACOG have stated that pelvic exams, pap smears, etc. are NOT a prerequisite for an oral contraceptive prescription - all that is needed is a simple health history review and blood pressure check.
This is one of those areas that many providers deviate from the recommendations and still insist on pelvic exams and/or pap smears before prescribing oral contraception.
So why do they do this? Medicine is a huge business, and my opinion is it's about maximizing revenue - these invasive exams generate far more revenue than a simple history interview & blood pressure check.
Follow the money.......
Hex
I stick to what I stated, the first use of an oral contraceptive should require history, physical including pelvic exam and pap smear and check for the HPV infection.(http://www.cancer.gov/cancertopics/factsheet/Risk/oral-contraceptives}
I agree that any repetitive pelvic exams, in the absence of clinically significant pelvic symptoms, for oral contraceptive refills is suspect of physician self-interest, monetary or other. ..Maurice.
Maurice,
I have emailed a few schools (professors), and never received a direct answer. I had a couple that had stated they cannot give medical advice... A couple physicians and nurses (even practitioners), they all answer similarly to you (the ones that did answer).
You stated: ...a physical examination including a pelvic exam would be appropriate prior to prescribing the first dose of a contraceptive.
Do not take this personally, but a pelvic exam is NOT appropriate. Here are references: CDC's U.S. Selected Practice Recommendations for Contraceptive Use, World Health Organization's Medical eligibility criteria for contraceptive use, and World Health Organization's Selected practice recommendations for contraceptive use.
The pelvic exam does not contribute substantially to safe and effective use of the contraceptive method (source: CDC).
I understand that you are not teaching that part. I don't know since this may be taught in the clerkship period. But shouldn't you know? This is why things are like they are in the HC system. What good is draping when the exam is NOT required.
Please forgive me that I do not have the words to continue, and I really don't know where to begin with this after citing this example repeatedly. Perhaps someone else may help me....
--Banterings
Dr. B.,
The current guidelines from ACOG, AAFP, ACP and WHO, among others say otherwise.
To quote the ACP guidelines: "With the available evidence, we conclude that screening pelvic examination exposes women to unnecessary and avoidable harms with no benefit (reduced mortality or morbidity rates). In addition, these examinations add unnecessary costs to the health care system ($2.6 billion in the United States). These costs may be amplified by expenses incurred by additional follow-up tests, including follow-up tests as a result of false-positive screening results; increased medical visits; and costs of keeping or obtaining health insurance."
I also read the link you provided and there is nothing there that indicates a PE is needed before prescribing oral contraceptives. In fact, oral contraceptives reduce the risk of both ovarian and endometrial cancer.
Several other studies and experts in the field (UCSF, Columbia University Medical Center, CDC & others) have concluded that the pelvic exam in an asymptomatic female is of little or no value. Even where symptoms are present, both sensitivity and specificity are low.
In any case, it looks like oral contraceptives will hopefully soon become available over the counter here in the US, as they have been in other parts of the world for many years without any problems.
Hex
Banterings and Hex, you have presented good arguments based on your documentation. There appears, however, to be a difference regarding potential risks for the affect of oral contraceptives on cervical cancer between the National Cancer Institute and the CDC.
I think, as with differences in views between various advisory groups with regard to when to begin mammogram screening, the patient should be informed by the physician about the facts and the alternate views regarding screening as part of the informed consent before initiating oral contraceptives. In the case of oral contraceptives, the physician's action should be based on the decision by the patient with regard to the genital exam but decision to prescribe the patient oral contraceptive should not ride on the patient's rejection of the exam. However, the rejection of screening, by the patient, should be documented in the chart.
When evaluating the conclusions and recommendations made by the various medical organizations, these organizations are not personally involved in discussion or obtaining consent from the individual patient whom the individual physician has medical and legal responsibilities of writing that prescription for a years supply of pills.
Sure, once the pills become "over the counter", it becomes the patient's full responsibility to any outcome unless the patient's physician is informed and is thus involved. ..Maurice.
Maurice,
Reading the cancer.org guidelines, they point to a greater risk of developing some future cancers (and a decreased risk of others). How is a PE at the initial dose medically justified?
I could understand in the future, but if the woman is asymptomatic...
