Patient Modesty: Volume 72
What has been written throughout all these now 72 Volumes of Patient Modesty has been descriptions after descriptions of the "bad", thoughtless behavior of the medical system with regard to the dignity of the patients under the system's care. I have repeatedly voiced on this thread the need for my visitors now, beyond simply writing here about the problem, to make an effort to change the way the medical system "thinks" and "works".
I have found today evidence that the system is looking for ways to make changes in teaching, practice and behavior. The Association of American Medical Colleges (AAMC) has now publicized its attempt to make such changes. It is guided by a statement by the AAMC Board of Directors who in 2014"affirmed the value of fostering a positive learning environment with a formal statement that reads in part: 'We believe that the learning environment for medical education shapes the patient care environment. The highest quality of safe and effective care for patients and the highest quality of effective and appropriate education are rooted in human dignity.'"
So, to my visitor, there you are: this major medical system organization involved in medical school education and the teaching of medical practice to the residents and fellows in this profession is looking for change. It is now your opportunity to write to the AAMC and express your concerns of the current system and your advice for the future. This will be your opportunity to "plant a good" which has a chance to flower. ..Maurice.
Graphic: From Google Images and modified by me with Picasa3.
posted by Maurice Bernstein, M.D. @ 8:37:00 AM
205 comments
205 Comments:
I am going to be very cynical on this; if medical schools did not realize that conducting intimate exams on anesthetized patients without explicit consent was not trampling on the dignity of the patient and abusive, coupled with the lack of action by licensing boards, and the lack of encouraging better selection in the choice of gender, I do not buy this dignity campaign. It is just PR. Dignity is the new term in healthcare just like "green" (environmentally friendly) is in consumer goods. Either that, OR the dignity they are talking about is that of the providers (protecting them from the corporate monster).
--Banterings
The dignity of being a physician is certainly being diminished by some of the TV "doctor" series and, of course, the picking out of the barrel by the news media all those "bad apple" doctors. Nevertheless, I am eager to admit that the medical system continues, in many ways, to diminish and even ignore the dignity which should be applied to their patients. One example of that kind of medical system misbehavior I actually wrote for the Bioethic.net website but also reproduced on this Bioethics Discussion Blog. It was about the use of "Medical Slang"
I am saying that the medical system is performing in many undignified ways of themselves but also in ways which impair the dignity of their patients. That is why I have continuously advised my visitors to contribute to the making a change in that system. ..Maurice.
Maurice,
News is NOT about the average, mundane, people doing what they should; it is about the deviations from the norm. Just as with the healthcare system, they report the bad of every profession equally.
I tell people, Whenever you point a finger at somebody, there are 3 fingers pointing back at you." Failure to self regulate, the indignities forced upon patients, arrogant God-loke attitudes, Tuskegee, etc., you wonder why healthcare has a negative approval rating and bad reputation.
The only thing necessary for the triumph of evil is for good men to do nothing. —Edmund Burke
Perhaps healthcare needs a 12 step program....
1.) We admitted we were powerless to continually and consistently treat patients with dignity—that our lives had become unmanageable.
2.) Came to believe that a Power greater than ourselves could restore us to sanity.
3.) Made a decision to turn our will and our lives over to the care of God as we understood Him.
4.) Made a searching and fearless moral inventory of ourselves and our profession.
5.) Admitted to God, to ourselves, and to our patients the exact nature of our wrongs.
6.) Were entirely ready to have our patients teach us what human dignity is.
7.) Humbly ask patients to participate in adding dignity to the healthcare system and God to bless such endeavors.
8.) Made a list of all persons we had harmed, and became willing to make amends to them all.
9.) Made direct amends to such people wherever possible.
10.) Continued to take personal and systemic inventory, and when we or the system were wrong, promptly admitted it.
11.) Continue to involve patients and other non-providers for the improvement of healthcare and for God to continually bless such endeavors.
12.) Having had a spiritual awakening as the result of these steps, we tried to carry this message to providers, and to practice these principles in all our affairs.
--Banterings
Ha, I vouch for the idea of
the twelve-step program!
Hello everybody,
I have been reading Dr. Bernstein's bioethics blog for a few months now and, after some hesitation, decided to "dive in" and get a bit more involved with this.
I suppose I should introduce myself first. My name is Dany, and I am from Canada. I am 41 years old and I am a member of the Canadian Armed Forces (I have been in the military for nearly 21 years).
One of the reasons that lead me to this blog, and made me interested in issues of Patient Modesty, is some personal past experiences (which I may discuss at a later time) and the questioning and introspection that followed. I have often wondered if my own experiences has not, in some way, shaped and altered my perception of things. To say that I am a shy guy (with regard to exposure in a medical environment) would be an understatement. But more on that later.
Reading this blog certainly opened my eyes to certain aspects of the medical world that, to be honest, I am not sure I wanted to know. It also highlighted fundamental differences in the provision of health care between Canada and the United States. One thing I intend to do is present those differences and give my own spin on them, as they relate to modesty issues.
I also have some ideas about how to get the word out on these issues. I believe there are changes happening, albeit at a slow pace, and it is important to keep bringing them up.
Danny,
I look forward to reading what you have to say.
Maurice,
I’ve been away from my computer for some time but found this one to work on for a while, anyway.
When I wrote my dissertation regarding positions for a prostate exam (minus a few concluding paragraphs), I was purposefully provocative. So, when I signed back onto the blog, I expected to find that you had made an effort to eviscerate my arguments one by one. Instead, I found that you were characteristically dismissive. You also continued to be unconvincing, especially in light of the evidence provided by Banterings, and because you repeated your effort to “knock down straw men” rather than address the issues. I provided anecdotal evidence, based on casual observations, that the “bend over the table” method led to a misdiagnosis while the “lateral and drape” method did not. I recognized that anecdotes have no scientific basis and deliberately avoided overgeneralization. All I asked was that you refer me to scientific evidence that the “over the table” method was less likely than the “lateral and drape” method to result in missed anomalies or pathologies. Now, that would be convincing. But I have no intention of “beating a dead horse,” so I’ll move on.
I looked at the AAMC site you cited and where you cherry picked a single statement and suggested that now is our chance to influence a “major medical system organization.” I read the entire document and found mission statements, priority statements, and goal statements. There were no set of objectives associated with each goal or method statements regarding how the goals and objectives were to be achieved. I saw no invitation to submit ideas, papers, etc. to the organization and no requests for proposals. Instead, I saw where the document writer indicated that the AAMC would “continue to engage constituents, colleague organizations, and nonconstituent thought leaders and experts as appropriate” which were its sources for the document in the first place.
Upon further investigation, I found that the AAMC is dedicated primarily to preventing the shortage of physicians due to the expected increase in patients, increase in population, increase in the number of elderly, and the cutting of funds to residency training. Those who created the document want the AAMC to be a political force and enjoined us to join them at pressuring our legislators to do whatever is necessary to prevent physician shortages. They want me to “stand up for patients. Stop the coming physician shortage. And secure the future of graduate medical education (GME) — by joining the AAMC's advocacy community today.” Although these may be noble goals, nothing I’ve read indicates that members of the organization are particularly interested in humanizing healthcare delivery any more than it already is, whether it be via medical education or changing the healthcare system itself. The statement, “You are doing your part by dedicating your life to the care of others” makes me think that those at the AAMC are targeting medical providers and medical students rather than people like me. That’s your bailiwick, Maurice, not mine.
In spite of my skepticism, I have decided to “stand up for patients . . . and secure the future of graduate medical education (GMC) , , , [and] the future of residency training – by joining the AAMC’s advocacy community today. . . By signing up,” I “will receive communications about the issues that matter to” me “and opportunities to take action.” I’ll keep the readers of this blog apprised as to the “issues” that I’m told “matter to” me and to the “opportunities” recommended “to take action” unless you all want to join me in this endeavor.
Ray
Thanks Ray for joining. Your further evaluation of the goals and actions of that organization will probably appear as more valid to my visitors than if I joined and reported back here.
With regard to positing the patient for the rectal exam, I looked up Bates Guide to the Physical Exam which is the "bible" for teaching in our school and the book mentions that "several" positions are satisfactory including standing and bending over but settles to further description on lying on the left side and suggests this is the a common posture for the exam. Also The need for attention to patient discomfort with the procedure is noted.
My conclusion is that we should teach both methods and a discussion between examiner and patient should settle on the positioning to be carried out. ..Maurice.
It's interesting that the current topic happens to be about the digital rectal exam and the respective merits of the two positions. I remember my first rectal exam. Back then, I didn't know what it was, let alone what it was called. I just did what the doctor asked me to do.
She asked me to lay down on my side, facing the wall, with my knees up. Odd... But I wasn't too worried. She must have been in a hurry, because she forgot to tell me what she was about to do. Come to think of it, she didn't mention how either. Or why. She just pulled down my underwear.
That might explain why, as soon as I felt her finger, I nearly jump off the examination table. She steadied me with her other hand, completed the exam, and told me I could put my clothes back on. As I was doing this, she discarded her gloves, signed the form I had brought with me and just left.
I'm sure she was just really busy that day.
I left the doctor's office feeling ashamed, confused and somewhat angry. What was that all about? I remember looking at the form again, to see if I didn't miss a check-box with “put your finger in the applicant's rectum” somewhere but no, there was nothing like that on it. I only went to see her so I could get the stupid physical exam form signed, because I needed it to go to a summer camp.
As hard to believe as it may be, I did not have a clue as to what happened to me that day until a few years later. And when I finally understood, that just made me more angry. I was left the only question: why? Why was I given a DRE at 16 years old? I have yet to find an answer I'm happy with. One thing, however, stood out in mind that day: this will never happen again.
I've often wondered what I could have done differently at the time. I was too shocked to question her actions right then and there, and too embarrassed to bring it up with anyone else later. There would be little point in doing anything about it now. Since that very lousy day, I can count on the fingers of one hand the number of physical examinations I had. I'm sure you can guess how often I allowed the doctor(s) to perform that procedure.
But the thing is, as I'm getting older, this is coming up more and more often on my list of “things I really don't want to do but maybe I should.” The only compromise I have allowed so far is to do PSA blood tests (and yes, I know they are not ideal and really aren't meant to replace the DRE. In fact, they are not recommended as the only screening test).
My last physical was almost 2 years ago and I'm due for my next one in a few months. I know the doctor will ask, it's almost guaranteed. They always do. And I'll have to ask myself if I should allow it or not. I understand, in a rational way, the risks of not doing this screening but you see, when I'm sitting on the examination table, I have this 16 years old riding shotgun in the back of my head. And he's not a happy camper.
As mentioned in my first comment, reading this blog certainly highlighted the differences between medical care in the United States and Canada. In some cases, I was amazed by those differences but in others, I was shocked.
First off, and if this is common knowledge among the readers, I apologize in advance, but I feel I need to mention them to explain my opinions. In Canada, health care is “free.” Regardless of your economical status, you will receive medical care if you have a need for it. Almost every medical expenses (with some exceptions) will be covered by this and, if you ask me, that is a good thing. However, this comes with some drawbacks. Some are obvious, others are more subtle.
The management of health care (from the number of hospitals and clinics that are open to the number of doctors – specialists or not - , technicians, nurses, etc. hired) is done at the provincial level (think state) and each province has their own unique approach to this. As you can imagine, this is very expensive and many provinces are faced with budget constraint that often results in cutbacks in “non-essential” services for the population. This directly affect the numbers of beds available in any hospitals to how long you will have to wait for an MRI or other specialized procedures like colonoscopy/endoscopy.
With that in mind, there is also a penury of physician in some provinces. Believe it or not, there are waiting list for many health clinics (family medicine centres, private clinics, etc) only so you can be added to the list of patient of any given doctor. For many, when you are accepted as a patient, you're not going to be too fussy over the fact that your doctor is a man, or a woman. That being said, when available, preference of gender will be respected. Many clinics will attempt to accommodate you within the resources available to them (remember they're not there to make money; they are handed down a budget from the government and have to follow it). You can “shop around” until you find what you're looking for but it might take you a while.
One less obvious impact of this is the fact that you, as a patient, don't have the leverage of “taking your business somewhere else”. You don't get billed for the care given and you're certainly not affecting the doctor's bottom line as he or she is getting paid by the government, not you. Yes, medical care is free, but you may not have as much options as you would like to have.
Personally, this has caused me to have to deal with opposite gender care providers in some occasions. I try to avoid it as much as possible (as I am extremely uncomfortable with that) but sometimes it is impossible, unless I refuse care. I count my blessing for not having been seriously ill/injured yet but as I get older, I get the feeling I'll have to make some somber decisions.
Dany, thanks. Interesting reading. ..Maurice.
Dany,
While no RCT's have been conducted specifically comparing the accuracy of the DRE to biopsy results, meta-analysis results of other study data show that it is a poor test with both low specificity and PPV with respect to prostate cancer screening - in other words, it's no better than the PSA test.
For this reason, a number of professional medical associations recommend against their use for cancer screening.
Hex
The thing that everyone missed here is that a 16 year old does NOT need a prostate exam!!!
Dany,
I am going to make some assumptions about age here, and that you are around 40 yrs old. I bet the doctor is practicing. I would track her down and ask her for an explanation. If she refuses, then ask if she prefer you to go public with your story and have other victims see that they are not alone, I'm sure that she will speak to you then. I can see no reason for her to do this other than for abuse and personal gratification unless you suffered from an endocrine disorder, STI, or colorectal disorder.
Educate yourself first about the procedure, then do not accept an answer of her "being thorough" or any other BS. Something like her being a young doctor, needing practice and wanting to get familiar with what a healthy prostate feels like makes sense, but does not justify what she did. I am sure that you are not her only victim.
For your future healthcare, refer to 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. Find a provider that practices trauma informed healthcare.
Hex,
As to the value of a DRE, take a look at this cartoon on the bottom of this post on my blog.
This is a good segue to a recent post on the allnurses site that I have contributed to. The post is titled: "Nudity in healthcare classes education or violation?" Very interesting because this topic was discussed here. The attitude of many here is unsettling, implying the OP has mental issues or is even being childish. (I will note that some believe that this helps give providers the patient's perspective.)
One in making fun of her also makes fun of child sexual assault:
Quote from Kuriin "You've complained about eating food in what appears to not be actual lectures and now this? lol. Can you point on the teddy bear where the bad teacher touched you?"
You can see my responses to this and other disgusting comments here:
Then these people defend themselves as compassionate healthcare providers... Does anyone still think that there is not a problem with healthcare providers???
--Banterings
Ray
Thanks for the welcome. There's a few other issues I'll bring up, as I think they are of value. Hopefully it won't come across the wrong way.
Dr. Bernstein
Thank you as well. Having your perspective on things is helpful. Hope you won't mind too much if I seem to high jack the blog for a bit :)
Hex
I appreciate the information you are providing. Refusing DREs is one thing, but I did not want to do this blindly (not knowing what kind of risks I was taking regarding the chances of developing that specific cancer). I have no history of prostate cancer in my family on either side (that I know of). Does that mean I am safe? Well... I assume so but it is difficult to know with any certainty.
I learned about PSA blood test only 4 years ago. I thought it was a wonderful thing, since now I wouldn't have to consider DREs again (or at least have a reasonable argument against it if I came across a well meaning but persistent doctor). Then recently, I came across a guideline issued by the Canadian Task Force on Preventive Health Care regarding prostate cancer screening.
(http://canadiantaskforce.ca/ctfphc-guidelines/2014-prostate-cancer/)
That was a bit of a bummer. Looks to me like I'm back to square one. I do know PSA has a relatively high yield of false positives (about 11.3% on average), that the results can be skewed by having sex (yeah, really) within 48 hours of doing the test... And so does eating red meat, apparently. Plus the usual warning about cancers (you know... Obesity, smoking, etc.). The reasoning behind their recommendation is that biopsies might cause more harm than good . And according to the Canadian Cancer Society, 1 in 8 men is expected to develop prostate cancer during his lifetime and 1 in 28 will die from it (those are for 2014). Sobering thoughts...
I guess what it comes down to is how comfortable I am with those odds... For the time being, I think I will stick with PSA screening only, until something comes up then I'll have to consider the more traditional screening method. I am not looking forward to that...
A. Banterings
Yeah... That's what I came to understand when I realized what that doctor did. As I said in my comment, it took me a few years to clue in on that (I was almost 20 years old). There is no reason I can think of. Was it “power-tripping”? Was this doctor a “bad apple”? Did she genuinely believed she was helping me? Was there some other circumstances at play here that I missed? I did not present any of the conditions you listed.
What really anger me with this is not so much that she did a DRE but that she never asked, let alone informed me of what she was going to do. That's the part that gets me the most. Thanks for that resource but in my case, it wouldn't help much. I am in the military and my choices of providers are very limited. I don't get to pick the doctor I want and most are probably not trained to deal with this sort of thing. Maybe I should just bring it up in confidence on my next physical check up and see what he/she says...
Here's an another marked difference between our two countries...
When I read that a growing number of physicians in the United States are imposing a chaperone for physical examinations, I thought it was a joke at first. I simply could not believe it. My initial reaction was “Gaaaaah! No! That is so wrong!”
This is very uncommon in Canada. I have never heard of any doctor suggesting or imposing this to any patient. Even for intimate examinations or opposite gender doctors. To be fair, I thought maybe things might have changed while I wasn't looking (being cared for by the military, maybe it was different in the “civilian” world) so I asked questions to friends, coworkers and family members. No, things haven't changed.
(An “observer” can, however, be imposed by law in rare cases if a doctor is accused, and found guilty, of a crime related to his/her practise. There is such a case that came out of Ontario recently.)
If a person were to ask for someone else to be present (spouse, friend, family member, etc.), many doctor will accept it. But that other person is more than likely not going to be provided by that doctor (or clinic). For many, the doctor-patient relation is special and it is based on trust. Bringing an “observer” damages that trust in my opinion.
With regard to paediatric care, things are a bit different. Parents of young children will be allowed, sometimes offered right from the start, to stay during the examination (and I believe this is the right thing to do). But as the child ages, and definitely at around puberty, that choice is often left with the child. I have not looked into the legalities of this, say for example if the mother of a teenager were to insist on being present (I'm pretty sure the doctor would allow it) but often time, it is recognized that this is a discussion best left between the parents and their child. I suspect many doctors would not be too keen on this, on the ground that a physical examination is already embarrassing enough for anyone, allowing for relative privacy is only common sense.
One legal nuance that really stands out in Canada is that, when dealing with health-related or medical issues and guardianship of children (including parental rights), the doctor-patient confidentiality comes fully in effect when a teenager reaches 16 years of age.
Speaking from personal experience, as a child, I was followed by a male pediatrician (right up until I was 14 years old or so). To this day, I still remember him politely asking my mom to leave the examination room at some point so he could move on to the more intimate part the examination. That was before I hit puberty. After that, my mom didn't even bothered to come in with me. She knew I would have been quite vocal if she had wanted to stay. This was my choice, and both the doctor and my mother respected it.
I can almost understand the reasons why things have come this far in the United States but I wonder at the long term repercussions of going down that road. I guess I can already see it. I hope there is still some honest and frank discussions happening between doctors and their patients and that common sense or personal preferences are allowed to prevail.
Dany,
You said:
I am in the military and my choices of providers are very limited. I don't get to pick the doctor I want and most are probably not trained to deal with this sort of thing. Maybe I should just bring it up in confidence on my next physical check up and see what he/she says...
This is absolutely incorrect! Although Canada's participation in the Middle East wars has been limited, other members of the British Commonwealth have also participated (at different levels). Canada's participation has focused on medical care. One thing that has been gained from the wars is insight to PTSD. Trauma informed care (1.) is critical to recognizing PTSD, (2.) preventing retraumitization, making the PTSD worse or creating first time cases from people suffering marginal trauma, and (3.) treating PTSD.
Trauma informed care in the military makes sense not only in the monetary aspect but also in human capital (people). It would only add to the overall cost of the military by creating soldiers more often suffering from more severe PTSD, add to the national healthcare cost (more disabled veterans), and tarnish the Canadian military's image.
If the Canadian military is missing this point, then it may be your duty to inform the proper channels about it. I can't see any military NOT doing this in light of the cost paid already in human capital.
The other issue is the United Nation's push to end cruel, inhuman, or degrading treatment in healthcare. The current military focus is on the torture of prisoners, soon it will also look at the whole of military healthcare. See "Abusing Patients" and "Military Doctors and Deaths by Torture: When a Witness Becomes an Accessory/."
Here is a link to Lars Petersson's website (I have been having trouble accessing it). He has written about the abuses in military healthcare in his native Germany along with other countries.
--Banterings
It's from the UK, and she got fired over it... just thought I'd share "yet another isolated incident" about a "super rare bad apple" in the health care field. (No mention of criminal charges, and the uncensored pics are out there if you care to look for them)
http://metro.co.uk/2015/03/09/paramedic-sacked-for-taking-selfies-with-dying-patients-5094798/
Jason
Banterings,
I chose to wait before answering your comments, partly because I wanted to cool off a bit, and also I wanted to think about how I was going to address the points you brought up. First, I want to make clear to you that the CAF is committed to providing the best care they can to all military personnel. This also includes mental health ranging from management of stress, including PTSD, all the way to more serious mental illness. Is there room for improvement? You bet. But there are two major obstacles to this: money (as always), and a persistent taboo in the service about mental health. Many members still have this idea that they are showing a weakness by admitting, and seeking treatment, for a mental problem. The culture is changing, but slowly. An other problematic is that some of our members are sometimes retiring with untreated/unresolved health problems. As veterans, they no longer belong to the CAF, but are handled by VAC. Many find out the hard way that “support” isn't what they thought it would be.