The CDC, WHO, and others note: The pelvic exam does not contribute substantially to safe and effective use of the contraceptive method. This includes injectables, gels, and patches. A PE is only required for an IUD.
This is example of ritual in medicine.
It is obvious that you would be uncomfortable (then) prescribing the first dose without a PE, then what about the patient's comfort of having to go through an unnecessary PE to get BC? How can there truly be consent then? Who is going to get these initial doses? Teen to twenty something girls. How can they not feel violated and coerced when BC is held hostage unless they submit to such an invasive procedure.
This is the problem, healthcare can't see the forest through the trees.
--Banterings
Maurice,
You said:
Banterings, "how a patient feels" is transferred to the doctor or the medical student by observing the patient's behavior and listening to the words of the patient express their feelings. Though one might assume that on reading on this thread regarding the reactions to the behavior of professionals, every patient feels the same way, that, based on my own observations and simple logic, is the wrong assumption. Each patient is different from the other in their behavior and expression to medical diagnostic procedures and treatment. It is wrong to generalize "how a patient feels".
But in Volume 68, when I started posting you stated you were basically unaware of the issues saying:
...In view of the many years of practice up to the present, I have never been informed by a patient regarding a modesty issue and though I am not aware of a patient not returning because of a modesty issue , I suppose it is possible...
...No: I have never been aware of discomfort of the patient which was then attributed to modesty by the patient...
Then don said:
...I would say if you never observed a patient being uncomfortable with exposure....why? How could it possibly be in all the years of practice...you never ran across someone like us?
You responded:
I can't explain it Don... except to say that perhaps all my patients found that the value of the exam was more important to them than any discomfort with the exposure. And it also means that I never got a patient who would have such undisclosed concerns that they would have ended up writing to this blog thread. ..Maurice.
I have to ask, have you experienced this patient apprehension yet? Did you "miss it" over the years? If you have not experienced it, then what do you teach your students to look for?
Seeing what has changed your view will be insightful to changing the view of all providers, that is why YOUR insights are so greatly VALUED and APPRECIATED. It is also why you are bombarded with so many questions, at times they may seem insulting, but they are not meant to be.
I can tell you that I have learned much from you and, although I cannot speak for others here, I am sure that many of them learned something too.
--Banterings
But Banterings I wrote "the physician's action should be based on the decision by the patient with regard to the genital exam but decision to prescribe the patient oral contraceptive should not ride on the patient's rejection of the exam."
By the way, many serious medical conditions may be discovered in an asymptomatic patient on physical examination, for example: a heart murmur leading to the diagnosis of aortic stenosis or an as yet asymptomatic but potentially hazardous aortic aneurism. Risk of the examination procedure must be weighed relative to the potential health value. If the emotional risk to pick up an early cancer of the cervix or HPV infection is too great than so be it. ..Maurice.
Maurice,
The guidelines call for BP, BMI (weight), and liver enzymes.
You are right it is the physician's choice to prescribe or nor.
It is also the patients choice to report suspected extortion and insurance fraud. Then the courts can decide what is legal.....
--Banterings
"By the way, many serious medical conditions may be discovered in an asymptomatic patient on physical examination"
Would you happen to have a link to any actual numbers for the percentage of times something is found "randomly" through an asymptomatic genital exam? I looked but couldn't find even a hint at some numbers.
Of course finding the things you listed is "possible", but apparently very unlikely (hence the impossible to find statistics on how often those things are found as asymptomatic), and is similar to saying one could also find a diamond ring in a pile of dog poop while walking down the street... doesn't mean that everyone should start picking through every pile of the stuff they come across.
Jason.
Jason, I don't know the statistics but presumably physical examination in a "healthy" (asymptomatic) person has been found to be statistically unlikely to disclose some serious disease and that is why routine annual physical examinations in general for those without symptoms or chronic disease is beginning to be considered unnecessary by those who write about medical standards. But remember, statistics are one thing and the physician's need to be attentive to that individual patient's (the one sitting across the desk) well-being is another that has to be considered. But yes, after reading this thread all these years, I agree that the patient's modesty and dignity issues should be anticipated, considered and supported by the patient's doctor. ..Maurice.
Maurice,
It is not even about the modesty, it is about making a patient have a medical procedure that is not necessary.