I should also explain that the CAF doesn't “train” their medical officers. They are either direct entry level (hired from the street, negotiate salary, ranks and element, and you're given a shiny new uniform) or, the government pay for their schooling in exchange of a number of years of service. This doesn't mean that no training take place but it is more in line with “professional development” rather than core trade knowledge. The expectation is that they are already trained as physicians.
Now, to bring this back to the issue at hand. I was surprised that you brought up PTSD here. To me, PTSD is something associated with operational deployment (combat, or war). There are other circumstances but they are, generally speaking, rare. While I am willing to admit that what happened to me as a teenager had an impact on my life, I'm not so sure I would jump on the “PTSD” bandwagon. I do not believe I am suffering from PTSD (although I could be wrong on that).
I also have to consider a few things for myself. What is the most desirable end state here? What do I want out of it? Do I have a problem that needs to be fixed? Or do I want it recognized that something bad happened to me in the past? What would be the next step for me? I do not expect you, or anyone else, to answer these questions. I only listed a few of them to illustrate what's going on in my mind when I think on my own situation.
Would it help me if the physician who is doing my physical was aware of my past experience? Perhaps. Would it change the way the assessment is conducted? Probably not. Maybe the doctor will be gentler (as in showing kindness and compassion, not so much less “rough”. I haven't met a rough doctor yet), but I'll still have to decide if I'm going to let him or her perform an assessment of my reproductive system, or a DRE.
This news item should stir a bit of concern among my visitors here. It seems to me an example of a system issue. How do you identify a person as a physician? ..Maurice.
Dr. Bernstein,
I already saw this story about a month ago. It is sad about how this happened. It is disappointing that this hospital did not realize this "fake" doctor.
I personally think that all hospitals should have a system where all doctors and medical professionals are required to sign in everyday to ensure they are really employed by the facility.
I cannot help, but wonder if maybe a doctor or nurse at this hospital helped the boy to get access to the hospital.
Misty
Fake physicians, nurses, techs etc. Happens everyday at hospitals, it's nothing new. Stolen nursing licenses, nurses working with revoked licenses who just show up to work at hospitals and pretend they are from a temporary agency all the while diverting patients pain medication for their own use. I have seen this at many hospitals that I have worked at, doesn't surprise me.
PT
Well, to be fair, I suspect this teenager did not want to get his hands on illegal drugs.
My gut feeling is that he wanted to... How to put this politely? Further pursue his own education? Gain a greater understanding of the mysteries of womanhood?
It could all have been a dare. I've heard crazier stories.
We had an incident in Canada a little while ago were a woman, passing off as a nurse, entered the maternity ward of a famous hospital and walked away with a baby (out of the arms of the mother, no less). That made the news for a while. The child was found safe and sound, and the woman was charge with kidnapping, child endangerment and a few other things as well.
The hospital implemented new security measures almost right away. Electronic/digital locks on the ward, and electronic bracelets (likely RFID) that all new born babies had to wear while in the ward. These bracelets are designed to be difficult to remove and will trigger an audible alarm if an infant is moved outside of the ward without authorization.
Here is something that I feel will be an obstacle to any reform and I want to comment on it. I also think this should be an issue for the AAMC as well.
Any physician who graduated their medical education prior to 1990 (this is a very early, arbitrary date, the issue has been discussed and occurred as late as 2012) has learned to do pelvic exams on anesthetized patients. When the story first broke, there were many physicians that defended the practice and stated that patients had an obligation to participate.
The failure by med schools to address these transgressions of the past only undermine all credibility moving forward and convey they do not care about human dignity but still believe in the paternalistic system.
I hear all too often that "this is how things were done then" as an excuse or "I was following orders."
Guess what?
Those arguments did not hold up at Nuremberg and they should not hold up here. Having to address such issues will also prevent future Tuskegee's and torture of prisoners at Guantanamo.
--Banterings
A. Banterings
Did I read that right? That " patients had an obligation to participate". Since when do patients
have an obligation to do anything, they are after all
paying for a service. When I enter a hospital I can
choose to be non-teach, that is my right. It is my
choice to decide if I want an exam performed or not.
From the surface I believe female patients are
being used and I have many concerns with the
concept.
PT
PT,
There was a backlash from physicians and students who felt that patients have an obligation to participate. Here are research papers examining that question, which shows that this was a commonly healed belief.
The first four links listed is a really frightening attitude:
(NIH) The Obligation to Participate in Biomedical Research
AUTONOMY SUSPENDED: USING FEMALE PATIENTS TO TEACH INTIMATE EXAMS WITHOUT THEIR KNOWLEDGE OR CONSENT
(gotoanswer Stanford University)Pelvic exam during general anesthesia ??
Extraordinarily Disturbing
(NIH) Refuting patients' obligations to clinical training: a critical analysis of the arguments for an obligation of patients to participate in the clinical education of medical students.
(Cambridge University Press) Clinical Ethics in Pediatrics: A Case-Based Textbook (via GoogleBooks)
American Academy of Pediatrics Bioethics Resident Curriculum: Case-Based Teaching Guides
(NIH) Ethical participation of children and youth in medical education.
(NIH) Medical education in the public versus the private setting: a qualitative study of medical students' attitudes.
(NIH) Do patients have an obligation to participate in student teaching?
(AMA) Opinion 10.02 - Patient Responsibilities
Do patients have an obligation to participate in student teaching?
(Annals of Behavioral Science and Medical Education) Case Study: Paul's Dilemma
(KevinMD) When a medical student sees you, consider it your lucky day
Why do some women refuse to allow male residents to perform pelvic exams?
Ethical Dilemmas Students and House Staff Face
Visit W3Schools.com!
Visit W3Schools.com!
Notice comment #22, the med student feels patients ARE OBLIGATED to participate:
(Student Doctor Network) Ob/gyn rotation problems
--Banterings
Here is an interesting description by means of a "word cloud" graphic with text regarding "How Healthcare Professionals can Encourage Patients to Speak Up"
..Maurice.
I wanted to let everyone here know about a case of a lady who claimed that she was raped during her colonoscopy on Outpatient Surgery Magazine last week. You can check out this link. This case proves how vulnerable patients are when they are put under anesthesia and why it is best to avoid general anesthesia as much as possible. Look at the testimonial of James who MPM helped to take steps that his wishes for all-male team and colonoscopy shorts were honored. He was alert and awake during the colonoscopy. I wish more patients would find the colonoscopy article on MPM.
Misty
Maurice,
I spoke up recently. Met my provider face to face to talk about an unfortunate experience with his medical chaperone during an exam. My primary focus involved the importance of informed consent prior to entering the exam room in order to avoid embarrassment.
Note that I had to pay for an appointment to secure his time. That being said,he told me that I was wasting his time with such a "silly" problem. He told me that none of his other patients had ever complained and that if I had a problem with a third party being present, that I should have spoken up. Now, I am a reasonable and logical man so I asked him why it would be such a burden to ask for consent before the surprise encounter. His response was "that is just the way I do things here".
If this encounter is typical of prevailing attitudes, the only real answer "is" to speak up ahead of time. The question is, how do you educate the general public that this is the case? Frustrating, but the encounter did resolve my trauma. The trauma was replaced with the knowledge that I really was dealing with an ass and should just avoid using his services again.
Trauma Resolved,
Ed T.
Ed T,
I hate to say this, but LAW SUIT! I only say that due to his dismissive nature.
Obviously the chaperone policy was never explained and the chaperone did not ask consent to be there.
Obviously there was enough trauma to cause you to pay for a meeting with him.
I think there has been enough written on this blog, especially about Trauma Informed Care as recognizing the harm that can happen. All the guidelines call for discussing the use of a chaperone, hence you have a legitimate case. If nothing else, it will never happen to another patient.
Even if you ask for no money other than lawyers fees, you can ask that he follow guidelines.
Do this by asking for money, but settle for legal fees and him follow guidelines.
-Banterings
Thanks to Dr. Bernstein and the many other contributors to this site, I did what I previously thought would have been impossible: I underwent a colonoscopy on my terms.
My PCP has been urging me to have the procedure for years but I had been avoiding it do to feelings of embarrassment. I finally told him I would do the procedure if the doctor and hospital would agree to my conditions.
Two weeks before the procedure, I meet with a nurse to discuss my health history and receive instructions about the exam and necessary preparations the day prior to the procedure.
I asked if modesty shorts would be provided and she replied that in her 25 years at the hospital she had never seen them used. I replied that I could be a test case as they still had two weeks before my exam to order the shorts. To my surprise, she immediately made a phone call and arranged for them to be ordered.
Next, I told her that I wanted an all-male team. At this point, I expected to hear some reason as to why this couldn’t happen; instead, without asking me any questions, she immediately picked up the phone again, called the outpatient department and told them that Mr. G. would be in for a colonoscopy on March 16th at 7:30 and he wanted an all-male team.
On the day of the procedure I was concerned that my requests might not be met and because of the unpleasant prep the previous day it would have been difficult to walk out at that point. But my fears were unfounded. The nurse handed me a pair of disposable modesty shorts as well as a gown and I meet my doctor, anesthesiologist, and nurse who were all male. Also I reminded them that that I had indicated on my consent that no students or other non-essential personnel were to be present and they assured me that they would never allow any observers without first introducing them to me and receiving my verbal permission for their presence.
So the colonoscopy took place with my dignity and modesty preserved as much as possible and fortunately no there were no negative findings.
I know that not every hospital would necessarily be so accommodating but neither would this one if I hadn’t asked. And I would not have even thought that I could ask for such accommodations if the information on this site had not taught me that by being politely assertive as a patient can result in significantly better treatment.
MG
Also, the link below leads to an interesting article about the unnecessary use and negative effects of hospital gowns.
http://www.livescience.com/47947-hospital-patients-should-wear-own-cloths.html
Anonymous on March 22, 2015:
I am glad to hear that you had a wonderful experience. You did a great job speaking up about your wishes. It is interesting that the nurse had never heard of colonoscopy shorts before. It is great the nurse was nice and willing to accommodate your wishes.
Hopefully, they will offer colonoscopy shorts to other patients. Many patients are unaware they can wear colonoscopy shorts or boxer shorts backwards.
Misty
MG,
That was a great article! I am so glad that you had a good experience and NP found.
Here is the problem; "The King Has No Clothes!"
....or should I say "The Patient Has No Clothes!"
Why is it that people who are so educated are so stupid? Why do we need a study before anyone believes that being made to needlessly undress is humiliating? Why do they NOT realize that most undressing in healthcare is needless? 56% in this case?
I will not list the other things that providers do not know (such as pelvic exams on anesthetized patients). Read back from beyond this blog even and look at the things patients complained about, how they were brushed off, and how slowly we were vindicated.
I hear from so many that the healthcare industry is about humanity and science - it is NOT. It is probably about money.
There are individuals committed to humanity and science, but NOT the industry. The industry has lost all credibility and now it is too little too late. Providers cry about how miserable healthcare has become, yet society as a whole does NOT care. Is it no wonder why?
I await the day that some study proves what I have been saying for a long time; if providers preformed procedures in the same state of (un)dress as the patient, how different those procedures would be. We are coming to a new era where patients will write the procedures that providers must follow with legal actions and satisfaction surveys. Sure coming to work every day for your big corporate healthcare employer may be uncomfortable, but no more uncomfortable than being examined by a cue of medical students, but there is a necessity to it. If you are unhappy, feel free to seek employment from another big corporate healthcare employer.
I find it difficult to sympathize sometimes with the complaints that providers have about how miserable their working conditions are. I attribute it to "you made your bed, now lay in it only wearing an open back gown." When I hear individual stories, I am always sympathetic.
As patients we have choice to make. Do we learn to deal with the suffering of providers professionally and objectify them as human beings, or do we treat them as individuals, as human beings?
I would say we put ourselves in their shoes, but why subject ourselves to that humiliation and mental trauma? Let us just continue to do things the way we have always done them and call that malpractice attorney and make a police report.
Yes this was a rant. It is also TRUTH. Perhaps even more painful is that I used the same words and attitude that has been directed at patients.
DOES ANYONE SEE THE POINT YET?
It is not about what healthcare or providers know, it is about what they THINK THEY KNOW. By that I mean that all these long standing ritual beliefs are being proven untrue one by one. Yet providers resist even when the voodoo is debunked, let alone looking at looking at other issues not yet addressed yet.
That is my whole point. Anyone looking at this and feeling my words here are exacting revenge against providers is keeping the mindset of "what we know." Anyone who sees that I am describing the situation accurately is in the mindset of "what we think we know."
--Banterings
The competition was fierce. The leading manufacturer
of scrub uniforms wanted to sell the most sexiest
scrubs for female nurses. Symbols of Betty boop
in a short white nurses uniform adorned these nurse's
scrub tops. Lettering that said "I'm a sexy nurse"
covering the scrub top told everyone that she's a
sexy nurse.
To my knowledge no other industry has such uniforms
with such an implication for sex. Imagine you are a
male patient and in your room walks in three female
nurses with scrub tops that tell you they are sexy nurses and that you are to recieve a urinary cath
while the other two watch and assist.
Their purpose is to subjugate their male patients
and exert control. The public is reminded of this
with their bumper stickers " love a nurse, nurses
call the shots and naughty nurse." We are again
reminded with the tee shirts that say " feel safe
at night, sleep with a nurse."
Yet, they have the audacity to state each year that
nursing is the most trusted profession.
PT
Medical staff convenience trumping patient privacy, or a case of every member on staff (from the people who planned it to the installers to the medical staff themselves) being too stupid to grasp the issue?
http://www.cbc.ca/news/canada/prince-edward-island/patient-privacy-violated-by-information-screen-1.3005166
"The use of a big screen containing patient information in the emergency department .... The screen helps staff keep track of patients in the treatment area. It displays a list of patients, including last name, first initial, age, room or bed number, initial of treating doctor and other notes."
"Health PEI also said it trusted the public not to read the display."
Jason.
I seethed at the male medical student
that objected to females refusing to be used as teaching subjects and believed
they had an obligation to do so.
With a mentality like this, what good
can speaking up be? The problem is the
whole industry is built on such shaky
foundations, which explains things like
pelvics on anestethized patients, cate_
therizations, etc
This is going to be in 2 parts:
I am going to revisit a topic that I have taken much condemnation for, and that is anything dealing with a patients genitals in a medical setting is sexual.
The short version is that the definition is basically involving the erogenous zones or inducing (sexual) arousal. I remove intent and purpose from the experience. I write about it in my post Patient Dignity 02: But it is Sexual... I do intend on updating this post with this new info.
I am sure that by now everyone knows that I do NOT make assertions without backing it up with research. Having to validate such things (that are as obvious as the sky being blue) to providers is another insult to our dignity. It is very easy for the person wearing the clothes to marginalize us as an outlier or label us mentally disturbed. (Unfortunately, I do not have a study [yet] to show that having to prove such things is an affront to our dignity.)
The latest study is one out of Canada, titled: ‘Not the swab!’ Young men’s experiences with STI testing:
For most participants, STI testing was characterised as a potentially sexualised (as opposed to a strictly clinical) experience. In particular, the genital exam represented a vulnerable and highly sexualised situation (McWilliam and O’Donnell 1998). While service providers have training to neutralise these situations, patients tend to rely on their social context and personal experiences for clues about how to behave. Clearly, the exposure of one’s genitalia – or the ‘nude body’– is never rendered neutral or stripped of cultural value (Barcan 2004). Thus, the vulnerability of a man’s exposed body is fundamental to understanding young men’s experiences with STI testing: ‘It is through the body that gender and sexuality become exposed to others, implicated in social processes, inscribed in cultural norms, and apprehended in their social meanings’ (Butler 2004: 21). Connell (2005) would add that each masculine performance is context dependant, and masculinity can be contested at any time and place. Vulnerability in this context is epitomised by the possibility of an ‘unwanted erection,’ a situation in which a man is unable to choose between his ‘public’ and ‘private’ sexual impulses – for many young men, this reflex may represent ‘a glaring failure of privacy’ (Velleman 2001: 39) and a loss of control over their sexuality (something that may also cause them to question their masculinity).
Continued...
Part 2
Our data illustrate how male-female social/sexual relations, even within clinical encounters with female service providers (e.g. genital exams), remain ‘dangerously feminised’ (Flood 2008: 342). Many young men in our study also shared narratives that illustrated the importance of sexual activity to the development and maintenance of masculine identities. Building on Flood’s notions of sexual activity and masculine status as well as Gurevich and Colleagues' (2004) work on ‘health anatomy’ and masculinity, we were struck by the narratives that featured sexual activity as both a vehicle towards masculine status and, concurrently, as the cause of illness. Linking sexual activity with potentially emasculating outcomes (e.g.‘falling ill’) may make it more difficult for young men to assert claims with impunity regarding their masculinity as derived from their sexual activity.
Beyond this validating my "sexual" assertion, this also shows the dander that women pose to men in healthcare. This also provides excellent references.
Even though this is Canada and focused on STI healthcare, it is definitely applicable to the United States and ALL areas of healthcare.
--Banterings
"Not the swab!" Young men's experiences with STI testing.
I find the information gathered in these types of studies to be maybe not that accurate in regards to encompassing society as a whole. If you are a person who is very modest or embarrased about intimate exams you probably aren't going to see an ad on a bathroom door asking you to get your genitals examined with a 1 1/2 hr interview about it and say "Hey! What a great idea! I think I"ll run down and do that right away."
It's odd that the only example they give for not wanting a female provider is getting an embarrasing erection. That's like saying the only reason women prefer a female provider is because they may become aroused buy a male provider.
What about the fact that a lot of people just don't like being naked and examined by the opposite sex for their own personal reasons. We are trained from the time we are young that the genders get their own privacy. The medical field does not make much effort to accommodate this right.
Ardi Santoso wrote the following to this thread today. ..Maurice.
I looked at the AAMC site you cited and where you cherry picked a single statement and suggested that now is our chance to influence a “major medical system organization.” I read the entire document and found mission statements, priority statements, and goal statements. There were no set of objectives associated with each goal or method statements regarding how the goals and objectives were to be achieved. I saw no invitation to submit ideas, papers, etc. to the organization and no requests for proposals. Instead, I saw where the document writer indicated that the AAMC would “continue to engage constituents, colleague organizations, and nonconstituent thought leaders and experts as appropriate” which were its sources for the document in the first place.
Maurice,
When I saw the piece I too thought the same. It was solely PR gimmick.
Go back to my first comment on this volume. This is what happens when an industry sets it's own standards and regulates itself.
Times are changing. What happens if we as a society decide that the rules that healthcare applies to patients should apply to providers? I know this is not the most reputable source, but I am still researching the matter.
Then Weekly World News [By KEVIN CREED} reports that the Spanish city-state of CEUTA, tried passing a law in 1995 that makes doctors strip when patients do! This is the only English reference that I can find to the law.
I have been told that people may seem disheartened by the last volume or two, losing hope, and giving up. Is that the case?
Do NOT give up!
That leads me to my work; What started out as a letter evolved into a web page to a research paper, and now at 100 pages and 2/3 done, it is going to be a book. I am hoping that this will make a change. Just like all my work, my sources are cited.
When I am finished, I will be looking for people to proof read it before the final version. I am also open to anyone that wants to contribute to it as well. If you are interested, you can contact me here:. I have no problem with crediting you.
It may seem extreme, but my thoughts are that we never get as much as we ask for, so if I ask for the unreasonable, I will get the less than reasonable. It is all backed by research and cited sources. Most of you are familiar with my writings here, but you can also visit my blog.
--Banterings
I listen to a radio station our of Chicago, recently I have heard a ad for a "men in healthcare" seminar and includes male nurses, techs, etc, I believe it was advertised at rsu.edu but not sure......a ray of hope, don
Nurses: When you're at work, do you often find that you're too busy having sex with Physicians and
Patients to provide clinical care. Don't worry, it's a
common problem in the media too!
These are comments presented in nursing times.org
and the truthaboutnursing.org. Many within these sites
are trying to change the image of nursing. Seems there is a love-hate relationship with shows such as nurse Jackie as she struggles with drug addition. The naughty nurse image that these shows portray. The sexy nurse Halloween outfits and the sexy scrubs
that nursing uniforms advertise.
How did these perceptions come about. The advocates for nurses will tell you it's the media's fault or it's the porn industry's fault, or maybe it's dirty old male patients fault that have fueled the misconception.
First, it's no secret that female nurses commit more boundary violations than their male counterparts. It's no secret there is a high drug addition rate among nurses, particularly female. Every hospital has their favorite room or areas where staff meet. It's been said that hospitals rank second only to the hotel industry in regards to sex on the premises.
The nursing industry will just use any lie to their advantage to associate blame for their misguided image all the while using more lies to lead you the general to think they are the most trusted profession.
Been to any major hospital lately? Notice that most staff are wearing only color coordinated scrubs. Just one effort by the corporate big wigs to improve the image of those working in the asylum.
PT
I must do this post in 2 parts......
PT,
Excellent post and right on target!
Let me start out with some insights I have gained into nurses from my own research. The sample size is not larger enough for me to make publishable conclusions, but they do adhere to accepted and predictive psychological explanations of behavior.
As I referenced above, the manipulation of one's genitals (without any context) is a sexual act. Despite the context of healthcare, it can still feel sexual. Even though the above referenced material focuses on the patient, I argue that the nurse also experiences the medical encounter as sexual. Let us consider the following situation that most nurses have experienced: The 20-something female, finishing nursing school, starting rotations, and beginning a career. This probably accounts for 70% of nurses and in our lifetime , it may have been high as 97% of all nurses. This excludes male nurses and women entering the profession later in life. Of course, the same conditioning may affect these groups the same way it affects the younger female nurses.
One of the reasons that the teenager brain does not begin to look like an adult brain until the mid-20s. (See: NIH, "The Teen Brain: Still Under Construction") Couple this with the fact that this is the height of a woman's fertility. A woman’s best reproductive years are in her 20s. Fertility gradually declines in the 30s, particularly after age 35. (See: Age and Fertility - American Society for Reproductive Medicine) Dare i use the phrase "raging hormones?"
Hard wired into our braina are behaviors that are affected by fertility. (See: Hormones, Brain and Behavior, Five-Volume Set) Women's sexual desire (sex drive peaks in their late 30s to mid 40s (See: Time Magazine, The Science of Cougar Sex: Why Older Women Lust), also affecting their behaviors and conditioning. Couple these physical factors with the conditioning that nurses receive that lower their inhibitions and their "ick factor" when dealing with the human body. Finally as students and newly hired nurses, they are on the bottom of the food chain and are given what the average person considers the worst jobs in healthcare.
Can anyone NOT see why nursing has been sexualized???
Human evolution has made traits in women that demonstrate fertility and good health favorable to men. Today we call these traits "beauty. (See: National Geographic, The Enigma of Beauty) and (See: Fertility Affects Women's Attractiveness, Study Finds - Huffington Post)
Anthropologically, women with these traits were desirable by men. Women then could choose which man was the best provider. Women learned to use this power to give them power in male dominated society (which most human societies are). Cleopatra is one of the best examples of this. Historically, nursing and teaching have been bastions of female power. The (historically) paternalistic structure of healthcare afforded nurses great power in their professions. Just as in all healthcare, many abused this power to assert their position and for narcissistic reasons ("power corrupts..."). Nurse Ratched is a good illustration of this.
Continued....
Part 2:
The Civil Rights and sexual liberation movements of the 1960s also affected nursing. Along with women entering male dominated professions, men began entering female dominated professions. There is no question that in recent years there is an underlying sense of despise of male nurses by female nurses. That has been discussed on this topic in the female nurse telling the male patient "I've seen it all before" when same gender care is requested.
The sexual liberation movement has also led to women expressing themselves and their sexual desires. Perhaps the best example of this is sexual harassment cases where a woman is a perpetrator. The more open atmosphere in regards to sex, the way sex is portrayed in the media, and other factors has led to an overall sexualization of our modern culture. (See: American Psychological Association's report, "The Sexualization of Girls") and (See: Sexualized Culture Is Creating Mental Health Issues in Our Youth - Huffington Post)
This has created the perfect storm that has allowed the sexualization of the nursing profession. Part of the sexualization has been from the inside out; by the nature of what nurses do (touching patients' genitals), it sexualizes the profession. Other outside factors that have sexualized nursing (the 1960s movements), have also sexualized nursing from the outside in. That is, nursers may sexualize patient care (not overtly) as a means to hold their position of power. Again, the example of the female nurse telling the male patient "I've seen it all before."
The biggest failure of our healthcare system is NOT the denial that these issues exist, but the denial that these issues CAN exist. The system simply says, "we are professionals" so it can NOT happen and the problem is solved.
The other day, I was reading previous volumes where I stopped lurking and began posting. I found the post that changed my whole outlook. Maurice stated (in Volume 67); "Medicine absolutely does not recognize "PTSD, emotional trauma, psychological trauma, etc" are possible side effects of professionally performed "exams, treatments and procedures due to modesty issues" to the frequency extent as described on this blog.")
In reflection, I find this statement to be TRUE.
With the help of others, I have demonstrated with science-based evidence that it can happen and it DOES happen. Still, healthcare does not acknowledge it and it continues to be, "the way we have always done it."
That is slowly changing because of lawsuits. It is the money driving the change. Despite that, I do not believe that most providers believe this happens and is unacceptable by societal standards. If that were the case, why are pelvic exams on anesthetized patients without explicit consent still occurring in 2012?
--Banterings
Don, I could not find a link to the ad that you mentioned. However, I did find something very similar at a different
college.
This is currently being advertised on a sports radio station in the Buffalo, NY area.
StayingFit,
The below paragraph in the link you provided to that college in Buffalo:
“Although there are a fair amount of men at Mercy Hospital, the balance is uneven, and this can be a problem,” Ms. Guarino says. “For example, some men may be more comfortable with a male nurse. We need to respect that and be able to provide that care.”
was very encouraging. It is encouraging that this female nurse understands that there are many male patients who prefer a male nurse for intimate care. I always appreciate it when female nurses are sensitive to this fact.
Misty
Occasional reader and commenter here. I wanted to get a reality check on what happened yesterday. I saw a doctor with a sore throat and flu-like symptoms, expecting to get a throat culture. He put on a face mask and did a throat swab, and I gagged and coughed on him after the swab touched my throat. (This has always happened when I've had this done.)
He then opened the door to the exam room a few inches and tried to continue with an examination of my chest. I insisted that he needed to close the door. He did close it, but then he said something like, "If you call here tomorrow and I'm out sick, this is why."
In his office, there is a secretary just outside that exam room door, and a glass wall with the waiting room on the other side. If the door is open, the secretary can hear, and the patients in the waiting room can see inside. It seems to me that the door should be closed at all times. Plus I'm very skeptical of any idea that opening the door protects him from infection, especially with him wearing a mask.
I guess it's more the principle of the thing. I'm male, and my chest is not a private part. My visit was not about something particularly embarrassing. But I would think that a closed door is sacrosanct, just as it is when I visit my lawyer, tax preparer, or psychologist. What do you think?
"Class of '96"
Misty
While it is true that Ms. Guarino is a nurse, she hasn't worked as a nurse for 20 years. Her primary goal at Trocaire college is to increase the number of nursing students. She is doing this by reaching out to prospective male students. She says " some men may be more comfortable with a male nurse. " She says this so as to debunk the myth that male nurses are gay, part of her ploy to get men into nursing, to effectively increase attendance. She says " you will
get a job." Note that she doesn't say it will be a
nursing job. This was one tactic used by female nurses for years to dissuade men from entering the nursing industry.
Spend some time and look at what many students
say about this college online. Ms. Guarino as well as
all female nurses know well that most men would
prefer same gender care. What efforts did she ever
make in this regard at hospitals, none. This is nothing
more than a marketing ploy to increase attendance.
PT
Doug Capra wrote the following to me yesterday. The question he raises about the physician author's intent writing the Kevin MD piece he linked to is important in terms of the resistance of physicians to frankly exclaim that there might be harmful "uneven power dynamics" not only noted between employees and/or employer but also between physician and patient. ..Maurice.
Here's a recent article on KevinMD that you might want to post on your blog. The power differential in medicine has been discussed often on the blog. This article is about that. I find it fascinating that the doctor who wrote the post doesn't apply her thoughts to medicine, but since she published it in a medical forum, it's clear to me that she's implying that the power issues as one that needs to be addressed in the culture of medicine -- thought I seem to think she's implying that it has more to do with doctor-nurse-cna relationships that with patients. Anyway. take a look.
Doug
Change the culture of uneven power dynamics
My wife has 7 grandchildren, 6 are boys. I try to set a good example for them by the way I treat my wife and all the women in our family. A couple have asked me for relationship advice, and this is what I tell them:
Little boy and little girl are playing outside.
Little boy says, "My daddy is a police man."
Little girl says, "My daddy is a fireman, and he drives a firetruck."
LLittle boy says, "I have a toy car to play with."
Little girl says, "I have a dolly and stroller to play with."
Little boy stands up in disgust, pulls down his pants, and says, "I have one of these."
Little girl lifts her dress and says, ""I have one of these, and I can have all those that I want...."
This may seem crass, but (especially to teenagers) it illustrates the point of power dynamics in relationships. Examining how we pick mates, natural selection, etc., we see the modern day version of guys want to be a good provider to have the pretty wife, girls want to be pretty to get guys that are good providers.
Of course, this is very simplistic, 1950s, human interactions are never so simple, there are emotions to take in to account, we have working mothers (her earning power an attractive trait), and now stay at home dads.
Even though it seems that the women have less power, they are receiving this attention because of the power they have.
The other issue that jumps out is that flirting is an art form. A catcall is not flirting. Flirting can do everything from finding a spouse to getting a little better table at a restaurant. Flirting is how I met my wife. There is a point where it goes from "sweet" to "ick" though.
For other interactions in society, whether it be merchant-consumer, employee-employer, (even) doctor-patient, etc., there are power imbalances. But anthropologically and socially, this explains why we have so many lawyers in our society. Civil and criminal litigation are the great equalizers.
--Banterings
I thought you all would be interested in reading this excellent discussion, Same gender intimate care for men started by LeftEddie. He provides excellent insights about the importance of men being able to have a choice of same gender intimate care. Make sure you also look at the comments below the article. There are a few all-male clinics in the US and I understand his pleas for more all-male clinics. Women have much more choices than men because there are many all-female practices in the US. Some of the all-female practices have male practice administrators, but they only deal with finances and administrative tasks. They have no interactions with female patients and do not ask them personal questions.
Misty
I don't tthink all-male clinics is the answer. All medical
facilities need to staff accordingly, respect the rights
and needs of all patients. All patients should be asked what their preferences are.
PT
....and the hidden curriculum continues to flourish!
I came across this disturbing post on KevinMD that is less than a month old.
I always thought the use of a chaperone should be a shared decision between the patient and physician. How wrong I was. Cia Matthew, the author admits that you have the chaperone act as an assistant. So you have a preceptor, a student, a chaperone-----uh, I mean assistant, the clown on a unicycle, the "Life in the ER" film crew.......
I think that it would just be more efficient to anesthetized the patient and bring in all the students at once.
I guess this is the AAMC's value of fostering a positive learning environment; positively ABHORRENT.
Nothing changes!
And this statement about trust made by the author, after the article began with a lie, is a total joke:
I want my patients to trust me. And not merely because I’m a doctor, but to trust me because I’m also simply another human who gets how uncomfortable this nakedness and question-answer sessions are.
--Banterings
Banterings, sorry to say you have misinterpreted the whole medical student article. The student was confirming exactly what I would have taught "as a doctor, that student will need to learn to "understand the power, trust and pain" associated with the relationship, the procedures and treatments present, the disease,treatment and outcome which the patient is and will be experiencing.
The article had nothing to do with cheating the patient but instead the physician's better understanding the patient.
This article is worth reading by all here. ..Maurice.
Oh I'm so touched by all the sensitivity the article conveys
and as you can see another physician has already piped
in on her take with the issue. You see, you already have chaperones as assistants but now you also have scribes and that makes a crowd. Next thing you will see is another female assistant in the room, wait that's the nurse, cna or Lpn. Yet, there should be a fifth person, that someone needs to retrieve the physician's stethoscope to insure it gets cleaned before the next patient cause I'll bet big money it just hangs around someone's neck between patients.
PT
Maurice,
While I agree with you that the article appears that way, the beginning clearly says have the nurse doing something, not just standing around. That leads to the question, is it necessary to even have the nurse there?
How much of the assistant's presence was for the comfort of the male preceptor's and student's comfort? HONESTLY?
Someone (PT possibly) discussed the necessity of a female assistant during a vasectomy and the urologist insisted the assistant was necessary.
Did they even have a conversation with the patient about a student doing the pap smear?
The fact that these things are assumed take away choice from the patient.
I know where the article wants to go, but it didn't get there.
--Banterings
I found the student medical article
enraging! They have no right to assu_
me chaperones will be tolerated. What's
descried there isn't respectful medical
care. Not even close. So the allegations
of sensitivity are plain false. At least
not until the patient has a choice.
Recently, a man was arrested at a Wal-mart for looking up women's dresses. These women never knew this
had occurred until store surveillance cameras recorded
the events. Once the women learned of this they asked for the man to be prosecuted. The man was identified, arrested and charged with voyeurism. In most states voyeurism is a class e felony and punishable from 1-4 years in prison. There seems to be a rash of these behaviors lately and can be seen by using a search engine and look for
" Man looking up women's dresses at Wal-mart"
Compare this behavior to hospital staff and instances
where nursing staff would " Lift" blankets from male
patients to take a peek at a male patient's genitals
as was the case of " Whoa' innapropriate." We're the
police notified? No. Did the nurse manager hear of
this, yes. Did anyone do anything about it, no. Did a
female nurse say this was OK and no harm was done
to the patient, Yes. Did any harm come to the women at Wal-mart. No. How often does this occur to patients
at hospitals were someone peeks at a patients genitals
when they are comatose and not assigned to the
patients care. I can tell you more than people realize.
Why, because the opportunity is there. One case I know of at a hospital whereby a female nurse brought
another female nurse to view the penis of a comatose
patient because she wanted to show the other nurse
a piercing on his penis. In fact his pierced penis was a
circus show on that trauma unit all night.
PT
Maurice
Would you or did you ever consider wearing scrubs
implying that you are a sexy Doctor? Have they ever
had such scrub tops available for physicians? I've
never seen them and I've known well over several
thousand physicians. Never seen any of them wear
anything of the such. Now, don't get me wrong, I'm
sure someone out there thinks you're sexy, however,
considering nurses have had so many styles with
writing on them indicating they are sexy, why would
physicians not have the same choices? Wouldn't it
be fair that gynecologists have the opportunity to
wear scrub tops implying that they are sexy when
examining their female patients. Certainly, many
male patients have been catheterized by multiple
female nurses wearing scrubs that shout, I'm
sexy.
PT
PT, I don't wear scrubs and, to me, they are not "sexy". I haven't seen a general physician (non-surgeon) wear scrubs. To me, their "out of OR" use would be only to mark their wearer as a physician (like a stethoscope hung around the neck) and nothing more. As I may have written here previously, I despise the wearing of scrubs outside of an operating room or hospital. I have seen them worn on the streets near a hospital and it is disgusting and totally unsanitary. To me, this behavior represents laziness to change into out-of-hospital clothing and ignorance of sanitation. I would not accept "insufficient time to change" excuses. As far as I am concerned any "sexy" applied to scrubs worn by a nurse or a doctor is a distorted description only by the observer. If I was the administrator of the hospital, any doctor, nurse or any other worker designating their scrubs as "sexy" would be investigated and fired.
Let's take up this argument: There is no professional ethical basis for any medical professional expressing "sexy" behavior through words, appearance or actions. Any argument that appearing "sexy" is in any way therapeutic for the vast majority of sick patients is a false argument. Rather than being "sexy" the healthcare provider should instead should provide healthcare. ..Maurice.
Maurice
As you may know I have the same thoughts regarding staff wearing scrubs outside a medical facility. At many teaching hospitals all residents I've seen wore scrubs wether they be family practice, neonatology, radiology and internal medicine.
One female nurse showed up on a first date wearing
scrubs and in her big bag had a plastic intravenous
practice arm. If I had been her date I would have
dumped her in a heartbeat.
You can read what people have posted here.
Boards.straightdope.com. Nurses scrubs in public
You might have a point when you mentioned that
"sexy" applied to scrubs worn by a nurse or Doctor
is a distorted description only by the observer and
might hold some truth if that observer is blind,
has Parkinson's or cannot read.
I applaud you that you would be willing to take
action and challenge nurses wearing scrubs with
words such as "sexy" on their scrubs but with a
third of nursing staff wearing those kinds of scrubs
would be a formidable task for human resources.
Let's take up this argument: Nurses say that intimate
care is only clinical. Does the clinical notion still
persist if the nurse has " sexy" on her scrubs?
Would a patient perceive a clinical atmosphere
despite the nurse or provider displaying sex on
their garments?
PT
PT,
The problem is that that everybody who is wearing the clothes in the exam room denies that the experience is sexualized (when in fact it is). In my latest blog post, Patient Dignity: But it is Sexual... Redux, I continue the premise that I started in the original post, Patient Dignity 02: But it is Sexual....
I further the notion that the very definition of "sexual" is "that which involves the genitals." This time I do it with evidence based research, much of it linked through NIH.
I am writing a book, backed by my research, that will fix these problems with patient dignity. This post is based on part of the book.
--Banterings
I wanted to share this interesting article I found with everyone, Why The Urologist Is Usually A Man, But Maybe Not For Long. You all will notice that an all-female urology practice for only female patients has been started by a female urologist in Houston and that many women have flocked to her practice. This is encouraging, but I was disappointed that this article failed to talk about how many men prefer male intimate care. This article seemed to focus more on female patient modesty. Male patients deserve same gender intimate care if they desire too. We need more all-male urology practices for male patients. I know all-male urology practices would see many male patients who have avoided medical care.
Misty
I wanted to let you all know that Chicago Tribune published this article, The naked patient: The modesty movement won't take it lying down the other day.
Kay Manning, the author of this article interviewed Dr. Sherman, three patients (Texas teacher, colonoscopy patient, and Katherine) that Medical Patient Modesty helped, the colonoscopy patient's doctor, and me. I am glad that this was published in a major newspaper. We definitely need to raise awareness about patient modesty as much as we can. Patients need to understand that they have rights to same gender intimate care if they wish and maximum amount of modesty for procedures. Also, medical professionals need to be educated about how patient modesty is important to many patients.
Misty
After my outpatient surgery last year I had some thoughts. The intake? nurse for day surgery was very thorough in her medical evaluation etc - but one question not asked was if I had any modesty concerns. As it happens I did/do. Not sure about others but I go into what I think is a state of psychological shock prior to operations/anaesthesia and am not in the greatest state of mind to be my own advocate. I am a male and have issues with female caregivers for reasons I won't get into here. If she had asked me I would have answered yes to modesty issues. Bringing it up myself is somehow unmanly so I suffer in silence like most men. My anaesthesiologist was of course female (only male was surgeon) - I brought up my modesty issues and her response was sympathetic but essentially asked if I had considered counseling. No mention of any considerations for me to make me feel comfortable. The medical system has to initiate conversation with pts - esp male to get honest answers. Nurses who claim most men don't take into account how men are conditioned to not be weak. Big news -we cry too - just its on the inside.
To Anonymous from today: I am surprised to read that a patient speaking about their personal modesty issues in a medical environment would necessarily be a candidate for "counseling". Psychological counseling would not be appropriate unless the patient has a serious mental disorder attributed by the patient to his or her life experiences and producing disabling symptoms. Simply expressing concerns about the professional's response to matters of their patient's modesty does not require counseling. ..Maurice.
To be fair to the anesthetist she was responding to the notation on my admission form 'no benzodiazepenes'. A previous surgery had resulted in short term memory loss/depression for about three months post op. I told her I wasn't sure if it was the benzo's or perhaps reliving childhood trauma/PTSD.
A few more things from my experience: My intake nurse did not close the door to a hallway with others seated outside - I was not comfortable sharing my modesty concerns/reasons for them with her and a handful of strangers. The other intake nurse closed the door for the female pt before me. Was my door left open for her security?
The nurse who gave me my gown etc just opened the curtain in the changing area without asking if I was ready. I am hyper-aware that I am in foreign territory in the hospital; taking away autonomy from a patient - something as simple as not asking to enter their space is demeaning and reinforces the power gap. The old dressed/naked control move. Whether this is intentional or not the effect is the same.
I am hopeful that healthcare is changing - treating a patient holistically rather than just the disease. That pts are sentient beings - not just physiology. That men are not violent rapists/pedophiles who need to be controlled with forced nudity, humiliation and lack of autonomy. That not all females are nurturing.
I think it takes a special type of person to identify with opposite gender pts - female nurses identify with female pts and are therefore quick to protect modesty of same. I believe that men are more empathetic with females pts than the other way around.
I am also hopeful that the pendulum is swinging back to egalitarianism after decades of mistrust/outright dislike of men/masculinity. Without a coincident shift in the social paradigm with respect to gender polarization reform will be difficult. But I am hopeful. thx for providing this platform Maurice.
Kevin
must do this post in 3 parts:
First: Misty,
Congratulations on the article. I have added that to my news references dealing with patient dignity.
Maurice and Kevin,
The concept of deeming a patient mentally ill if they raise modesty concerns is nothing new, it is part of the "hidden curriculum." In Joan Emerson's
Joan Emerson's Behaviour in Private Places: Sustaining Definitions of Reality in Gynecological Examinations, this technique is explicitly used to elicit compliance.
I, myself have been accused of having some mental illness in the position that I take in regards to my dignity.
I also want to touch on another issue that involves patient dignity. This may sound like a rant, but by now I am sure everyone knows that I back my assertions with evidence.
One of my tools for testing procedures, protocols, guidelines, beliefs, etc. is the extreme case scenario. When I say extreme, I mean to the point of absurd. The purpose is to show that these written procedures are faulty. One that I use is "How different would procedures be if the providers had to be in the same state of undress as the patient."
Yes it is absurd, but answering that question seriously would demonstrate what "medically necessary" and "patient dignity" really is.
Some, for example, have been harmed through repetitive medical display, which they experienced as violating. Others have suffered from attributed shame.