Maurice,
I reread your comments and saw that you stated:
...but decision to prescribe the patient oral contraceptive should not ride on the patient's rejection of the exam.
Then you are correctly following guidelines provided the patient is informed that the exam is NOT necessary for the prescription. I fully agree that that it should be recommended, but NOT required.
I had missed this. I went back and reread because after all this discussion, I could not see that you would make prescribing conditional upon a PE when guidelines say they are not required.
"...many serious medical conditions may be discovered in an asymptomatic patient on physical examination" was Twana Sparks' defense. This contradiction against your position on informed consent was what made me go back. I believe that I may not the only one that missed this.
The biggest problem in the Doctor-Patient relationship IS communication. From this example it is easy to see how a physician may not express something in the best way (such as an exam being OPTIONAL), a patient not hearing what the physician said and misconstruing it (as being required).
Your statement, " If the emotional risk to pick up an early cancer of the cervix or HPV infection is too great than so be it" is also one that all providers should be asking with every procedure. Emotional/psychological risk should be weighed against EVERY guideline and procedure, after all guidelines are only recommendations of the standard of care.
There are many good physicians that DO ask this question, and determine that the emotional/psychological risk is greater and they omit recommended parts of procedures and exams. The problem that many providers have had with doing this is that it was thought ONLY being done only for the patient's comfort, failing that it is also done for their emotional, psychological and mental health and well being.
The standard of care should be determined solely on scientific results (tempered by benefit/risk analysis, social norms, mores, customs, and preservation of human dignity), but they are (unfortunately) also based upon ritual and consensus.
In the case of providers who require PEs for oral contraceptives, they are simply putting their comfort (in being thorough) ahead that of the patient's comfort.
--Bnaterings
Here is something which an ethicist-physician wrote on a listserv I subscribe and just fits this current discussion. It's about the difference and confusion between "care" and "caring", the same word as a noun but also as a verb. Read what the physician wrote. His very last sentence is just what we are discussing here. Right? ..Maurice.
This distinction also led to one of the most famous quotes in medicine. Namely, Peabody's:
" One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient."
Treatments, interventions, procedures, therapeutic maneuvers, tests, etc... those are things we do. Caring is why we do them. It's also why we sometimes refrain from doing them.
Maurice,
This last Wednesday (2/18/15) when you wrote of giving students a lecture on how to perform rectal and genital exams, I was reminded of my 2012 response to one of your publications on Joel Sherman’s blog entitled “Teaching Medical Students about Patient Modesty” in which you wrote, “Male genitalia exams for an ambulatory patient is done standing and rectal examination with the patient bending over a table.” In my 2012 response to this statement, I told of my experience with a female physician who required that I undress in front of her and bend over a table for a transrectal prostate exam and then pronounced that I had cancer. I contrasted her “bare-assed bend-over-a-table” approach to what I considered the more humane and respectful “lateral and drape” approach used by the internist to whom I had gone for healthcare for more than 20 years. I received no response to my 2012 post so asked you on Wednesday to respond to it since you had brought the subject up, which you did. Now, I’ll respond to your response on Wednesday to my 2012 post which was a response to a sentence in the piece you published on Joel Sherman’s blog.
First, in your 2/18 reply, you defended the “bend over the table” approach as being “more accurate than if performed with the patient laying [sic] . . . on his side” and then added that “the anatomic relationships . . . are more easily defined if the patient is standing.”
The reason I’m so long in getting back to you is because I wanted to try to confirm the accuracy of your statements regarding the greater “accuracy” of the “over the table” method. The data I had on Wednesday simply did not confirm it. First there was the statement made about three years ago by the internist to my question if “bending over a table would make it easier than lying on one’s side to detect a lump on the prostate. His response was, ‘Absolutely not.”’ Second, there are female physicians who work in the vicinity of the urologist and internist whom I visited who use the “lateral and drape” method. Surely, if they thought the “bend over” method was superior to the “lateral and drape” approach, they would use it. Third, there is a video I came across some time ago in which a physician informs patients that there are three methods used by physicians to perform transrectal prostate exams, one of which is with the patient in a lateral position.