As a result, one could reasonably envision a scenario where a disproportionately large number of medical students might want to gain exposure to these issues from a small number of patients. Protecting the individual patients’ right to respectful and confidential medical care should remain the priority. Alternative strategies should be employed to expose students to these issues so they can develop competency while protecting patients from overexposure. Such strategies might include the use of case discussions, videos, and case reports, which prevent patients from feeling “on display.” Source: Association of American Medical Colleges (2014) Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Nonconforming, or Born with DSD.
Maurice started this volume with another document from the AAMC. This document addresses the extreme situation of children with DSD. The first problem that I have with this document I also have with the first: It fails to address abuses of the past.
“Those who cannot remember the past are condemned to repeat it.” Santayana, (1905), The Life of Reason.
Another issue is the failure of providers to NOT know that these practices are traumatic and abusive. I guess when you are the one with the clothes, YOU are comfortable with repeated genital exams.... This IMHO is borderline on mental illness, specifically sociopathy.
Sociopaths lack moral emotions, empathy, conscience, or remorse and guilt for their acts. Source: NIH, The Neurobiology of Moral Behavior: Review and Neuropsychiatric Implications.
Are physicians NOT trained to ignore emotions so as to make decisions scientifically and be able to preform painful procedures on patients?
Continued....
Part2:
This is from: Anne Tamar-Mattis, JD (September 15, 2014) Report to the UN Committee Against Torture: Medical Treatment of People with Intersex Conditions
Americans born with intersex conditions face a wide range of violations of their sexual and reproductive rights, as well as rights to bodily integrity and individual autonomy. In infancy and throughout childhood, children with intersex conditions are subject to irreversible sex assignment and involuntary genital normalizing surgery, sterilization, medical display and photography of the genitals, and medical experimentation. Intersex individuals suffer life-long physical and emotional injury as a result of such treatment.
...Various human rights bodies have recognized that the medical treatment of people with intersex conditions rises to the level of human rights violations.
…The United Nations Special Rapporteur on Torture (SRT) has also called for an end to the abuses against intersex people:
“Children who are born with atypical sex characteristics are often subject to irreversible sex assignment, involuntary sterilization, involuntary genital normalizing surgery, performed without their informed consent, or that of their parents, ‘in an attempt to fix their sex’, leaving them with permanent, irreversible infertility and causing severe mental suffering. . . The Special Rapporteur calls upon all States to repeal any law allowing intrusive and irreversible treatments, including forced genital-normalizing surgery, involuntary sterilization, unethical experimentation, [or] medical display ... when enforced or administered without the free and informed consent of the person concerned. He also calls upon them to outlaw forced or coerced sterilization in all circumstances and provide special protection to individuals belonging to marginalized groups” (SRT 2013)
…genital normalizing surgery risks psychological as well as physical harm, including
depression, poor body image, dissociation, social anxiety, suicidal ideation, shame, self- loathing, difficulty with trust and intimacy, and post-traumatic stress disorder. (SFHRC 2004)
Medical display, genital photography, and excessive genital exams
Many intersex individuals suffer lasting psychological effects as a result of repeated genital examinations and/or medical photography in childhood, which can be “experienced as deeply shaming” and may lead to symptoms of PTSD. (Hughes 2006) While some genital exams are necessary for medical diagnosis or monitoring, others are done without specific indication, sometimes to satisfy provider curiosity. A leading patient advocacy group has likened such procedures to child sexual abuse (CSA):
“[C]hildren with intersex conditions are subjected to repeated genital traumas which are kept secret both within the family and in the culture surrounding it. . . . These children experience their treatment as a form of sexual abuse, and view their parents as having betrayed them by colluding with the medical professionals who injured them. As in CSA, the psychological sequelae of these treatments include depression, suicidal attempts, failure to form intimate bonds, sexual dysfunction, body image disturbance and dissociative patterns.” (Alexander 1997)
….Accordingly, we make the following recommendations to address the plight of intersex individuals in the US:
That enforcement agencies investigate possible violations of, and take action to enforce, laws prohibiting FGM, involuntary sterilization, and unethical human subjects research to protect children with intersex conditions; and
That US courts recognize genital normalizing surgery and involuntary sterilization performed on intersex children as violations of their federal civil rights, and offer intersex plaintiffs comprehensive remedies for these harms.
Continued...
Part 3:
The United Nations and other organizations feel that these medical procedures ant the training of medical students are criminal actes that rise to the level of Human Rights violations.
Note: These documents from BOTH the UN and AAMC do NOT address gender of the provider as the problem, it is simply the treatment of the patient.
But I ask, with the cases presented in these volumes, such as Kevin's, even though it is not as severe, is it no less egregious, immoral, unethical, and unprofessional?
True that participating in the murder of hundreds is worse than participating in the murder of a few, but it is still murder. Again, my example of murder is extreme, but how many abusive genital exams are acceptable? Just as murder, the answer is NONE!
This is paramount to the Holocaust when you take into consideration that most preventive health guidelines call for an annual physical (including a genital exam) for every person. Even in the face of evidence based guidelines that dispute the annual wellness exams, many organizations still recommend them and even state "despite lack of evidence..."
Failure to acknowledge abuses of the past only furthers the notion that providers and organizations STILL do NOT see that these procedures are traumatic and harmful.
This article, Visit W3Schools.com!The medical gaze and children with DSD, is based on REAL cases. How could the students in the article not realize the trauma of the genital exams before this focus group?
Thankfully times and laws are changing, and these infractions will be treated as the crimes that they are. It is time to treat patients as human beings again.
Nurses and doctors entered training to help patients. Nearly 100 years ago, Peabody complained that new physicians relied too much on science and had lost “an interest in humanity”. It’s been said recently that medicine has become “far more interested in diseases than the people who suffer from them” (A. Miles, 2009).
Here is an example of ethics from 2009:
Klasko gives the example of a Georgetown University study in which medical students were asked to give a sleeping woman in a hospital bed a pelvic exam, with the attending physician telling them it was okay, even though the patient was asleep and hadn't given her consent. Ninety-five percent of the first-year students wouldn't do the exam, even though they were told it needed to be done. Only 33% of the fourth-year students refused to do the exam. Source: The Atlantic, (2009) Reprogramming the Ethics of Med Students
Finally this 2001 research paper concludes:
The review reveals that these arguments either cannot be verified or do not necessarily place any obligations on the patient. It is argued that, while a medical student may have a right to clinical education, the obligation to fulfil this right rests with the medical university and not on the patients of its teaching hospitals. Source: NIH (2001), Refuting patients' obligations to clinical training: a critical analysis of the arguments for an obligation of patients to participate in the clinical education of medical students.
So how far have we progressed?
Did anyone read that last paper I cited?
--Banterings
Anonymous
It is outside the scope of practice for a nurse to
assess a client to formulate a plan of care. If a
nurse ever said that I need counseling I would
report her/ him to the state board of nursing.
It is not the role of an anesthiologist to suggest
any patient for counseling. I would have cancelled
the surgery immediately, right then and there. I
would then report her to hospital administration,
Chief medical officer and the state medical board.
PT
I didn't take any offense to her remark about seeking counseling to be truthful. I have undertaken a self directed cognitive/behavioural approach and have come a long way. For a man to admit being a victim to a strange woman is very difficult - easier to avoid healthcare. It doesn't follow the socially derived set of algorithms. No one knows what to do/say. Aren't men the perps all the time? I was more offended at the lack of a protocol to follow on their part to be honest. If a pt presents with an abuse history which will/could affect the outcome then proceed with these specific actions to minimize risk. I mentioned to my GP about the childhood abuse and my modesty issues and he basically said deal with it - the chances of having male providers was 0. I'm in Canada with socialized healthcare - downside is there is nothing resembling a free market here - kind of the Henry Ford choice of car colour.
I wrote to Misty quite a while ago about my issues - she posted them here. Maurice - you said you were tired of the moaners and groaners - maybe a kind of tough love but it helped me pick myself up and be proactive. Thanks for that.
Abuse by females is the last taboo - when that door finally gets kicked in and we start viewing everyone in the same light then healthcare will change. Social conditioning of men like me to be strong and the concept of female victim I believe is the huge reason why men avoid healthcare. We as men know the fallacy of this scenario but haven't as of yet found a voice.
I lost an uncle to bladder cancer - he wouldn't return to care after the cytoscopy. As a coincidence a friend just had a cystectomy for bladder cancer. He described three female nurses being present to insert the scope or catheter? Not sure. Anyways apparently the extra two were there to restrain him as it was going to be painful. I'm not sure I'd be OK with something like that.
Kevin
Kevin,
Maurice has come a long way. In one of my earliest posts (Volume 67), Maurice stated: Medicine absolutely does not recognize "PTSD, emotional trauma, psychological trauma, etc" are possible side effects of professionally performed "exams, treatments and procedures due to modesty issues" to the frequency extent as described on this blog.
In Volume 68 Maurice stated: It is my opinion now, whether or not the experiences written here are statistical outliers, the problems previously described on this thread and the potential consequences are of sufficient importance that changes in the medical system should be made.
Healthcare is not a nice place for men, and I have demonstrated that time and time again.
As to the "moaners and groaners," What started as a letter to healthcare providers has turned into a book for me. I am currently at 100 pages of text and 300 footnotes. This is going to change dignity in healthcare.
Did you see my previous post about the UN starting to look at abuses in healthcare as human rights violations?
As to you being in Canada, here 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.
I would hand him a copy of the booklet I linked to and simply ask that GP why he is not following the guidelines of the Public Health Agency of Canada??? Then tell him to "deal with it."
--Banterings
Here is an interesting story related to an example that Maurice has used before: the model posing nude for an art class.
A visual arts professor at University of California, San Diego, has come under fire this week for an assignment that requires students to be naked in front of the class.
This case mirrors so many medical encounters; There are "vague" warnings in the course catalogue (description) about nudity.
This further demonstrates how bodily integrity is so connected to our personhood.
This is also why nudity is also used in torture; an assault on the bodily integrity of a person strikes so deep that mental wounds are left.
Again, one of the biggest issues is how providers do NOT realize the trauma that the exposed body can produce." To me, that is more egregious than the malicious acts because it shows a disconnect to their humanity and a lack of common sense.
I think that the hurdle is what Beauchamp and Childress allude to as "choosing health." That is, people put their health above all else such as nudity and embarrassment.
--Banterings
Banterings - yes I have read that pamphlet - it is very good. Like the rest of us I'm sure healthcare professionals are inundated with information - they prioritize attention based on importance. My GP seemed sceptical when I told him of my issues. I think like Maurice has stated I am seen as an outlier - I call myself the 'inconvenient male'. Also there is a disconnect between hospital and private practice. GP's are granted 'priviledges' at hospitals - I don't think their opinion carries much weight there - and like anyone else don't want to rock the boat by advocating for the weak little man who can't suck it up. Unfortunately advocating for how how men are treated but also potentially affect his career and relationship within the peer network. Conformity to group think. Largely why this conversation isn't taking place there.
I realize that my view is based upon my own life experience - but after long thought/research I've come to this conclusion - I apologize if I am re-stating previous material.
Women need to control male sexuality. Male nudity with female caregivers is always dictated by the "Goldilocks" approach. If the male is too eager to expose - bad. If he's too shy and needs coaxing - what a baby - grow up. When he complies to instruction or she controls exposure and he is compliant- just right!
Growing up in the 60's my nudity at the beach etc was dictated by my mother. Shouldn't be an issue that I was nude - but - girls of the same age were afforded swimsuits. Even at that age I was aware of the fact I was treated unfairly/differently. Especially when girls in their suits would stare/stand in judgement/taunt me or other boys. We just had to 'man up'. To me this is a concerted effort by women to train boys that their nudity/sexuality was to be controlled by females. Perhaps also to enforce the idea of male disposability - train us that we have no autonomy. The tribe needs strong warriors not crybabies to protect them (the females). No one mentions that while we are implored to 'bring back the girls' - there were no boys to bring back. Why? Because Boko Haram had killed them outright. Male disposable. Female valuable. How can a male receive equity in healthcare with this paradigm ingrained?
Kevin
It is heartening that MD's like Maurice have had a shift in their thinking. Essential first step. I think healthcare professionals have known this (psychological/PTSD effect) all along - just no one raises the issue as they had no solution or were not able to change the system. We are social animals - everyone wants to fit into their social or peer group. Deviate and you risk rejection (or becoming a leader?).
Female sexuality/desire is a very complex issue and hidden under deep layers of social conditioning. Females are able to operate in a condition of cognitive dissonance. Saying one thing but doing another.
I am considered attractive by females - and have been objectified/touched/grabbed many times. But the mindset is that women don't act/think like that. A male friend who witnessed women's behaviour at a strip club was shocked at the aggressive behaviour of some of the females. Touching the performers etc. This behaviour apparently is not tolerated when the dancer is a female. They are protected by bouncers.
A female GP was filling in for my male years ago - went to see her for a knee strain so wore shorts. She actually commented - oh, you wore shorts? in a mockingly derisive tone. In her mind likely thinking; whats wrong with you men and your modesty issues? The short answer? Women.
Kevin
Kevin,
I was temped to agree with you on the issue of "women," but I can only partially agree with you on this.
I think there has been an elevation of women both academically and in the workforce to counter abuses of the past, but the issue of "power corrupts..." has infiltrated this movement.
(See: Fortune Magazine, 6 reasons why men are falling behind women, NBC News, Men Falling Behind Women, and Why Men Are Falling Behind in Higher Ed.)
Some other byproducts of this movement are "stay at home dads" (I am not implying this is bad), men assumed guilty in domestic disputes/sexual assaults, etc.
The reason that I don't agree is because of abuses against ALL genders:
Dr. Stanley Bo-Shui Chung accused of dozens of unnecessary intimate exams on female patients
Accused doctor testifies to value of regular breast and pelvic exams
Here is a simple solution; tell your providers that you have converted to Islam and it is against your religious beliefs for a woman to see your genitals. That will work, even in Canada.
--Banterings
I did qualify my views earlier as being solipsistic. My point is that gender politics have taken away accountability for one half of the population and the other half have no power/voice. Sorry I don't have links to studies but I remember reading about a conference? in the UK which talked about females as perps in abuse. It was attacked by women who didn't want the message to get out. Similarly conferences that discuss men's issues are attacked as well. Ironically - many of the victims of female abuse were women themselves. I would imagine these women feel the same way about female healthcare providers.
The muslim option is in theory plausible except I have a strong aversion to lying, and they would have to turn a hospital upside down to make it work (not likely). I would rather the system change somewhat so everyone was given the same consideration; that everyone involved was treated with the same respect. Social conditioning does not magically evaporate when you put on a uniform. A woman that finds me attractive just wears a 'mask' as a nurse. A woman that dislikes masculinity (so ingrained in culture most of us don't even realize it) will use the power imbalance to exhibit this using my nudity to belittle me. The forced nudity scenario is not lost on me as it is so prevalent in healthcare - esp with males.
For me its not necessarily the nudity - its the combination of having no power and a specific gender given access and control over me. Vulnerability. I have had some small operations done where I was able to control some of the process - it made me feel safe and respected. Sometimes its just small things which show respect and compassion.
In my immediate family I have/had 3 RN's, 2 LPN's, a plastic surgeon and an orderly. I am not really an 'outsider' in the healthcare system. More an observer closer with a close up window.
The 'man up' attitude displayed by female health staff is an extension of this dislike of masculinity. An expression of one gender telling the other to just get over it because we are in charge.
I get that my statement that its 'women' causing the problem is over generalizing. But when one gender affects a large proportion of the other in respect to accessing healthcare its hard not to. How many more 'women's' health initiatives do we need before we admit men die earlier and are more likely to commit suicide? We are not valued and therefore have no voice.
Kevin
Banterings - not sure if your comment was sarcastic RE: muslim and genitals?
I get it that my views may be taken as woman hating - they are not. Just my experience as a male in this society. As a male taking my kids to the playground it was inevitable that I would be glared at by someone there - the "I'm keeping my eye on you" look. Until it was proven (by my kids coming over and hugging me or something) I was a potential threat. Just because of gender. Usually a female glaring. How does she drop that bias at work?
I watched the Sharon Osbourne vid where she reacts to the Catherine Kieu genital mutilation of her husband. I get that there is a shock value here and she's an entertainer. What is insulting however is the reaction of the female audience. I assume these women have sons/husbands/brothers/fathers they care about? So how can they laugh? Its behaviour like this and my experience in this society as a man that erodes my trust in women. I don't hate women - I just don't trust them implicitly to be nurturing and empathic. I know that in the case of anything improper with a female (sex abuse/physical violence) I will have to prove my innocence. It's a given. Negatives are hard to prove. I won't stay here long - am not a troll - just wanted to bring forward a reason why men may avoid healthcare. Do the men in your life open up truthfully about why they avoid healthcare?
Kevin
Kevin,
I absolutely agree with you about the feminist movement creating a culture that demonizes males. There have been a backlash by WOMEN against the feminist movement. Here is just one example: 15 Sassy Photos Show Why These Women are Rejecting the Feminist Movement. This coupled with the push to get women into STEM fields is only creating an female dominated imbalance in healthcare.
I too had been the victim of an accusation of misconduct early on in college. What had saved me was when she cried foul to our group of friends, they scolded her because she had made it known the night before that she was taking me back to her dorm room (an apparent warning to the other girls in our group). This is commonly an issue when men are abused by women, EVEN MEN (i.e. the police) do not believe this happens.
See: 10 Reasons False Rape Accusations are Common, New Republic, College Sexual Assault Rules Trample Rights of Accused Campus Rapists, Time Magazine, Some Rules About Consent Are ‘Unfair to Male Students’, and Students accused of sexual assault struggle to win gender bias.
As to "muslim and genitals;" It was a strategy I offered to help you protect yourself. If you are Judeo-Christian, you can still claim religious exemption (Book of Leviticus among others...).
I felt a bit of sarcasm (I am NOT offended) when you said "Sorry I don't have links to studies..." The citation of references and studies is from my first interactions here when my views, experiences, and "common sense logic" were considered outliers, because the practices of medicine were derived from the science of the profession.
Just as healthcare could not see that having one's genitals exposed not embarrassing and traumatic, AND (the issue of) pelvic exams under anesthesia is NOT informed consent, again healthcare is missing that it is being hijacked by feminism!
Physicians decry having to give up their practices to become employees of healthcare systems, the burnout, lower wages, etc. Nurses decry staffing shortages, wages, etc. Why does the public NOT rally to their support? The way the public has been treated. There are other issues other than dignity, but they are a significant part of the problem.
As to your "trolling," I do NOT believe you to be trolling. Your words and arguments exhibit an intelligence above trolling. I do hope that you hang around, you have offered some insights that I have not thought of previously and have contributed to the discourse here.
In my reference above to genital exams and children with DSD, one has to ask how can such learned people as physicians, nurses, medical students, etc., how can they NOT realize that those situations are not humiliating, traumatic, assaultive, and a violation of human rights and dignity?
The answer is, "Because THEY are the ones wearing clothes."
I ask, at what point are genital exams only traumatic?
--Banterings
Kevin
It is my hope too that you hang around. At some point
we are going to need your help. I'd like to comment
on your " Goldilocks" approach. Whereby you write
that, " When he complies to instructions or she
controls exposure and he is compliant- just right."
In that regards the patient, male is still considered
a dog off the street in that he has no morals due to
his willingness to expose himself. There are many
instances where nurses unnecessarily expose their
patients.
State of Indiana Board of nursing
1) Disregarding a patient/client to dignity and the
right to privacy or right to confidentiality.
State of Texas Board of nursing
1) Surreptitious touch, voyeurism, or exposing the
patient's body when not necessary.
Arizona State Board of nursing
1) Disrobing or draping practices that reflect a lack
Of respect for the patients privacy, deliberately
watching a patient dress or undress.
In each state these consequences are considered
sexual impropriety and can result in license
revocation. Interestingly, I have reviewed the
governing body for ultrasound technologists, the
Ardms.org located in Rockville MD. On their site
nothing is mentioned about draping practices.
PT
I will do this in 2 parts:
The U.S. medical system is changing, and the traditional self-governing of the medical profession and physician professionalism is being challenged, according to a series of viewpoints published in a themed issue of JAMA.
The importance of the patient’s well-being in physician professionalism and how medical training encourages this in medical students is one of the major themes addressed in the issue. Also addressed is the topic of ensuring physician competency and professionalism through licensing, maintenance of certification, and accreditation processes.
“The aim of each physician clearly should be to care for and protect the interests and well-being of patients to the best of that physician’s abilities, while making sure her or his abilities are maintained as new discoveries are made,” Dr. Catherine D. DeAngelis, editor in chief emerita of JAMA, wrote in an editorial (JAMA 2015;313:1837-8 [doi:10.1001/jama.2015.3597]). “Characterizing the qualities that determine professionalism in physicians is more difficult. Terms used to define the qualities of medical professionalism include sound knowledge and skills (clinical competence), excellence, accountability, sound work ethic, good communication, wise application of legal understanding, ethical conduct, humanism, altruism, and self-regulation with accountability.”
Source: Clinical Psychiatry News
Read the May 12 issue of JAMA here:
Here is my take: There are too many law suits, too many arrests and convictions, and the public really does not care. It is not apathy on the part of the public, but how the healthcare system has treated the public. What is really driving the change is that physicians no longer wield the power and influence that they once did (See:
Physician Professionalism in Employed Practice).