http://www.prostatevideos.com/prostate-health/routine-examination/ This physician does not suggest that, for the sake of accuracy, one position is preferable over another. Using what you have written, one would conclude that he and the other physicians I’ve mentioned, including the internist, are remiss in failing to inform patients about the limitation of the “lateral and drape” option. My initial conclusion based on the information I have, however, is that the two methods of positioning patients for a prostate exam which are in question are within acceptable boundaries and neither is superior to the other. CONTINUED
Ray
CONTINUATION
Since none of the data I had confirmed your contentions, I sought the opinions of one expert in human anatomy who instructs medical students but is not a physician and five physicians who also instruct medical students, three of whom I know personally. I was able to get the opinion of the lay professor and the latter three physicians. None of them were able to confirm either of your assertions of fact. The lay professor was unwilling to say anything about which position, if either, would be most accurate since he had never performed a prostate exam. Regarding whether or not “the anatomic relationships . . . are more easily defined if the patient is standing,” he responded “Maybe theoretically, but I don’t know of any evidence.” The three physicians said basically the same thing as the expert in human anatomy about the “anatomic relationship.” Two of the physicians used the “over the table” method but said they did so because of its convenience and because that’s the way they were taught, not because they thought it provided greater accuracy than the “lateral and drape” approach or because of a more well defined “anatomic relationship.” The third physician educator laughed and suggested that your defense is “pure blarney” and suggested that, “He’s jerking your chain.” He had used both methods and could not recognize a difference in accuracy. He did admit that some physicians may believe they get greater accuracy from the bent over position than the alternative but thought it had more to do with what “they were used to” rather than anything anatomical. I even did some probing but could not get any of the physicians to confirm your assertions of fact.
Well, it doesn’t really matter. Let’s assume you are correct; in fact, at the risk of violating the value I place on reasoned debate, I’ll even concede, without evidence, that you are correct by virtue of your credentials – the “bend over” method is preferable to the “lateral and drape” method because it is more “accurate” and because “the anatomic relationships . . . are more easily defined.” When you come right down to it, both justifications for the “bend over” position are really moot points. As a patient, I’m most interested in knowing who is more likely to miss an anomaly of the prostate, physicians who use the “over the table” approach or physicians who use the “lateral and drape” approach. If I am provided with good scientific evidence that physicians who use the method you advocate are less likely to miss an anomaly of the prostate than physicians who use the method preferred by my internist, then I will concede that the “over the table” approach may be preferable to the “lateral and drape” method. Credibility by credentials won’t do.
As it stands now, it was the lesser of the two experts – the internist who used the “lateral and drape” method – who made the more accurate diagnosis; it was the specialist – the urologist who used the “over the table” method – who erred. And, in part because of her error, I went through an unnecessary cystourethroscopy (conducted with as much sensitivity as possible under the circumstance) cost me and the state of Missouri mucho bucks. CONTINUED
Ray
CONTINUATION
Second, I’ll turn to the first sentence in your post – “[P]hysicians as well as the patient are aware of the need not to prolong the male genitalia followed by rectal exam.” My studies have convinced me that social life is more complicated than what can be expressed by the use of platitudes. My old and sagacious graduate professor was, I believe, correct: “Ray,” he said, “this is a complicated multivariate world.” Regarding your statement, I’d wager that most patients and most physicians “are aware of the need not to prolong” any medical procedure. I’d also wager that a large percent of patients prefer that their health needs be balanced with their need for dignity, that they prefer prostate exams to be carried out expeditiously without unnecessarily adding indignities while carrying out a procedure, especially when the physician is female. I submit as a hypothesis that, given a choice, many if not most patients would prefer to spend more time in an examination room if it meant greater preservation of their dignity than to spend less time and experience unnecessary assaults on their dignity. This hypothesis lends itself to examination and you may be the only one among us who is in a position to conduct such an examination. I know I’m not.
What I do know is that some providers are like some politicians who I hear on television; they know, absent of evidence, what the people – or, in the case of physicians, patients – think and feel. For example, I recommended to a hospital administrator who was also a physician that for ethical reasons patients be asked to give their authorization to serve as teaching subjects on a separate form. The administrator sidestepped the ethical issue and with great confidence asserted, “Patients don’t want to have to read and sign any more forms.” “How do you know?” I asked. “I just know,” he said, “I’ve been doing this job a long time. I know how patients feel.”
So, not having the resources to conduct a study as methodologically sound as I would have liked, I conducted a quick and dirty survey of potential hospital patients including students and members of the community. I found that 42% of respondents preferred a separate form, 36% preferred the way it was done and the remaining 22% didn’t care.
Now, as I suggested, this study was far from methodologically sound, but it was a sight better than what the administrator had to offer – his own paternalistic imputation of preference onto patients – and it provided the basis for hypothesizing the outcome of a more rigorous study.
Third, your frequent reference to the genital exam is not relevant to the anecdote about my experiences with the female urologist. Of your four paragraphs, most of your first paragraph, all of your second and third, and some of your fourth addressed patients’ positioning for a genital exam. No mention was made in my 2012 anecdote about positioning patients for genital exams. To introduce it in your response confuses the issues addressed in the anecdote by taking the form of the so-called “straw man fallacy” – a countering of arguments never made. It is a ploy often used successfully by people who wish to sway public opinion, wish to break down informal discourse because it is deemed patronizing, and it is likely to be fatal for those who use it in a formal debate. CONTINUED
Ray
CONTINUATION
Fourth, you opine that “examining the patient supine and then in a lateral position makes for a ‘sloppy’ exam.” Again, this statement is irrelevant to my 2012 post which not only made no mention of “examining the patient supine” for a genital exam but made no mention of positioning patients for a genital exam, period.* However, your statement does conjure up an image of the protocol for a testicular and hernia exam used by physicians who I know use the “lateral and drape” method for conducting a prostate exam. In addition to the internist I featured in my 2012 post, there are two female physicians who live in the vicinity and use the “lateral and drape” method. All three permit their male patients to undress and dress in private and wear a gown during the examinations. They first do the testicular and hernia exam with the patient standing. The two women physicians do the exam with their hands beneath the patient’s gown rather than having them expose themselves. When they conduct the prostate exam, they also put their hands beneath the patient’s gown. Now, I don’t know if you believe their approach is “sloppy,” but they would probably take umbrage at the suggestion, and for good reason. Sloppy work increases the likelihood of mistakes. The innuendo of the accusation, then, is that their approach puts patients at greater risk than the “bend over” method. If the two women physicians are the critical thinkers that the internist is, there’s little doubt in my mind that they all would challenge this accusation with, “Prove it.”
At this juncture, I am unconvinced that the physicians I’ve mentioned do a sloppier job than physicians who adopt the “bend over” method of balancing patients’ health needs with their need for dignity when it comes to prostate examinations. I would change my mind with convincing evidence that they err at a higher rate than physicians who have patients bend over a table. By contrast, I am unconvinced that you instruct students in a manner that would give them the tools to avoid exposing patients to unnecessary indignities during prostate exams. I am unconvinced not only because of the reasons given above but also because your words, if taken literally, appear to suggest that you continue to obdurately cling to the belief that the typical patient-physician relationship is one that invites the average patient to request of the physician that s/he change the ways s/he has always performed prostate exams, this in spite of the overwhelming evidence against it. I can hardly imagine the typical patient feeling comfortable asking the typical physician, “Here’s what I’d like you to do to preserve my dignity. I’d like privacy when I undress and dress; I’d like a gown to put on; I’d like you to conduct the prostate exam with me positioned on my side; I’d like you to drape me when you do this.” I and other contributors to this blog have provided ample evidence that suggests that this just “ain’t” likely to happen. If so, then any suggestion that it is incumbent on the patient to ask is born of cynicism. That said, I can be convinced to change my mind, but you’ll have to give me evidence. Persuasion by credentials does not impress me; evidence born of facts does.
* I do know of physicians and nurses who have conducted what I consider faux genital exams on male patients who are supine but only when the patients are unconscious. Witness, for example, the ENT physician Twana Sparks at Gila Memorial and nurses described on this blog who “fiddled around” with anesthetized male’s genitalia in order to elicit laughter from their colleagues. CONTINUED
Ray
Maurice,
The summary/conclusion of my last dissertation was somehow wiped out. I'm headed north to MO to weather the cold, so won't be able to resubmit it. à tout à l’heure todo el mundo
Ray
Ray, an examination of the rectum involves more than just examining the prostate but also the rectum itself and the pelvic structures palpated through the walls of the rectum. Due to the asymmetrical effects of gravity the symmetrical examination on rectal exam (by standing rather than supine rotated on one side) leads for the best examination. Most importantly also is that the entire exam can be performed more rapidly without getting up on a table for the male. ..Maurice.