Convicted pedophile, Dr. William Ayres, once the president of the American Academy of Child and Adolescent Psychiatry, and other physicians defended sexual abuse as part of a routine exam at his trial.
Later it came to light that those defending Dr. Ayres were also prominent members of the American Academy of Child and Adolescent Psychiatry, had some personal or professional connect to Dr. Ayres, or were his former students. (Source: San Jose Mercury News, Dr. William Ayres defends practices in molestation trial testimony, AND San Mateo Daily Journal, Doctor defends physical exams in molestation trial)
Allegations have arisen that some of the defense witnesses have been manipulated by Dr. Ayres. (See:Dr. Etta Bryant defends Child Molester ayres)
Continued...
Part 2:
These feeble attempts are nothing more than a PR campaign. The problem is that providers do NOT believe that patient dignity is an absolute right; they believe it is what ever they can spare that is not inconvenient. I am sorry if this seems offensive, but was of 2012 we are having the conversation about pelvic exams, without explicit consent, on women who are under anesthesia for surgery. As far as we know, this practice STILL continues.
If providers really cared, where is the outcry?
The abuses in healthcare here in the United States haverisen to the level of Human Rights violations, so much so, that the United Nations had to get involved. Even if the changes (which should have been made 100 years ago) are implemented, it is going to be too little, too late. Just like every pivotal social change, there is a need to ensure that it never happens again; a "cleansing" OR "cleaning up" if you will...
Historically there were many: Stalin's "Purges", "The Boys from Brazil" (post Nazi Germany), and more recently ISIL.
There are 2 things that can go as far as making the changes that need to be made. The first is from my "12 steps" post (above): admit to past transgressions and make amends. The second thing is that medical training needs to teach "the patient experience" just as they teach "on doctoring." (I know how the medical establishment feels about this concept, it has been expressed here previously. I am just stating what it is going to take. We all know that it will NOT happen.) Healthcare is going to "fiddle while Rome burns"
Again, I know that it is NOT all physicians and NOT all medical schools. Let me give you an example (that I have alluded to already): Radical Islam. The rest of the Muslim world has not condemned it, when it reached a certain point, the world had to deal with it (and still is). There has been collateral damage, I do not condone it nor even accept it, but as in all human endeavors…
Can anyone say that did not see this coming? Again, just my opinion.
"Those who cannot remember the past are condemned to repeat it." —George Santayana
--Banterings
I open with a few quotes from Florence Nightingale herself:
“What cruel mistakes are sometimes made by benevolent men and women in matters of business about which they can know nothing and think they know a great deal.”
“Women have no sympathy . . . And my experience of women is almost as large as Europe. And it is so intimate too. Women crave for being loved, not for loving. They scream at you for sympathy all day long, they are incapable of giving any in return for they cannot remember your affairs long enough to do so. “
“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.”
Apparently women now comprise fully 30% of internet porn traffic. The popularity of 50 shades of grey has started conversations about women’s sexuality. Feminism cannot keep the genie in the bottle much longer as regards to women as victim and females as gender neutral or sexually benign. If half the things my son tells me about high school are true it would seem that the sexual aggressors are the girls now. These are tomorrows healthcare providers. Again – no gender hate just an emperor has no clothes situation. We trusted the parish priest with our son as he was a man of god. We trusted the soccer coach because he was such a great guy, We trusted our son’s female teacher as women are not sexual. We trusted our female healthcare providers as they are gender neutral and professional. Power, control, access, trust – perfect storm.
I think we are at the point where the door is opening a crack – soon it will be kicked wide open and victims of females will have a voice and an audience. Gender neutral will cease to be the ostrich head in the sand paradigm we use. We will see all people as potentially good or bad. No longer will women be given unfettered access and remain unchallenged when they harm anyone egregiously. Only then can we initiate dialogue and implement the changes required to reform healthcare to one centered on the pt..
Absolute power corrupts absolutely. Lord Acton.
Banterings: I meant no offense at the mention of peer reviewed studies – I just do not have time to do proper research. I have studied cultural /social anthropology and have an innate ability to see patterns in behaviour from an objective viewpoint - I write what I see. If my viewpoints are of value then I will tarry a while longer.
Kevin
A. Banterings
Let me also add that's it's a shame on the entire
medical industry. An absolute shame that the
federal government had to step in to create and
implement Hipaa, to protect patients medical
information. Here we are 19 years almost to
the day and hospitals still can't get it right.
PT
Kevin,
That Florence Nightingale quote was absolutely brilliant and so true!
I also ask you to please contact me directly. I would like to ask you a couple things (not appropriate to bring up here) that I would like to ask you about/clarify. You can contact me from my Blogger profile here:
That is very interesting way of looking at relationship dynamics when you say "women crave for being loved." That fits in to the historic view (stereotype) "women give sex to get love, men give love to get sex."
I too see trends. (I predicted gas reaching $4 a gallon in the early '90's; simple reason was that is what the rest of the world was paying.)
I took no offense at the mention of peer reviewed studies...
You cannot offend me, but you are welcome to try...
--Banterings
I forgot if I have recently made the following statement but if I did, I will say it again.
I am so pleased that the conversation which is being carried out on this thread is no longer simply "moaning and groaning" ones experiences and outcomes but the conversation is now dealing with symptoms and the pathophysiology of the systemic problem. It is important to discuss and understand the mechanisms involved, in as much detail as possible, to sort out methods of resolution, the treatment of this illness of the medical system.
Read the very earlier Volumes of this thread to see the differences, differences which I think should lead to congratulations to those who had made these differences to be now present. Hex et al, what do you think about this change in the context of this thread? ..Maurice.
"the conversation which is being carried out on this thread is no longer simply "moaning and groaning" ones experiences and outcomes but the conversation is now dealing with symptoms and the pathophysiology of the systemic problem. It is important to discuss and understand the mechanisms involved, in as much detail as possible, to sort out methods of resolution, the treatment of this illness of the medical system.
Hex et al, what do you think about this change in the context of this thread?"
It's still a toothless tiger.
You are one doctor. occasionally another person from the med field will show up, but as soon as their view is challenged, they skulk off into the night to never be seen again. If this discussion is to have any kind of effect beyond the dozen or so regulars, you should be encouraging your medical friends to join in, and maybe... just maybe... have their eyes opened. Then maybe... just maybe... they'll get some of their medical associates to come here and have their pre determined views about what I as a patient am supposed to think / feel / accept challenged.
THAT would be actual progress, even if it is one doctor / nurse at a time.
Jason.
Just found this on a ..gulp..feminist website...the door
opens a little more...
http://jezebel.com/5335061/sexual-abuse-by-women-the-crime-no-one-wants-to-investigate
Kevin
I would be read here as unfair if I failed to direct our readers to a CNN news story about a law suit by sonography students who felt forced into performing a vaginal study on each other.
I repeat that when medical students examine each other at my medical school it is always with the consent of the "student patient" and there are no consequences for refusal. Further, as I have previously noted here, there are no genital/rectal exams practiced on medical students but only on paid teacher-subjects. ..Maurice.
Many patients don't get consent either, that's why they
call it an ambush.
PT
There should be no problems as long as it is done in a professional manner and according to established guidelines. They just need to woman up and stop being silly....
(This is meant to be sarcasm and to make everyone think.)
--Banterings
Finishing the year teaching my first year medical students, I have a bit more time now to contribute to my blog. I just put up a new topic which I think would be of interest to those writing to the Patient Modesty thread. The title is "Commercial Surrogacy: Women$ Bodies$ as Container$". This is certainly an issue of which deals with many of the topics broadly discussed on the thread you are now reading. Go read that thread and get a discussion going on there. ..Maurice.
At least the med students were awake and had the chance to refuse.
Can the same said for the patient rape... I mean "teaching experience".... on anesthetized women?
Jason.
Since Maurice posted the link to the lawsuit by the sonography students I have been struggling with my feelings and what I was going to say in this post. I was most bothered because I thought that I was feeling indifference to the students.
I realize that it was not indifference, but I believe that ALL providers should participate as patients in their learning. I also believe that graduated and licensed providers should also participate with students.
Ethically, the members of a profession, any profession, are responsible for advancing the profession and training the new, upcoming members of that profession. That will drive change!
Historically, healthcare has never come out and said, we are going to make the process more difficult for us, but easier on the patient. It has only come after multiple arrests and lawsuits.
Here are 2 examples;
If healthcare is sensitive to the psychological wellbeing of the patient, how could teaching hospitals, teachers, schools, and students allow pelvic exams under anesthesia and what happens to intersexed children?
The problem that I have with the story is that if these were patients at a teaching hospital, they would be called silly because the students are professionals.
I do sympathize with them as patients and human beings, not as professionals.
--Banterings
Banterings, medical students are not as yet "professionals" but they are in the process of being taught what is expected behaviorally when they finally assume full responsibility for their patients. We teach them punctuality. We teach them being honest and being ethical. Yes, we teach them about empathy and informed consent and we even teach them about matters of patient sensitivities and modesty issues much of which has been written about here by my visitors.
Yes, it is my understanding that pelvic exams by students on patients without the patients' informed consent is being eliminated from medical school education practices. This was a wrong practice regardless of its potential for important technique and anatomic education.
Banterings. based on my reading of comments by medical school teachers on a world-wide medical education listserv, the views of society are not being ignored. ..Maurice.
Maurice
Implementation of social views on medical ethics arise as a direct result of exposing the cloistered world of healthcare to the air of public scrutiny - almost always by a lawsuit/complaint. Otherwise it exists in isolation. Was Twana Sparks' behaviour a one-off? Or was she hidden inside a world where workers went along and didn't tattle. My gr 2 female teacher would stand and watch us use the urinals so we wouldn't 'misbehave'. We knew it was wrong but lacking agency had to accept the situation.
Jason's comment about changing the system - we can all agree that there will be no change from within lacking pressure from without. We need those within the system to bring issues into the light of public scrutiny without fear of repercussion. We need to create an atmosphere of advocating for positive change within healthcare rather than the feeling that they are breaking the rules by squealing.
From reading some comments on allnurses etc - there are many within the system who realize that there are problems - we need to reach out to these folks to get a foot in the door and switch medicine's behaviour from the standard defensive posturing.
I have heard of hospitals up here in Canada dealing with complaints in a setting where the medical staff can engage in dialogue without legal repercussions. Non-adversarial. Sometimes an apology and a sincere gesture to change procedure is all that's needed. When they stonewall we either walk away or get a lawyer. Most walk away. System has protected itself - no change. I think evicting lawyers where possible would go a long way.
Kevin.
I also find it interesting how a non-consensual pelvic exam is ok in medical situations - whereas if I did that to a woman in my home I am sexually assaulting her. Why is someone like Twana Sparks exempt from criminal process? This dichotomy needs to be addressed. A criminal act has to be seen as such irrespective of the arena in which it takes place.
I also think that any healthcare personnel who witness assault etc without reporting it should be held liable as their inaction allows the abuse to continue. The nurses etc that observed Dr. Sparks were likely afraid of termination if they reported - what if they were terminated because they didn't? This shift in mindset would help dismantle the Old boys and old gals club inside healthcare.
Sorry to double post - didn't want to lose the train of thought.
Kevin
Maurice,
I agree about the student part, that is why I recommended graduated/licensed providers.
If compassion/empathy IS being taught, then why is it that "pelvic exams by students on patients without the patients' informed consent is being eliminated from medical school education practices' and they have not been eliminated 50 years ago?
Where is the public outrage by the providers on listserv?
What about intersexed children? According to the UN, this rises to the the Holocaust, ethnic cleansing in Yugoslavia, torture by the CIA, Tuskegee, prison abuses in China, yet nothing from the healthcare community.
Forgive my cynicism, but how can I believe that compassion and empathy is being taught. Has your school or affiliated hospitals come out with limitations on student participation in patient care?
Further proof will be they will eventually come out with policies on treating intersexed patients. These guidelines will not apply to all patients. Again the fear is bad press, law suits, arrest, etc., it is NOT knowing what is sensitivity in the deliverance of healthcare.
I guarantee that if an attending invited 10 students in they all would go (passing the buck saying the attending got consent). I doubt any would say, "even with consent this situation has the potential to traumatize the patient, there should only be 2 or 3 students in there."
Even if the medical education system changed today, what about ALL the providers already out there?
Conscience is lacking in healthcare. Of course there will continue to be violations because they do NOT believe in compassion and empathy, they are just following cumbersome rules that interfere with medical efficiency.
Compare this situation to what is happening with police departments. The President has stopped sending them military surplus because they could not be trusted to use it properly. The mayor of Baltimore (and other cities) is threw the police department under the bus. The longer that police officers remain silent, the lack of empathy/compassion that the public will have for them. I can make the same case about radical Islam.
Compassion and empathy are like treating and diagnosing, the only way to learn them is through experience.
--Banterings
One of my friends works in the oil and gas field. He is a heavy equipment operator and also drives the large trucks to haul the equipment, so he holds a number of licensees and certifications for his job. He got selected by his company for the random drug testing they are required to do in order to keep their operator status active. His boss pulled him and one other guy off the job and drove them to one of these generic employment lab/testing facilities. Once there, he gets the typical brash and rude treatment from some woman CNA or whatever they use there to collect. She stood in front of him and demanded he drop his pants to his knees, pull his shirt up to his neck and urinate in the cup as she stood in front watching. He is very old fashioned and modest expressed being uncomfortable doing it that way and asked to do it in a different way. He gets (of course) just more insensitive attitude demanding that he comply. When he resists again she walks out of the room and reported that he refused the test. He never REFUSED THE TEST, he REFUSED THE TREATMENT. I don’t blame him. He ended up getting his active status to work suspended because of this. He is not some dangerous prisoner; he is an honest working man. The absolute disrespect and inhuman way they treated him set me off. Absolutely unbelievable.
What would happen if a male demanded that a female stand in the middle of a room, pull her top up to her neck, pull down her pants and urinate as he stood in front of her watching. IT WOULD NEVER *&^%$ HAPPEN. Yet it is the kind of thing that is perfectly acceptable to subject men to. I have heard and seen enough of this kind of treatment of males to last a lifetime.
Mike
Mike.
I applaud your friend for standing up for himself and all men. He put his job on the line for something he see's as wrong. I believe both his employer and the clinic are the one's that are in the wrong. Now it's time for him to fight to get this wrong made right. If he has a union, file a grievance with them and let them do their thing. Also, complain to his employer and anyone else he can think of. Hopefully some where along the way someone will take notice and put a stop to this sort of garbage. Best of luck to your friend.
AL
Mike,
Women need to control male nudity/sexuality. Of course reverse the genders and there would be war. I hope he files a grievance and that the CNA is fired. Men do not have to put up with this crap and women certainly wouldn't. How long must we tolerate this behaviour from "healthcare professionals". When will there be a tipping point so this behaviour is punished?
As a man he really has no voice as he will be shamed as that nurse tried to do. But he needs to become vocal. We all do.
Gender neutral? I bet 99% of the employees subject to the testing will be male. Imagine a male nurse demanding a largely female workforce urinate while he witnessed so he could validate the authenticity of the samples.He would be considered sexual, perverse and voyeuristic. Boggles the mind. Sometimes I truly am speechless.
Kevin
Mike,
If this is in the United States, your friend should note as of 2010, DOT Rule 49 CFR Part 40 Section 40.69, "Urine Specimen Collection Guidelines" take directly from the United States Department of Transportation (DOT) web site require:
SECTION 9. DIRECTLY OBSERVED COLLECTIONS
A directly observed collection procedure is the same as a routine collection procedure with the additional requirement that an observer physically watches the employee urinate into the collection container. The observer must be the same gender as the employee; there are no exceptions to this requirement.
DOT Rule 49 CFR Part 40 Section 40.67, "When and how is a directly observed collection conducted?" take directly from the United States Department of Transportation (DOT) web site require:
(d)(1) As the employer, you must explain to the employee the reason for a directly observed collection under paragraph (a) or (b) of this section.
(2) As the collector, you must explain to the employee the reason, if known, under this part for a directly observed collection under paragraphs (c)(1) through (3) of this section.
Note that this subpart states:
(g) As the collector, you must ensure that the observer is the same gender as the employee. You must never permit an opposite gender person to act as the observer. The observer can be a different person from the collector and need not be a qualified collector.
This was apparently a failure on the employer's part as well.
--Banterings
I have a feeling Mike may be referring to the oilsands project in Canada. After some quick research I noted that all procedural guidelines up here used vague language ie privacy should be considered, given where possible, may require observation.
The DOT language is specific as regards gender observing - in Canada not so much. Its like governing bodies here know there's an issue but don't want to go there; they leave way too much latitude and hope it all works out.
Not to mention the stupidity of random testing. Everyone is a suspect until proven otherwise. The airport in Israel uses profiling to select out persons of interest. We body scan/pat down 92 year old ladies. This is just another indication of how the rights of the individual are trampled on for the 'greater good'.
Kevin
Comrade Kevin,
It is for the common good that we make these sacrifices. In the US, we have the "Patriot Act" that does the same.
Besides, we are not men or women, we are all citizens and that makes it acceptable and efficient. Just ask any doctor, they will tell you it is fine...
--Comrade Banterings
This is Mike with an update on the urine test story, and its not good. This all happened here in the US, Texas actually. Since the woman that conducted the test (he doubted she was a nurse) is infallible and whose word is law said he refused the test, he lost his job. Nobody wanted to hear his side of the story. SHE claimed he refused the test-he was fired, just like that. I appreciate the feedback and will encourage him to challenge this incredibly unfair ruling. He was so embarrassed and self conscious when he told me about it I doubt he fought it as hard as he probably should. His immediate boss was for sure not on his side and just claimed there was nothing he could do since he "refused the test". He never refused the test but then again throughout this ordeal nobody was ever on his side. I am encouraging him to fight it.
MikeB
Maurice,
I am glad that you get my humor (maybe even enjoy it).
Mike,
The fact that a woman was conducting the test is a violation of federal law!
She would be the one signing the paperwork saying he refused the test, proof she was administering the test in violation of federal law.
He has a claim for sexual harassment, sexual assault, and assault (at the very least) against the female administering the test and the clinic (allowing it at their place of business). He can also press criminal charges against her for assault and sexual assault. (Note: assault is "threatening," "battery" is touching.) He can also file a complaint against the female and the clinic with the DOT and they (both) can lose their DOT testing certification.
He has a claim against his employer for sexual harassment and a hostile work environment. (Note: sexual harassment only requires an employee be harassed while in the course of his/her job. There is NO requirement that he/she be harassed by another employee.) Your friend needs to contact the EEOC in Washington DC. There is also OSHA violations for "workplace violence prevention program" that ALL employers (depending on number of employees) are required to have. (Again, there is NO requirement that he/she be harassed by another employee.)
An EEOC claim will surely get his former employer on his side.
Tell him to find a good personal injury attorney.
--Banterings
Hello Everyone.
Google D.O.T. SECTION 40.69. Read part B. It's the same o B.S. We're all professionals here. Gender shouldn't matter. AL
AL
Just read through pertinent section of 49. Absolutely no mention of gender or modesty. Gov bodies are so focused on the sample chain of evidence the suspect is not even considered. Very similar to healthcare. The worker is not a prisoner nor have they waived any rights personal autonomy/integrity. Freedom andPursuit of happiness...yeah right. The tone of the regs is of punishment of the collector if they do not follow the rules. I see where the 'quasi nurse' was coming from. Does not make it right though. The absolute refusal to see the suspect as a person has me gobsmacked.
Life, Liberty and the pursuit of Happiness.--That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed. Hmmmmm. (headscratch)
Comrade Banterings..we have been watching you closely, your opinions are causing us concern.
Kevin
AL
I did read the document, and you are correct, as long as we are assured of their "professionalism" then all bets are off. I know just how PROFESSIONAL these people are in below physician roles. Both my in laws are in the medical field. One told me a story where they allowed people in long term care to bring in personal items to make their hospital stay less grueling. This practice was effective, but soon had to be discontinued as the "professionals" (CNAs mostly) were stealing the patient belongings right out of their rooms.
Mike
"(d) As the monitor, you must not watch the employee urinate into the collection container. If you hear sounds or make other observations indicating an attempt to tamper with a specimen, there must be an additional collection under direct observation (see §§40.63(e) , 40.65(c) , and 40.67(b) )."
I don't see a problem here; what am I missing?
Ed
So what would a person who suffers fron extreme paruresis do in a situation like this. I am sure someone who suffers this condition would find this pretty much a worst case scenario. Does he just not get to work anyware that requires this test?
Here is the possible answer to the question as to whether "shyness" in this case with regard to urinating in public (paruresis) could be considered a disability under ADAAA which would prevent the loss of a job because of refusal to urinate in front of another (male or female). Here is the link to an interpretation of the ADAAA law from the office of legal counsel for the U.S. Equal Employment Opportunity Commission .
The conclusion of the statement: "As was true prior to the ADAAA, a person with paruresis is required to show individually that he or she meets the definition of “disability.” The ADAAA and its implementing regulations make this showing much easier, by including bladder and brain functions as major life activities, lowering the standard for establishing that an impairment “substantially limits” a major life activity, and focusing the determination of whether an individual is “regarded as” having a disability on how the individual has been treated because of an impairment, rather than on what the employer may have believed about impairment. No negative inference should be drawn from the fact that paruresis is not specifically mentioned in the EEOC’s regulations implementing the ADAAA." ..Maurice.