Maurice, Ray, et al,
Here is a study from Brazil: Patient Positioning During Digital Rectal Examination of the Prostate: Preferences, Tolerability, and Results.
NIH reference:
--Banterings
I do this in 2 parts:
I posted that link last night to support the position that Ray has correctly taken. I realize that this was a Brazilian, but the author correlated his experiences in Great Britain, the Far East, and the US to supporting the study results.
CONCLUSIONS
The preferred position reported by Brazilian Urologists to perform DRE of the prostate is the modified lithotomy position, while our patients prefer or think it is less embarrassing to receive DRE in left lateral position.
Results of DRE in the different positions evaluated demonstrate a faster examination time in the standing-up position, and similar prostate asymmetry rate, positive DRE rate, and incom- plete palpation of the prostate rate. Pain, urinary urgency, and bowel urgency scores are also comparable between each position, except for squatting down with elbows on the table, which may show increased bowel urgency score.
EDITORIAL COMMENT
...The need to undergo a Digital rectal examination (DRE) as part of the Prostate cancer screening continues to torment many patients.
...It is no surprise that most patients prefer the left lateral position which is my experience in the United Kingdom as well as the Far East. This could be attributed to the ability to avoid eye contact in this position. Also, the foetal position is somewhat comforting. On the other hand, The North American Urologists tend to prefer the knee-elbow/bent over position which is quicker...
...A previous attempt to investigate the tolerability and acceptance of the patients have been presented by Furlan et al., yet this new study sheds more light and adequate statistical power.
...Left or right lateral position seems to be mostly preferred by the patients while the modified lithotomy position is mostly preferred by the urologists. The main argument for the patients perforation is decreased embarrassment. In our every day practice we attempt to adopt to our patients needs and comfort in order to keep their compliance and cooperation, therefore the lateral position seems to be more popular while doing full abdomino-pelvic examination. However it is common to use a standing up position for annual prostate screening and therefore this data should be correlated to the status of the visit (first, routine annual or part of other urological investigated issues) and be explained to the examinee beforehead. One should realize that even a small, simple clinical issue might be so important for the well being of the patients, for his further cooperation that eventually will lead to a better diagnosis and early detection of treatable disease.
Continued....
Part 2:
Now for my editorial:
I have a real problem with some of the editorial commenting, especially the PATERNALISM contained within:
...we attempt to adopt to our patients needs and comfort in order to keep their compliance and cooperation...
This last sentence is vague, which may imply that the physician's choice of position is more important by referencing the "well being of the patients." But, the application is solely for the patient's comfort as seen in the contingency of "well being of the patients, for his further cooperation."
One should realize that even a small, simple clinical issue might be so important for the well being of the patients, for his further cooperation that eventually will lead to a better diagnosis and early detection of treatable disease.
Finally there is the hidden hypocrisy that the study uncovered but the authors failed to comment on:
...the modified lithotomy position is mostly preferred by the urologists...
Assuming that the ML is preferred by all urologists, it is evident (first) they are willing to deviate from the better of the positions (dare I say evidence based), and (second) when they do deviate, it is for the convenience of the physician (speed and efficiency of the exam) and NOT the comfort of the patient. The following from the study illustrates this point:
Total DRE time was lower for the standing- up position compared to all other groups. Timing among modified lithotomy position, left lateral position, and squatting down with elbows on the table was similar.
This is part of the fallacy of evidence-based guidelines: when the differences in the options are so slight that the physician is willing to deviate for the convenience of the physician (speed and efficiency), then evidence-based guidelines are NO better than ritual. This supports my stance that the patient's preferences are the deciding factor in deciding the course of exam/treatment, and the physician's fiduciary duty obligates him to comply despite feelings of not feeling comfortable or thorough.
--Banterings
NOTICE: AS OF TODAY FEBRUARY 25, 2015 "PATIENT MODESTY: VOLUME 71 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 72
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