P.S.- I think I have written the following previously but then I would like to express my thoughts again: I am most pleased to observe how in the recent Volumes of this "Patient Modesty" thread, there has been expansion of discussion to broaden modesty issues beyond the OR or exam room but into other areas of concern which deal with the more general matter of human dignity as challenged in various ways. Examples would be such as into the area of the workplace as in the current commentary but also police practices, education, sports and other society inattention or disregard for an individual's concerns and dignity.
Including such areas of concern gives a more valid perspective of the challenges for change. What goes on in the OR or exam room is really part of a bigger societal picture. ..Maurice.
Maurice,
You are correct. Modesty/patients rights issues in the healthcare system are really just a symptom of a much greater social purview. I thinks its interesting how we can relate to the plight of a few - and show empathy - but when we pull back and the numbers expand we lose the ability to identify on an individual level. This happens naturally when policies are drafted - patients become abstract ideas bereft of individual traits - the proverbial number in the matrix. No allowance for deviation from a robotic drone moving through the system. This concept distills back down to the 'hands on' implementation of healthcare, police services, corrections etc. The necessity to streamline causes total disregard for individual autonomy; this lack of balance can set up the individual for a less than ideal experience. Policy should be written with the input of those who have just been through the system - not those alone in the isolation of ivory towers.
Years ago I had dealings with a hospital administrator at whose facility a relative was receiving substandard care. Upon my questioning of a particular physician's standard of care the administrator admitted he had never actually practiced 'hands on' medicine. Serious headscratch. You don't have to be Einstein to see the problem here.
Kevin
I inadvertently deleted the commentary posted by Banterings yesterday. I apologize to Banterings and my visitors. What follows is what he wrote. ..Maurice.
Maurice,
Bravo!!!
You beat me to the punch with the Americans with Disabilities Act (ADA)!
Do not forget that that EEOC also covers religious beliefs; so if you are Jewish or Christian, the Book of Leviticus prescribes separations of gender as well.
There are many other state laws that come into play as well. Even thought DOT regs say that the collector does not need to produce a photo ID, here in Pennsylvania a new law just went into effect:
New Pennsylvania law requires physicians to wear photo IDs
■ States are working to guarantee that patients know whom they are seeing and are not deceived by health professionals who misrepresent their training.
A new Pennsylvania law aims to make it clear for patients who is taking their blood pressure, giving them an injection or preparing to operate on a loved one.
Under the law signed Nov. 23 by Gov. Edward Rendell, physicians, nurses and other health care professionals soon will be required to wear photo identification badges that state their credentials in large block letters, with descriptions such as "physician" or "registered nurse."
"The idea is that you can read this instantly at a conversational distance," said John J. Laskas Jr., MD, a dermatologist in Glen Mills, Pa., and chair of the Pennsylvania Academy of Dermatology and Dermatologic Surgery's patient safety and scope of practice committee. "Then the patient knows and can make a judgment whether or not this is the level of expertise they need. We need to know and have a right to know the credentials of the person who is giving us care."
Beginning in January 2011, the state health department will have 90 days to develop interim regulations and then 18 months to finalize them. All Pennsylvania health care employers will need to comply by June 2015.
The Pennsylvania law is one example of how states are working to ensure that patients know whom they are seeing and are not misled by health professionals who misrepresent their level of training. At least two states -- California and Arizona -- have enacted laws requiring that any advertisements for medical services include the health professional's title and license type.
Illinois adopted its Truth in Health Care Professional Services Act in July, requiring health professionals to post their license when seeing patients in their office. They also must wear a visible badge stating their license credentials during all patient encounters. Source: American Medical News
--Banterings
My Quest to Understand, Define, and Maintain Medical Modesty, Part 1 of 4
I want to thank Dr. Bernstein for his work to run this site about medical modesty. I also want to thank the people at patientmodesty.org—some of whose names I think I recognize here as well—for having provided me my first contact with others concerned about modesty, or as I usually say, privacy.
I am a 61 year old man with a doctorate in religious studies who teaches at a midwestern university. I have never been particularly comfortable with strangers touching me, though I am not aware of an incident in my childhood that caused a concern. It was difficult to get used to going to a barber; my mother had cut my hair when I was small. Dentists were a particular horror, but that was at least partly because I went to them very rarely and usually to have teeth pulled. It wasn’t until I was in my mid twenties when I overcame that fear and became comfortable with dentists, though not until I had about half my teeth filled.
I have no recollection of disliking doctors as a kid, but I went to them very rarely and only went to a hospital once, to get a broken wrist set. It was when I had to have a physical to go to college in 1971 that I had my first confrontation with a physician. My friends complained about the cough test to determine whether they had a hernia, and I thought “if I have a hernia, I think I’d know, so I will refuse that test.” When the doctor asked me to remove my underwear at the end of the physical, I refused. He got angry and said “get out of my office and never come back.”
I didn’t see a doctor for 22 years after that, except for two quick visits to university clinics for minor injuries. By the time I was 39, I was married and it was time to see a doctor. It occurred to me that my childhood doctor was from a different era—he would have been born about 1906—and that if I encountered a doctor who was unhappy about my keeping my underwear on, I’d find another one. I asked my dentist who he went to and he recommended a very good doctor, one who was indeed unhappy that I never removed my underwear in front of him, but he was kind and accepting, and never judgmental.
When I developed a hydrocele in 2003, I showed it to him. All he did was transilluminate it—I did all the holding and touching—and he explained what hydroceles and spermatoceles were. He recommended an ultrasound, but when I asked how much that was necessary, he replied “well, if we lived in Montana and the nearest facility was a 6 hour drive away, I wouldn’t recommend it.” I took that to indicate the risk was low and I decided to monitor it myself, and educate myself about genital health. That is what I have done ever since, and I have not felt the need to show it to a physician again. The web has become an excellent source of information and I have used it extensively, because if I am going to be the gate keeper of that part of my body, I have to know how to do it right. I wish physicians, rather than starting by asking their patients to remove their underwear, would start by explaining what they want to check and why, and what the various dangers and problems are. I am not sure I would have agreed to a routine genital exam when I was 17, but I wouldn’t have waited 22 years to see another physician, and would have had more peace of mind.
My Quest to Understand, Define, and Maintain Medical Modesty, Part 2, By RobH
My next major challenge was rising PSA, which started at 1.5 in 2003 but reached 4.3 in 2012. My physician had asked to do a DRE pretty much every year and I had always refused. But in 2012, my primary care physician recommended I see a urologist, which was a huge challenge. Nevertheless, I decided I would do so, and that I would allow a digital rectal exam, too, because I had also noticed some difficulty urinating. It showed a slightly enlarged prostate, but nothing else. It was not a painful test, but it was a big violation of my privacy, acceptable the first time because I was wondering what it felt like and what it would show, but less acceptable subsequently.
The urologist I went to was essentially a surgeon. He said that the next step was a biopsy and if there was cancer, “maybe I could wait a few years” but the next step he would recommend was surgery. He never mentioned “active surveillance” once. I had done plenty of reading about prostate surgery and was aware that there was a slippery slope toward surgery that more often was harmful than helpful. I asked the doctor about the PIVOT study, where 750 men with prostate cancer had been divided into two groups randomly and tracked over a decade, one group having had their cancerous prostate removed, the other not. For men with PSAs under 10, the death rate statistically was the same, and my PSA was barely over 4. He said the study was “flawed,” a statement I attributed to his bias toward surgery (the study was published in New England Journal of Medicine, after all).
So I went on a quest to find another urologist, and as a result of speaking to several physicians I ended up at the University of Chicago Hospital’s urology department, several hours drive from home, but light years better in quality. Because the urologist there had residents and medical students to assist him, I had lots of people to talk to, and that was very important; I was reading extensively on the web and I needed to bounce my understandings off of experts. They listened and responded. I chose a urologist whose expertise was active surveillance, so that his biases matched mine, at least. I made it clear from the start that my underwear was staying on and they accepted that graciously! They had to accept the DRE from the previous urologist, which they did. I asked the urologist how necessary a DRE really was, and he emphasized that the PSA was much more useful, as was the IPSS (International Prostate Symptoms Score) for tracking difficulties with urination. He recommended a “free PSA” test and it showed that I had between 26% and 30% free PSA (I have done this every 6 months for 2 ½ years, now), which greatly reduces my chance of having prostate cancer. Perhaps I will need a biopsy someday, but it is not urgent.
As positive as this sounds, I should also underline the immense anxiety I have felt for the last 2+ years. I easily spent an hour a day thinking about all sorts of scenarios and how I would deal with them, especially what I would say. The “nightmare” cases on patientmodesty.org both made the anxiety worse and forced me to think through the arguments I would make, the tone I would take, and the ways I would respond to objections. Ultimately, all that was very good, I think.
My Quest to Understand, Define, and Maintain Medical Modesty, Part 3, By RobH
A friend of mine a year younger than me, meanwhile, had acute urinary retention twice and had to go to the emergency room to be catheterized, until he was put on a stronger medicine to shrink his prostate. Partly out of fear of that happening to me, and partly because my urinary difficulties were getting a bit worse, I started on Flowmax. I also started to talk to my primary care physician more frankly about my approach and my insistence on maintaining my privacy. (I should add this was a new primary care physician because I had changed insurance and could no longer go to the previous one, though he has continued to provide me with advice periodically.) My new physician was mildly sympathetic. He never requires patients to disrobe, much to my surprise; he listens to people’s hearts through their shirts and tests their reflexes through their pants.
My conversation with my primary care physician about catheterization was the most complicated, because I noted that if I ever had to be catheterized, I would first insist on a male, and then insist that the male assist me to catheterize myself; it was only if that proved impossible that I would allow him to do the touching. Intermittent self catheterization is a procedure recommended by some physicians for acute urinary retention, so I had medical opinion at least partially on my side. My physician was cool about the subject. Interestingly, when I said to him that my biggest concern was that I remain kind and friendly to the nurses and not respond to unprofessional comments in an unprofessional fashion, he really warmed up and was interested in helping me strategize how to maintain my privacy in the most polite, kind, friendly, professional manner possible. I have since emphasized that aspect on two other occasions to physicians and it worked both of those times as well. Rather than coming off as emotional, I come off as a compassionate patient concerned about the care givers. He also told me that both local hospitals have patient advocates and if I asked to see them, they would support my request.
I don’t know whether trouble comes in threes or my health has suddenly started to deteriorate, because in the last year there have been more challenges. A basal cell carcinoma on my face required Mohs surgery twice. In between I had a “full skin” exam. I thought I wouldn’t mind a female dermatologist, since I was keeping my underpants on anyway. But afterward, reflecting on it, I decided that at age 61, if I was uncomfortable about something, I would do or say something about it, so I asked my primary care physician to connect me with a different dermatologist who was male. He seems like a nice guy—he did the second Mohs surgery—and when I do a “full skin” with him in the fall, my underpants are staying on. I will assure him that if he is not happy about it, he should be thankful he isn’t my urologist! If I find a full skin with a male dermatologist to be uncomfortable, I may space them out to every two or three years, rather than annually, as the increased risk would not be great.
To Anonymous from today: Thanks for participating on this thread. However, if you are planning to return to post (and you certainly are welcome to do so) please, even if you do not want to sign in to Blogger.com with a name or pseudonym, please terminate each posting with your own unique pseudonym so that the readers can identify which Anonymous is writing. Again, thanks. ..Maurice.
My Quest to Understand, Define, and Maintain Medical Modesty, Part 4, By RobH
When I went to my urologist a few weeks ago, I spoke to a resident and was very up front and frank with him. He was prepared to give me a full genital exam and DRE, I think, but he never had the chance to say so because I set the agenda of the conversation. He admitted that the DRE was done because it was quick, easy, painless, and didn’t cost anything, but it wasn’t a particularly useful or specific test, and it rarely found anything serious. I stated a new rule I had formulated, which I call the “1% rule”; if something is a risk to my health that requires examination of a portion of the bathing suit area, that portion of the area can be uncovered for a male physician to examine it (and only that portion) if the risk to my health is greater than 1%. This means that I am conceding medical nakedness 99% of the time, so that feels quite generous to me, while reducing the real risk to my health to quite a low level. If men with PSAs under 10 develop prostate cancer at the same rate whether their cancerous prostate is removed or not, it is safe to say that the DRE does not provide a 1% protection to my health, so modesty trumps. No more DREs for me, at least for a few years anyway. I know the American Urological Association recommends them, but what would you expect? They’re urologists! They want to be careful and thorough, they are used to the procedure, they don’t want to lose patients or get sued, and they are not interested in modesty. I am, so my calculation produces a different result.
The urology resident also agreed that if I was kind and polite, I probably could manage to get someone in an emergency room to teach me to self-catheterize. (Of course, if I can’t, there are two large hospitals near me, so I can always go to the other one.) He also said his urology department could do it. For that matter, my primary care physician will probably agree to teach me; he has said if I have acute urinary retention, I could come to him as well (assuming I can get an appointment at the right time, of course). I am pretty sure that if I ever need to have a prostate biopsy, they will (reluctantly?) agree to my wearing colonoscopy shorts or the equivalent. I am now at the point where I feel confident I can politely, kindly, calmly, professionally insist, and I don’t give a damn what anyone thinks about me. Any attempts to intimidate me are unlikely to work; if anything, they will cause me to blow my cool and push right back. That’s why I emphasize that I want to be polite!
My Quest to Understand, Define, and Maintain Medical Modesty, Part 5, By RobH
It turns out I need to have a colonoscopy because there was blood in my stool when I did a hemoccult test last month. I have been following the recommendation of many medical organizations that starting at age 50, one should have a hemoccult test annually or a colonoscopy every ten years. I have managed to skip the colonoscopy for my 50s, so I am grateful for that. I met with my primary care physician first to strategize how to approach the gastroenterologist, and he was helpful. He stated that there were no medical procedures that really required exposure of the genitals except operations on the genitals themselves, and that a request to wear an athletic supporter or boxer shorts worn backwards during a colonoscopy was not out of line.
The meeting with the gastroenterologist went well. He said that if I can’t find colonoscopy shorts (he doesn’t offer them; I should have asked why), I could wear boxer shorts backwards, as long as I cut the hole bigger. He had no problem with that at all and said if the nurses asked, just to tell them he had approved. I will, nevertheless, put it in writing on the permission form that my shorts are not to be removed and I am not to be catheterized. It remains a disgusting procedure with a gruesome preparation, but it definitely exceeds the 1% rule, so the appropriate portion of the bathing suit area will be made available for the procedure. I will keep the boxers even if they are permanently soiled as a souvenir of my triumph over unnecessary medical nakedness.
I now feel I have a workable philosophy that I can explain to doctors and nurses intelligently. They can laugh if they want, but I can also politely insist. The bathing suit area is private. Medical personnel have no automatic right to examine or touch it. Their right to examine or touch it is based on medical necessity. Medical necessity is defined by the 1% rule. The 1% rule prevents just about all unnecessary medical nakedness. If I have to have an appendectomy, I will require surgical shorts or underwear, because there is 0% medical necessity for the genitals to be exposed during that procedure. That will be true throughout the recovery process as well. If anyone complains, I will apologize, but add that I am not requiring them to think outside the box at all because they have no need to see or touch that part of my body anyway; so what’s their problem, really? If they agitate me, I’ll point out to them that their medical degree confers no right to see patients naked and they are simply insisting on a privilege they have neither earned nor need. I suppose I won’t add “that must suck for you” or something nasty and snide (well, unless they push me too much).
My Quest to Understand, Define, and Maintain Medical Modesty, Part 5, By RobH
At age 61, I no longer particularly care what people privately think of me. If I strive to be calm, kind, and polite, that will probably win out over funny looks, put downs, and passive-aggressive comments. If it doesn’t, hopefully I won’t drop the f-bomb on them (something I have never done in my life, I should add) and insist on a transfer to the other local hospital. Swearing would cause me to lose the moral high ground, and moral high ground is crucial for this approach to work. If a physician gives me his word to respect my modesty and then breaks it during a procedure—even if it is major surgery—I will probably cut him off, refuse to let him examine me further, and refuse to speak to him unless he offers an acceptable explanation and apologizes. I will calmly and politely make it clear before the procedure that cutting off such a physician would be an ethically necessary response to such an ethical breach. I gather it is a huge problem for a hospital when a patent refuses to continue to see a physician during the recovery process. But if they violate my privacy, that’s really too bad, isn’t it?
I did not intend to end this comment on a down note. So far, I have found that calm, kind, and fearless frankness works pretty well. It also helps to have a thought-out position, which I admit is tentative and could change as I deal with more physicians and hospitals. I welcome the comments of others about my definition of medical necessity and the definition of unnecessary medical nakedness that follows from it, so that I can continue to refine my understanding and approach.
RobH,
GOOD FOR YOU and GREAT POST(S)!!!!
You have made some good points that I am going to borrow.
You have written a narrative here where anyone making the demands that you remove your underwear that shows since "there were no medical procedures that really required exposure of the genitals except operations on the genitals themselves..." the person making the demands is suffering from some mental illness (most likely a combination of sociopathy, narcissism, and impairment of reason and critical thinking).
--Banterings
RobH,
As the founder of Medical Patient Modesty , I really appreciate your great postings. You have done an excellent job standing up for your rights to modesty. I find it interesting that you have been able to conclude that colonoscopy shorts or boxer shorts backwards can also be used for prostate biopsy. It is encouraging you’ve had some doctors who were sensitive to your requests to protect your modesty as much as possible. You are right that many procedures unless they are on the genitals do not require exposure of genitals.
You are an excellent role model for patients. Many patients won’t speak up. The truth is Empowered patients change things, compliant ones don't. If you go to a medical facility or doctor that won’t honor your wishes for modesty, you should move on to another facility or doctor that is willing to accommodate your wishes even if it means driving farther.
Misty
RobH - While the approach you have taken is admirable I also find it sad that a person has to jump through all these hoops just to be allowed medical treatment and have his modesty concerns addressed. Not many (esp men) are able to articulate their concerns like you in a calm and thought out manner. When I access healthcare I tend to feel like when I was a kid and the bully was holding me down - compliant but under duress the whole time.
Do you think your interactions with healthcare prof's changed their thinking at all? Or were you just a special case to be accommodated and then back to 'normal'?
Kevin
Dear Kevin:
The responses to my posts have made me more aware than ever that I need to advocate change when I interact with physicians. I have always had the needs of others in mind, but when one is dealing with doctors as a patient one always has one’s own concerns foremost in mind.
I think some change can come, but very slowly. I think we need to appreciate the situation doctors and nurses are in. They are responding out of their training; I don’t think psychological conditions are primarily at work, Banterings. Let us say that you are a primary care physician already aware that a particular patient is shy, so you ask questions about the person’s genital health in a routine checkup, but don’t actually ask whether you can make an examination. And what that person has mild symptoms of something he or she has decided not to mention, but then later develops a serious venereal disease or some other complication. The doctor may worry about a complaint made against him or her or even a malpractice suit. Physicians have to be very careful to follow the guidelines of their profession; they are a protection. That’s also why tens of billions of dollars of unnecessary tests are prescribed every year.
In a way, I feel bad about the parade of urology residents and med school students I see at the University of Chicago Hospital. They are trained to go in and perform certain basic examinations, then they encounter a very unusual patient who won’t drop his drawers! It’s their “territory” after all. This sort of hamstrings them. (I’m tempted to say “emasculates” but that’s not a very nice pun). I think it does not have to hamstring them; I go in with a list of questions and an agenda of subjects I want to talk about. That’s why I personally prefer to talk about a “checkup” rather than a “physical.” I think doctors need to think more on the line of “checkups” as well. My primary care physician looks things up on the web during our annual checkup and gives me the web addresses he consults. But some physicians are better at communication than others.
You can do this too, Kevin. Go in with a list of questions. Be friendly. Thank them for their assistance. If they ask you to do something you don’t want to do, apologize, not in a groveling way, but in a kind way, like someone has offered you a gift that you can’t accept for some reason. If they recommend a certain examination, you can always say “well, perhaps next time I see you.” Ask them what they are looking for, how they detect it, and how you can read about it on the web first. Ask about the risks and dangers to your health. If you don’t want to see a physician about something, you owe it to yourself to inform yourself. The great thing about male genitals is that they are on the outside and easy to examine on your own. There is even a YouTube video of a female doctor examining a naked young male patient for testicular cancer. Rather shocking, but informative.
Try to avoid the word “no,” for example: “Thank you for offering to make that examination, but perhaps we can pursue that another time. I am a shy person and prefer to do my own research on the web first. If you want to listen to my heart or check my reflexes, I will be glad to allow that. Can you recommend some websites where I can find additional information?” This makes you cooperative, intelligent, confident, and informed.
RobH
I have come across a recent news article that makes the case that students learning procedures on students is a far superior way to learn versus on real patients. It quotes the (in)famous Dr. John Henry Hagmann He retired from the U.S. Army in 2000, and is considered a pioneer in trauma (specifically combat trauma). Source: Reuters via Yahoo News
In the Army, Hagmann practiced emergency medicine for two decades. He rose to the rank of lieutenant colonel and co-authored an influential combat treatment manual.
After retiring, Hagmann founded DMI – also known as Deployment Medicine Consultants. It is based in Gig Harbor, Washington. Following the Sept. 11, 2001 terrorist attacks, demand for his courses grew and DMI emerged as a preeminent trauma-response trainer. The majority of DMI’s government contracts are with the U.S. military – in particular, Army and Navy special operation units.
“The mission of DMI is to train you to save lives in the combat environment, no one matches our ability to do this,” the company says on its website. “We are the single largest trainer of US military forces in operational medicine throughout world, and our record for excellence stands unchallenged.”
The allegations have lead to an investigation by the Virginia Board of Medicine and Defense Criminal Investigative Service. The allegations against against the good Dr. Hagmann (scientist and saint) are described as:
...During instructional sessions in 2012 and 2013 for military personnel, Hagmann gave trainees drugs and liquor, and directed them to perform macabre medical procedures on one another, according to a report issued by the Virginia Board of Medicine, the state agency that oversees the conduct of doctors.
Hagmann, 59, is accused of inappropriately providing at least 10 students with the hypnotic drug ketamine. The report alleges Hagmann told students to insert catheters into the genitals of other trainees and that two intoxicated student were subjected to penile nerve block procedures. Hagmann also is accused of conducting “shock labs,” a process in which he withdrew blood from the students, monitored them for shock, and then transfused the blood back into their systems.
...In one case detailed by investigators, Virginia authorities allege that Hagmann boasted to a student “about his proficiency with rectal exams” and took the student to a warehouse on his property. There, the report claims, the two “continued to consume beer” and Hagmann asked the student “about the effect (the student’s) uncircumcised penis had on masturbation and sexual intercourse.” The student told investigators “that he was inebriated and felt that he could not refuse Dr. Hagmann’s request … to examine, manipulate and photograph his penis...”
In his defense, Dr. Hagmann said, "...the Virginia board is applying the wrong standard in assessing his conduct: He said that his trainees are "students," not "patients" as the board calls them, and therefore he may have them perform procedures on one another as part of the educational process.
...the courses and procedures in question were all reviewed and approved” by officials at the Uniformed Services University of the Health Sciences (the government-run medical school that trains and prepares health professionals to support the military)."
Please note the sarcasm in this post.
-- Banterings
Banterings
That case shows another example of people surrendering to authority - becoming 'sheeple'. Echoes of Milgram's experiment ring throughout the halls of healthcare and other organizations. This study below illustrates a more specific example of obedience in healthcare. There are rules, right/wrong, protocols to be followed but most well meaning people are subverted by authority - apparently almost unconscious of their rule bending.
http://www.simplypsychology.org/hofling-obedience.html This seems vague as to referencing a peer reviewed study but even if half the nurses complied it is still relevant and explains a lot in terms of the social and hierarchical machinations within organizations.
Kevin
I thought I should let everyone know that I had a colonoscopy today and there was absolutely no issue about wearing colonoscopy shorts. The doctor was supportive. The staff already had a note that that was my choice and never said a thing that would question my decision. It was a very professionally carried out procedure using an intravenous anesthetic that wore off very fast; I was asleep in one minute, was awake 25 minutes later, and was walking around and changing clothes 25 minutes after that. The rest of the day was normal. And the procedure found no problems! I did suggest to the intake nurse that they consider offering colonoscopy shorts regularly and that they might get extra business if they did. I think I will follow that up with a thank you letter and mention the idea to them.
RobH
According to the 2008-2009 bureau of Justice, among the 39,121 male prison inmates who had been victims of
staff sexual abuse, 69% had reported sexual activity with female staff, yet the number reaches 90% in juvenile
centers. At one correctional facility in Baltimore there were 13 female prison guards and among those , 4 became
pregnant by the same inmate! Law enforcement will tell you it's a felony for staff to engage in sexual activity
with inmates, yet prisons guards whom I know personally tell me that when staff are found to violate this rule,
they are only fired, no charges are pressed.
In fact, the well publicized murder case of Jodi Arias in Arizona that was until recently in the news is no exception. I'm
told by prison staff that a few male guards frequently had sex with her. Just how really under reported is sexual
activity in institutions? By this I'm referring to prisons, mental institutions, schools, nursing homes and all medical
facilities. Just when we think we have heard it all.
Florida nurse strips nude, attacks patient.
www.freep.com/story/news/nation/2015/6/15/florida-nurse..
Not sure why all nurses wanted to quickly bury this story, probably because the nurse was female.
PT
PT,
It is what I have said ad nauseum: Power corrupts....
--Banterings
Hi All:
My apologies if you have already discussed this. But, a man has won a lawsuit that he brought against the medical team that performed his colonoscopy. He inadvertently recorded on his cellphone what occurred while he was sedated. These "professionals" mocked his fears, his medical issues, and even placed a false diagnosis of hemorrhoids in his chart. Why? Beats me. I doubt there is anyway to explain the inner workings of stupid, petty, immature minds such as these.
The story is here.
The good news is that these idiots lost, to the tune of $500,000. Even if this is not sufficient to force all such small minded individuals out of medicine, perhaps it will at least teach them to keep their mouths shut.
The bad news is that this simply confirms what so many of us already suspected, as to the sort of behavior that is tolerated while we are sedated, and the attitudes of many in the medical profession.
The really bad news is that, in spite of losing this lawsuit, it does not appear that any of the doctors involved were sanctioned by any medical board. How sad that, even when faced with such damning evidence, the medical establishment still protects their own, to the detriment of the patients in their care.
What this whole story misses is that this happened in front of other medical personnel! Chaperones only protect physicians, not patients.
I have written about it here: Patient Chaperones: A Practice that is Useless and Abusive
--Banterings
From Banterings - "What this whole story misses is that this happened in front of other medical personnel! Chaperones only protect physicians, not patients."
you mean someone employed by the hospital sides with the hospital, and protects their interests? I'm shocked...
From RobH - " It was a very professionally carried out procedure using an intravenous anesthetic that wore off very fast; I was asleep in one minute, was awake 25 minutes later, and was walking around and changing clothes 25 minutes after that."
If you were out, how do you know it was carried out professionally? In my eyes, it's a huge leap of trust that as soon as you were out the shorts weren't just pulled down to make their jobs easier. More trust in strangers than I have....
Jason K.
It is interesting that the doctors’ lawyers tried to argue that cell phones should be kept out of OR. The lawyers are only interested in getting the doctors out of wrongdoing. The colonoscopy patient’s genitals would have not been exposed if he had been wearing colonoscopy shorts. Patients have to take precautions to protect themselves while they are under anesthesia. You certainly cannot trust a chaperone that is employed by the hospital. You need a personal advocate not employed by the hospital present with you at all times to make sure that medical professionals do not do anything inappropriate to you or you need to opt for local or regional anesthesia with no sedatives to make sure you are awake the whole time.
Misty
I wanted to share an article on Outpatient Surgery Magazine about a lady who was bullied into signing consent form. She had repeatedly stated she did not want a hysterectomy. This case proves why it is important to have a personal advocate such as your spouse present during surgeries to make sure your wishes are honored once you are under anesthesia. It is encouraging that fathers are often allowed to be present for C-Sections. It should be no different for other surgeries.
Misty
Misty, this legal case does not lead to the conclusion that a family member must be in the operating room. What it leads to is that every patient should have a family member present when the patient is provided information about the surgery by the surgeon and reads with the patient that the written document states precisely what the surgeon had spoken to confirm that the document is consistent with the doctor's words before the document is signed. Any differences between what is spoken and what is written must be challenged and corrected to the desires of the patient for true "informed consent" be legally acceptable.
It is the responsibility of the patient, with the help of family or another, to be sure that a signed consent is informed. ..Maurice.
Here's a link to a paper on female corrections officers and male privacy. It is a very interesting read - dry though it is. It highlights actual case law where male prisoners have challenged the rights of female guards to observe them nude and conduct/observe strip/cavity searches. There is so much overlap to healthcare it is worth a read. Note the male prisoners were granted the right to not have their genitals groped by a female, but modesty from observation was excluded. Female prisoners were quickly granted special considerations as regards male guard observation/searches. Double standards like this really strike home when written as legal decisions. It seem the rights of women to employment (jails/sports locker rooms/means clubs etc.) legally supersede the rights of the male individual's right to privacy; but not the other way around. I realize that prisoners have surrendered some of their rights. Just what exactly they surrender is judged by possession of a vagina.
Kevin
http://scholarship.law.marquette.edu/cgi/viewcontent.cgi?article=1513&context=mulr
Dr. B,
"It is the responsibility of the patient, with the help of family or another, to be sure that a signed consent is informed."
Really?
Every policy and court decision I have read relative to informed consent clearly state that it is the responsibility of the physician performing the procedure to insure that an informed consent is obtained.
Further, courts have held that coercing or intimidating a patient in any way to sign the consent, or withholding relevant information invalidates the consent.
My advice to any patient is to ignore any and all verbal assurances the medical staff may give regarding your wishes, and insist that any concerns or limitations to your consent be included on the consent form in writing before you will sign it.
There's an old saying in medicine "If it isn't written down, it didn't happen." Any verbal commitments they make are worthless....make sure you get it in writing.
Hex
If you want to appreciate the dynamics in prison and the problems female guards contribute
go to yahoo and do a search Prison of passion: relationship between female officers, inmates.
Watch the video, abcnewsgo.com
PT
Hex, unfortunately it seems that in the current state of the medical system it is only the patient which needs to be "informed" as part of the consent process. The legal burden is on the patient to either consent or dissent given the options presented by the physician. It is the patient's signature on the consent form which makes the anticipated procedure legal. However, the "informed" should not be a "one way street" and so it is up to the patient (hopefully assisted along with a family member) to respond to the advice and details presented by the physician with the patient's own questions and views so that the physician therefore becomes "informed" which might lead to a modification of the permission which the patient signs. This is why my "speak up" advice to patients on this thread is so important. But the critical advice is to "speak up" before signing and before the clinical procedure is begun.
Since "be informed" is a necessity also of the physician, the patient reading what the physician has written for consent and then "speaking up" to attempt to make changes should be all part of the informed consent process.
So, Hex, in conclusion, when you write "it is the responsibility of the physician performing the procedure to insure that an informed consent is obtained." I would disagree since physicians have no "mind-reading" capacity and thus there is that responsibility of the patient to also do the "informing". ..Maurice.
Kevin,
The dirty little secret is that the double standard to discriminate (and abuse) males is taught in the formal medical curriculum....
"Genitalia: Boys always; girls when indicated (e.g. all sexually active girls and those with any symptomatology) should have an external inspection and an internal pelvic examination. Desirably, all adolescent girls should have pelvic examination at some time as a matter of routine." Hofmann, A and Greydanus, DE; Adolescent Medicine, 2nd Edition, 1989.
...and everyone wonders why men avoid healthcare.
-- Banterings
Way to go RobH. What you're doing helps all of us.
Was just watching a youtube video on the training/selection program for Australian SAS - special forces. What's the first thing they are subjected to? After giving them their equipment they are made to strip nude then have female soldiers walk through/talk to them etc. To mess with their minds - see what they are made of. Everyone except healthcare realizes how demeaning cross gender forced nudity is.
Kevin
I was reading this post on a blog written by a mother who is a physician (*** WARNING *** It is disturbing and may contain triggers): When is a person old enough to refuse treatment?
It is a prime example of the lack of common sense that healthcare providers have in how these procedures are viewed by society and how patients experience them. Many patients who have undergone this procedure comment on how it has affected their lives. Despite evidence (presented by one commenter) that the procedure is usually not necessary or can be safely preformed with sedation, these procedures are routine and sedation is not used.
As the writer of the article said:
It is such a shame when health care practitioners get desensitized about how serious some of these seemingly routine procedures actually are to patients.
The one comment made by Deine sums up society's views:
This is insanity. Powerful gang-raping vulnerable, “for her own good”. I so hope that after priests and media+politicians, doctors will be the next to be dragged through the dirt for child abuse.
The ACA, EMR, etc. are all means of reigning in healthcare providers. Government realizes that power has corrupted the industry. These are attempts to remove the power.
Despite guidelines that say pelvic exams are not required for oral contraceptives, many physicians still require PEs. So California solved the problem by removing the power; read California Women Can Soon Go Right To The Pharmacist For Birth Control.
Healthcare needs to be put on a short leash. Just like with the clergy sex abuse, healthcare needs to have the genital abuse of patients cleaned up. Maybe in the next 150 years, if providers earn the trust of society back, they can be let off their leash.
--Banterings
A. Banterings,
Thanks for all your contributions to this blog thread.
BJTNT
P.S. Again, thank you Dr. B. for continuing this thread.
I am sure that everyone has heard about the story: Cancer doctor sentenced to 45 years for 'horrific' fraud.
He pumped poisonous chemotherapy drugs into patients for years, telling them they had cancer. They didn't.
He over-treated terminal cancer patients rather than letting them die peacefully. When he could profit from it, he also under-treated actual cancer patients.
I wonder how much of this was due to physicians and other providers being taught to objectify patients? Was this the same conditioning that allowed Nazi physicians do what they did?
But that is NOT the most disturbing part of the story, this is:
Borman, who sentenced Fata to 45 years total on multiple counts of health care fraud, money laundering and conspiracy to pay and receive kickbacks, said the crimes called for "a very significant sentence for very, very terrible conduct."
U.S. Attorney Barbara McQuade's prosecutors asked for 175 years, the maximum.
The problem is that he was NEVER charged with ASSAULT or BATTERY. If there was NO money involved, he would be going FREE!
This is an extreme example giving providers a pass for actions that anyone else would face assault, battery, sexual assault, or sexual battery prosecution for. If we are going to allow physicians to do things that no one else in society can do, then they need to be held to a HIGHER standard, NOT a lower standard.
During his sentencing, he attributed his actions to a quest for power and greed.
"I misused my talents, yes, and permitted this sin to enter me because of power and greed," Fata said. "My quest for power is self-destructive."
As I have stated before, "Power corrupts..."
--Banterings
Another thing that I find troubling is the lack of outcry from healthcare providers about this atrocity. I have compared it to how the (dare I say) "normal" Muslims do NOT speak up against radical Islam. How could the rest of the world not have the perception that they support it?
"The only thing necessary for the triumph of evil is for good men to do nothing." - Edmund Burke
By the rest of healthcare not speaking up, they are in effect doing nothing.
I do give credit to the physician who treated Monica Flagg and the doctor's office manager, George Karadsheh, who filed a whistle blower lawsuit.
Healthcare providers are either with patients, or against patients. This statement is qualified by the original quote made by Jesus of Nazareth:
"Whoever is not with me is against me, and whoever does not gather with me scatters" (Matthew 12:30)
When it comes to patient safety (patient dignity IS a part of patient safety; it is the safety of the patient's mental well being and protection from harms such as PTSD), there is NO neutral ground.
--Banterings
BJTNT, please contact me directly. I have some questions for you about previos comments you made. You can contact me from my Blogger profile.
I posted, with Banterings' permission, what he wrote yesterday here onto an ethics listserv to which I subscribe to see what responses I would get from ethicists, physicians and lawyers there. I followed Banerings comment with my own:
The above comment is from a visitor to my bioethics blog thread on Patient Modesty. It is true that this doctor is going to spend decades in prison not because of the harm he caused to his patients but for the fact that he defrauded the government. Monetary loss trumps inhumane acts.
Notice how the prosecution of this case suggests how those psychologists who participated to varying degrees in the torture of prisoners will be prosecuted, if they will be, for collusion with the DOD and CIA but not for the harm and injury from torture which their participation supported. At least, that's what I get from reading the news of the APA involvement.
Is it true that in law, crimes involving money will trump inhumanity with regard to obtaining a winning prosecution? Seems like it, based on these recent stories of ethics and malpractice. ..Maurice.
Since Maurice has posted this on an ethics listserv, I am going to enlighten all here why Dr. Fata was prosecuted for the fraud and NOT for assault and battery. The goal of our criminal (legal) system is to maintain order and control in society. It is NOT about the victims (they are collateral damage). The civil (legal) system is where victims are made whole (as much as possible).
If our criminal system was about the victim, then proceeds that are confiscated from criminals (think drug dealers' money, houses, cars, etc) and fines would be distributed to victims instead of going to law enforcement agencies' budgets. It makes good public relations to let the victims or their families testify at sentencing, but that does little to help a person who has suffered a significant monetary loss.
When it comes to healthcare, especially with doctors and nurses, government and society have made a deal with the devil. They allow providers to do things that would send anyone else to prison for years and years in return for the magic and sacred knowledge they possess. The problem is that those that wish to abuse and assail patients can pretty much do it with impunity.
If you look at those convicted for crimes against patients, they have to involve hundreds of victims or occur for decades. Indeed the message is moderation in these indulgences. As Maurice points out, money trumps Human Rights. Thus is the case of Dr. Twana Sparks, who was the only ENT at Gila Regional Medical Center near Silver City, New Mexico and made them millions of dollars.
--Banterings
For the ongoing story of how Fata was found out, go to the Detroit News. ..Maurice.
The comments made by Dr Tiffany Ingham during a patient's colonoscopy were every bit as damaging as racism. She didn't
like his gender. This case parallels the Dr Sparks case in many regards and in the end Dr Ingham fled the state. She ran like
a coward.
PT
Banterings,
The lack of outcry is normal. I am sure more than one physician/nurse had previous suspicions about Fata's practice and adopted a 'see no evil' attitude. The problems inherent with self-policing as is done within professional associations is always at play. Throwing a peer under the bus is career suicide as the whistle blower in this case readily admits - but thankfully he is more concerned about the 'do no harm' part than the ass-saving part. When a member is outed as a slime-ball the program is to quietly wait for the smell to dissipate - like it never happened.
We all have our issues. My problem with any prof. association arises that when donning the uniform apparently all the human frailties are suddenly stripped away. Outwardly a mask is worn at work - inside lurks the 'real' person. Beneath the mask as humans we feel sexual attraction, hatred, jealousy...you name it. We all know this but for convenience's sake we play along. My cousin is one of the top plastic surgeons in my country (self-admittedly...hah); but I know him well and he was cruel and borderline sadistic to me as a kid. I am sure his clients see him as a capable, professional surgeon; I would see beneath the veil to the person who continually taunted/bullied me.
Prior to my recent surg. the nurse taking my pre-op blood pressure had to get a new cuff as I am muscular and it was too small. She was young - blushed and giggled when it didn't fit. Both of us knew what was going on - but she was 'professional' in her scrubs. If asked about it she would deny the 'emotional' side of the interaction. And no Banterings; I did not ask for her number.
Kevin
Kevin et al,
Previously I have focused on (basically) how physicians and other providers objectify and harm (psychologically) patients while being unaware that they are doing so. There is another part to my research that The Stanford Prison Experiment bridges into. That addresses the issues such self-policingand, AND why they have guidelines based on ritual and not science (annual pelvic exam) and are designed to subjugate patients to a subservient role (PPC).
BJTNT in previous posts referred to the problem with healthcare as PPC; power, control, and convenience.
I am referring to a real incident at an American high school in 1967 that shows the horror of mob psychology and group pressure. I am referring to "The Third Wave;" in 1981 it was made in to an ABC after school special titled "The Wave," and remade in 2008, titled "Die Welle" (the original German title).
The Third Wave was an experimental social movement created by high school history teacher Ron Jones to explain how the German populace could accept the actions of the Nazi regime during the Second World War. While he taught his students about Nazi Germany during his "Contemporary World History" class, Jones found it difficult to explain how the German people could accept the actions of the Nazis, and decided to create a social movement as a demonstration of the appeal of fascism. Over the course of five days, Jones conducted a series of exercises in his classroom emphasizing discipline and community, intended to model certain characteristics of the Nazi movement. As the movement grew outside his class and began to number in the hundreds, Jones began to feel that the movement had spiraled out of control. He convinced the students to attend a rally where he claimed the announcement of a Third Wave presidential candidate would be televised. Upon their arrival, the students were presented with a blank channel and told his students of the true nature of the movement as an experiment in fascism, presenting the students with a short film discussing the actions of Nazi Germany.
...The experiment took place at Cubberley High School in Palo Alto, California, during the first week of April 1967. Jones, finding himself unable to explain to his students how the German population could have claimed ignorance of the extermination of the Jewish people, decided to demonstrate it to them instead. Jones started a movement called "The Third Wave" and told his students that the movement aimed to eliminate democracy. The idea that democracy emphasizes individuality was considered as a drawback of democracy, and Jones emphasized this main point of the movement in its motto: "Strength through discipline, strength through community, strength through action, strength through pride.
Here is a link to the video "The Wave" (administered by Israeli Educational Television).
More to come on this....
--Banterings
I am going to post this and I am probably going to get a lot of negative feedback about this but here goes:
Healthcare has proven again and again that they can not be trusted.
A new report finds that the American Psychological Association gave federal officials what they wanted when it came to torture: an ethical policy that aligned with government interrogation techniques. The APA has issued an apology and said it will ban psychologists from participating directly in interrogations.
US psychology group colluded with govt 'torture' program: report
Washington (AFP) - The US's top psychology association colluded with the Pentagon and the CIA to devise ethical guidelines to support post-9/11 interrogation techniques that have since been labeled as torture, a report said Friday.
Some members of the American Psychological Association (APA), including senior staff, sought to "curry favor" with defense officials, according to the 542-page probe commissioned by APA's board.
These individuals issued an ethics policy that aligned with government interrogation techniques after the September 11 2001 terror attacks, such as waterboarding and sleep deprivation.
The association colluded with several government agencies, including the Pentagon and the Central Intelligence Agency (CIA), to devise ethical guidelines for the interrogation program under former president George W. Bush, according to the review.
The government agencies "purportedly wanted permissive ethical guidelines so that their psychologists could continue to participate in harsh and abusive interrogation techniques being used by these agencies after the September 11 attacks," the report said.
"APA's principal motive in doing so was to align APA and curry favor with DoD (Department of Defense). There were two other important motives: to create a good public-relations response, and to keep the growth of psychology unrestrained in this area."
The findings come after Democrats on the US Senate Intelligence Committee in December released a damning report detailing brutal and previously unknown interrogation techniques, including beatings and rectal rehydration, used by the CIA on Al-Qaeda suspects post 9/11.
APA Apologizes for “Deeply Disturbing” Findings and Organizational Failures; Announces Initial Policy and Procedural Actions to Correct Shortcomings
The APA board apologizes, recommends: participate in human rights activities, create committees, and maybe sing Kumbaya...
How about bringing state and federal authorities in to investigate criminal wrong doing?
--Banterings
I found this on the Canadian Women's Health Network: Getting Through Medical Examinations - A Resource for Women Survivors of Abuse and Their Health Care Providers
I believe this is pertinent to the ongoing discussion because it shows how much providers do NOT know and how they rely too much on "medical voodoo ritual."
A link from this page lead me here: Suggestions for Physicians and Primary Care Nurses
Under #5. Respect boundaries, it states:
Ask patients beforehand if they would mind somebody in training being involved in the examination or procedure. Include a description of the sex and status of the person, and ask this question ahead of time without the person standing there, so patients are given the option, without having to say in front of somebody, "No I don't want you there."
To reenforce my statement about what they do NOT know and "medical voodoo ritual," look at this 2004 publication:
Post-traumatic Stress Disorder Within a Primary Care Setting: Effectively and Sensitively Responding to Sexual Trauma Survivors
(Here it is linked on PubMed (NIH).)
--Banterings
I mentioned (above) the 1967 social experiment "The Third Wave." Where Milligram's experiments were with individuals, The Stanford Prison Experiment was a bridge encompassing both individuals and organizations.
I linked to the ABC After School Special that was made about it. I believe that this shows how an organization adopts an "us and them" view and creates policies that consolidate and protect the organization's power while subjugating the "them."
This is where healthcare has come up with beliefs, customs, norms, mores, etc. that are abusive to patients, scientifically unfounded, and defy common sense. One such example is [sic.] the AAP's statements of "normalizing" and showing the "routine" nature of the genital exam despite the fact that research (which I referenced previously) concludes that a genital exam is "never routine" (for the patient at least).
Perhaps the biggest fallacy that healthcare promotes is that just because one becomes a provider (and has a magic white coat), then they have the RIGHT to see ANY patient's (person's) body (naked), AND the patient (person) should have NO objections and comply. This is seen in the statement, "I am a professional."
***WARNING*** This may seem "pornographic," but it is actually [more] ABSURD. It is an extreme example to show the absurdity of the statement "I am a professional."
Let us extrapolate this to another profession. I am a porn star. I have been trained in all the safe sex practices of the CDC, California Department of Health, and Cal/OSH. I have had sex wit so many people so many times, that I do not experience sexual pleasure, it is just a JOB. "I am a professional."
So no healthcare provider should object to me touching their genitals...
Let's take this down a notch. I am a camera man in the porn film/video industry... "I am a professional." So no healthcare provider or any member of society should object to me looking at their genitals.
Let's extrapolate some more. Theoretically most (almost all) members of society can be educated, trained, and become a healthcare provider (not just physicians and nurses). Do you think that most people (if not everybody) would accept the notion that potentially any member of society if given a magical white coat can see their (naked) body and touch their genitals AND they should be comfortable with this?
Disclaimer: I know that there are other factors that come in to play with the above examples such as "being therapeutic" versus sexual pleasure. But I argue that these are the same, there is a benefit to both parties. Again, it is more to illustrate the absurdity of the "I am a professional" statement.
Just look at how people date/choose a mate. First there is a preference or perhaps NO preference (bisexual) in gender. There are other factors as well. Think of the "creepy" person would NEVER date due to that (perceived) "ick" factor. What about the patient's perception of some providers being "creepy?" What about the cultural sensitivity papers put out by provider groups about female Muslim and Hmong patients? Just as religion dictates gender norms in healthcare, so it dictates in marriage (sexual relations), thus validating my examples.
The policy should be, "I am a professional, may I have your permission to participate in YOUR healthcare?" "If not, we will find someone that you are comfortable with." But as "The Third Wave" illustrates, organizations are self-serving and protect their status and existence with power, control, and convenience (PCC).
--Banterings
Banterings,
That statement of some form of "We're all professionals here", often used by medical staff when patients express modesty or object to exposure, and typically rendered with an attitude of disdain or superiority, is one of my pet peeves.
A few years back I came up with the response, delivered calmly and politely: "So are all the hookers down on XXX street (well known local red light district), and I have absolutely no intention of being exposed to them either."
I've only had to use it a couple times, but it pretty much left them speechless, which was my intention.
Hex
Hex, by the way, I have never used that expression to a patient nor have I used that argument in my mind as an excuse to my patient. Remember, elements of medical professionalism are things that physicians must follow, like me, to continue to be considered a professional physician by those in the profession.. IT HAS NOTHING TO DO WITH SETTING ANY CRITERIA WHICH THE PATIENT HAS TO FOLLOW SUCH AS ACKNOWLEDGING THAT THEIR DOCTOR IS A PROFESSIONAL. ..Maurice.
Dr.B,
I've never had a physician say that either. Typically it's been someone in the support staff (RN, MA, clerk, etc,), and in all fairness, it hasn't happened all that often. It's pure supposition on my part, but I suspect that some of these folks let their position go to their head and assume they have some form of authority over the patients, which they do not.
My approach is to always treat another with respect until they prove to me that they don't deserve it. I will politely but firmly explain my position and what I will and will not allow, and whether or not they agree, I expect them to respect my right to make my own decisions. That said, if they become pushy, argumentative or snarky (as in "we're all professionals here") I will not tolerate it and will shut them down.
Hex
Hex, I can see why your comment would stop a nurse dead in their tracks - comparing any woman to a prostitute (as in that famous exchange between Bernard Shaw and a woman at a party...'would you sleep with me for a million dollars') would be a game-changer. Wouldn't want her giving me meds after though....
"We're all professionals". To me all that means is you receive remuneration for services rendered. As with any prof assn my own requires me to exhibit morals/ethics etc above reproach - in my personal as well as professional life. A way of becoming pillars of the community; respected. Of course these are social constructs largely based on Christian beliefs/morals. What if we were expected to be promiscuous, or have a 'boy' like Alexander the Great?
Any workplace with a high % female is inherently problematic. Workplace bullying etc. creates a stressful environment - how can we expect someone to function compassionately when they are under duress? As pt's we don't realize what is going on behind the scenes - we just know how we are treated. When stressed we all become self-centered - a survival mechanism - empathy is nearly impossible. Physicians making rounds may get a glimpse of this behaviour but don't spend hours at the nurses stn. observing catty backstabbing/ostracizing behaviour. Thought women were nurturing?
http://www.marieclaire.com/culture/news/a14211/mean-girls-of-the-er/
This article gives a little glimpse of how dysfunctional some health environments are. Probably more visible in the ER or ICU due the immediacy of life/death.
I had to hire outside nursing staff to come into the hosp to feed a relative - the semi-conscious rel needed to be roused in order to eat. The nurses would bring in trays of food and then take them away untouched. Watching someone slowly starve to death is not pretty. She had also not been bathed in a long time - the dead skin rolled up on her back when I found a compassionate nurse (a floater) to help bathe her and wash her hair. Meanwhile the nurses would always be found at the stn gossiping and sitting. She went into resp arrest after a blood transfusion - I am convinced she was given a unit of blood not her type. Funny - the bag couldn't be found afterwards. I am sure though if the nurses were interviewed they would say how hard they work and how stressful it is. If you hate your job even the smallest of tasks become difficult. If you love your job its easy.
Kevin
Would nurses be offended by the comment " we're all professionals here" should their mammographer be male? Hypothetically
speaking of course as there are no male mammographers.
Kevin, excellent commentary as I have seen this behavior not only by female nurses, but rather most females in the health care
industry. Most health care environments are toxic as those who do the backstabbing are the ones who are incompetent. Their
behavior is a smokescreen to divert the attention from their own incompetence.
PT
I've posted a comm3ent and it's been deleted, hope that
doesn't happen again.
Why is the onus of getting consent on the patient rather
than the doctor??? A person that might even be on an emer-
gency situation has every right to believe the information
being provided is accurate, and not the false reassurances
that all too often patients do hear to facilitate surgery
or some other treatment, with medicines or otherwise.
Just to let my visitors here know what I am doing these summer days between my teaching responsibilities: I am trying to spread the word about patient dignity and the need to look at the behavior of the medical system and consider changes. For example, I presented a 55 word story to a medical ethics listserv and an medical educators listserv which demonstrated the response to the "hidden curriculum" which causes a physician to switch from attention to his patient to the goal of maintaining punctuality. The story is called "Courage to Preserve Punctuality" and the text is limited to the limited 55 words:
The patient kept talking.
Dr. Smith recalled how to hurry the patient out the office so he could move to the next. He learned that from his attending physician as a clerkship student. "Since punctuality is important to be a medical professional, when behind schedule, do this:"
Courageously, he arose, wordlessly
opening the closed door.
I see that most of my commentators here write many, many, many more words to make a point than simply 55. But there is merit in telling a story and making a point in only 55 words. The author has to think out each word and be confident that it directly and understandably contributes to the point which is attempting to be expressed.
For 28 years the San Luis Obispo California New Times newspaper has sponsored a contest to select for publication a number of stories written by their readers.
The rules state that the stories must make some point, should have a beginning, a middle and a conclusion, the latter perhaps unexpected but defining the story. But what poses a challenge to the authors of the stories is that each story must be only 55 words in length, the title words not counting.
So I challenge my visitors here to write a 55 words story leading to a point, a conclusion, perhaps a bit unexpected. Here are the rules (as per the New Times criteria)
Hyphenated words can't count as single words. For example, "blue-green dress" is three words, not two. Exceptions to this are any words that don't become two complete free-standing words when the hyphen is removed, like "re-entry."
Also, please note that your story's title isn't included in the word count. But remember that it can't be more than seven words long.
Contractions count as single words, so if you're really seeking word economy (as you should be), keep this in mind. If you write, "He will jump," it's three words. But if you write, "He'll jump," it's only two. Very economical. By the same token, any contraction that's a shortened form of a word is also counted as a full word. Like using "'em" for "them."
An initial also counts as a word (L.L. Bean, e.e. cummings, etc.) since it's basically an abbreviation of a full word. The only exception is when it's part of an acronym like MGM, NASA, or IBM. The reasoning here is that the wide use of these acronyms has in effect made them into single words.
Remember that numbers count as words, too, expressed as either numerals (8, 28, 500, or 1984), or as words (eight, twenty-eight, etc.). But keep in mind our hyphenated-word rule. "Twenty-eight" is two words when written out, but only one when expressed as 28. Don't cheat yourself out of an extra word that you may need.
Any punctuation is allowed, and no punctuation marks count as words, so don't worry about being miserly with them if they work to some effect.
It's a challenge. Try it. ..Maurice.
Here is another 55 word story I wrote and presented to the listservs as an example of physician's inattention to patient consent.
Title: Consequence of Unethics
The hospital ethicist scratched his head in disbelief. What was the physician thinking about writing a DNR order without communicating with the competent patient? Two feet away from Dr. Jones, the ethicist looked directly into his eyes. "You have done something unethical!" With that exclamation, the ethicist rose up from his hospital bed and arrested.
..Maurice.
I just now wrote a 55 word story titled "A Matter of Definitions"
"Miss Jones is here to help me with the cystoscopy" the urologist told Robert as the
procedure was about to start. Miss Jones walked over to the table touching Robert's hand. "I am a qualified helper", she mumbled. Robert appeared anxious and unsatisfied.
Robert grabbed her hand to get up, stating "And I'm a sexist".
I wrote this story with the purpose of starting a discussion regarding definitions. Is patient physical modesty a matter of "sexism", that one gender is discriminating over the other? I don't think that this question has been previously fully talked about. ..Maurice.
Well if it is (sexism), what's good for the gander is clearly good for the goose!
Ed
But, Ed, is sexism a major factor behind the patient modesty issue? For example, when one gender states to the other gender "But I am a professional" or in the case of my 55 word story "I am a qualified helper", is this offering rejected purely on the argument that this statement coming from one of the opposite sex is untrue and therefore unacceptable...all on the basis of a view that those of the opposite sex are unable to perform their professional responsibilities while holding their sexual desire in check? Or is physical modesty issues unrelated to sexist views and appear irrespective of the gender of those participating in the examination or procedure? ..Maurice.
What is missed here is that it has nothing to do with sexism or anything else. What healthcare refuses to acknowledge that the patient is ultimately in control of their own body and the healthcare situation. The physician has a fiduciary duty to the patient even at a (financial) loss to the physician.
Saying that the patient's wishes "are not (economically) feasible," the physician does not feel "thorough in the exam," what the patient wants "goes against guidelines," etc., are all violations of the physician's fiduciary duty to the patient.
Sexism (gender discrimination) are the legal reasons to institute civil and criminal actions against all providers involved.
Healthcare has demonstrated over the last 150 years that it cannot be trusted. The most recent being the American Psychological Association apology for colluding with the federal government in torture of prisoners.
Does anyone believe that they would have apologized if the report was never made public?
I take the view of patients and healthcare as that of the people and government in the movie "V for Vendetta:"
“People shouldn't be afraid of their government. Governments should be afraid of their people.” ― Alan Moore, V for Vendetta
When we have gone 150 years without healthcare committing such egregious abuses to patients, failing to recognize the obvious, and treating patients with true human dignity, not what they feel they can afford, then healthcare can may be able to be trusted again.
― Banterings
Maurice,
I take your challenge!
Title: We reap what we sow...
The female patient vehemently objected to the all-male ED staff.
In the small rural hospital they were the only ones available.
"We will try to preserve your dignity as much as possible, but your consent isn't required in an emergency;" her clothes were cut off.
"We are professionals, like when you were our pediatrician."
― Banterings
"But, Ed, is sexism a major factor behind the patient modesty issue?"
Absolutely not! My personal opinion (for what that's worth) is there are very few folks who believe someone is incapable of performing any job today simply because of their gender.
"Or is physical modesty issues unrelated to sexist views and appear irrespective of the gender of those participating in the examination or procedure?"
IMO, for 99.9% of patients, modesty issues are totally unrelated to sexist views. The degree of appearance is obviously unique to each patient and the gender of the medical staff.
Ed
Maurice,
Feel free to present my 55 word story to the listserv.
― Banterings
Banterings, your story, in 55 words (as per the criteria) is EXCELLENT as expressing the issue of expressing "professionality" as an excuse for the ED staff's actions. However, I should point out that any patient in the ED as a medical emergency who is sufficiently aware of the gender composition of the ED staff and can object "vehemently" should be at that point be considered sufficiently competent (and particularly as a physician herself) to provide consent or dissent in response to how she will be treated. The exceptions, in an emergency, would be a patient who is unconscious or demonstrates incapacity to understand what is happening or about to happen and immediate management is required then the doctors can proceed without consent in order to stabilize the patient. What I am getting at is that even in an emergency, if there is time to inform the patient and the patient has the capacity to understand then patient consent is necessary to proceed. ..Maurice.
Brian Persaud who walked into the ED at New York Presbyterian was not afforded the luxury of informed consent (See:" Jury Says Forced Rectal Exam of Patient Not Assault").
Just as your story with the living will, physicians can easily circumvent patient wishes. Perhaps in this situation there was fear of altered mental state and a tox screen was not complete yet so they treated without the need for consent.
That is the biggest problem in healthcare, the patient's control of their own body has to be absolute. Providers can NOT be allowed a pass on saying they "felt it necessary."
I have seen on WebMD articles by providers who coerced patients into genital exams.
(Tell me how this is not abusive and coercive. Not it is from 2013, long after USPSTF and NCCA done away with the genital exam requirement.)
The whole healthcare system continues to prove they are not trustworthy. Either you protect patients, or you don't. Right now, patients are not protected.
― Banterings
Continuing with a discussion of the "bad apples" in the medical profession and how the profession and the victims should respond, I, with permission, have copied the comments of a "former critical care nurse, current nurse educator and scientist, and an ethicist" whom I will identify as "Sarah" who yesterday wrote the following to the bioethics listserv to which I subscribe. Doesn't what she write present the appropriate proportionality of the problem and also the approach for remediation? ..Maurice.
The cover of the New York magazine
featuring pictures of the 35 women (and an empty chair for those who remain
unnamed) who accuse Bill Crosby of a pattern of sexual assault is powerful. As
I read more about this case, it is sobering to hear over and over about how many
of these women (and countless others) reported their abuse but their claims were
dismissed. Now the women are told the statute of limitations has expired.
I again recommend Jon Krakauer’s new book, Missoula: Rape and the Justice System
in a College Town if you would like to get a sense of why we need to change the
way we investigate rape. In a nutshell, it is not about investigating the
woman to find a pattern of poor decisions. The approach to finding rapists is
looking for patterns in the accused.
I think there is a parallel to health care ethics. For example, we know that
patients file complaints about care providers, that clinicians make errors, and
that clinicians can behave inappropriately. But rather than these cases being
distributed as 2-3 occurrences across many, many clinicians, the vast majority
tend to be accounted for by a handful of clinicians who are repeat offenders.
These problem clinicians account for the majority of malpractice cases, patient
complaints, and inappropriate workplace behavior.
When we teach professional
ethics, while we need to focus on individual behavior, most of our students will
do well pointed in the right direction and given the skills to enact ethical and
professional values. What we need to give them are the skills for handling
colleagues who are not behaving ethically. This is where the problem lies.
To return to the rape analogy, education in colleges has shifted away from
telling young men “don’t rape” — the vast majority of young men would never
consider such despicable behavior. Instead, education has shifted to teaching
young men to “stop rape when you think it is about to happen”. This is a very
different moral stance. Rather than saying to the young man/clinician, "you
are responsible for your own ethical behavior”, it says “you are responsible for
intervening when you see an ethical harm occurring.” I would argue this is a
communitarian stance that makes the young woman/patient an ethical equal, rather
than a disembodied other.
Feel free to post this on listserv as a response:
It is not a few bad apples, it is an entire system. Since Peter Ubel's 2003 study (Don't ask, don't tell: in AJOG) and all the media attention of exams under anesthesia, you would think the practice had stopped. Not to mention all providers assuring patients that they are treated with dignity...
Yet in 2012 we are still having this debate: Fox News, Pelvic exams while under anesthesia sparks debate.
Where is the outcry from thew medical community? That is because they see nothing wrong with it. What is needed are long jail sentences for all involved in those still occurring.
Then we need to go back and investigate back to 2003 and prosecute those perpetrators too.
Let me prove what I said: Nobody in healthcare would refer to the pelvic exams on anesthetized women in 2012 as a criminal act and those teachers and students as criminals. After Peter Ubel's paper, this is nothing less than medical rape.
― Banterings
A recent headline made by one of Presidential candidate Donald Trump's people gives a good comparison to the point that I just made. The subject is marital rape.
Ivana Trump’s claim from 1989 — which she later dismissed — came in a deposition that was part of their divorce case in the early ’90s, and was detailed in the 1993 book Lost Tycoon: The Many Lives of Donald J. Trump, by reporter Harry Hurt III. The deposition detailed that she had been raped by her husband while he was in a fit of rage after a painful surgical procedure to reduce the appearance of his baldness — by a plastic surgeon that she recommended.
When asked for comment on this incident by the Daily Beast, and after vehemently disputing the claim and threatening the reporter, the special counsel at the Trump Organization, Michael Cohen, said, “And, of course, understand that by the very definition, you can’t rape your spouse. It is true. You cannot rape your spouse. And there’s very clear case law.” (Source: Yahoo News)
So I ask, how many physicians, teachers, medical students, etc. believe that genital procedures when coerced (think hormonal birth control or to play football), without consent (anesthetized pelvic exams), or against the the patient's wishes/preferences (gender choice) ARE not RAPE?
How many believe at worse these are only assault or battery and not sexual assault, sexual battery, or rape?
How many feel patients are obligated by the nature of being at a teaching hospital to allow student participation?
How many do NOT explicitly ask permission OR tell patients they CAN refuse?
That is the same mentality that says I do not need permission from my wife to have sex, there is implied consent.
We all know these things are taught and what really happens. Healthcare is very much like Islam: the radical clerics (providers) deny the human dignity of other members (patients) while the moderate clerics say nothing and do not condemn their actions OR report radicals (the white wall).
Providers deny this or paint those of us who speak up as mentally disturbed. In all truth THEY are the ones mentally disturbed with some form of sociopathy as not to realize something so blatantly obvious.
For 9 years people spoke of the obvious here. Why did it take the presentation of scientific research before it was believed? That is a serious flaw in the thinking of providers. How could this system with so many (supposedly) compassionate people think that pelvic exams on anesthetized women are acceptable (and some still do)?
Why do providers NOT care?
― Banterings
The more I hear "implied consent" used as an excuse, the more I think it should be acceptable as an excuse in everyday life, and not limited to the medical worlds use...
Just think... you have friends over for drinks, and a lady friend crashes on your couch instead of driving, you can claim assumed consent because she's spending the night at your place and force yourself on her. Call some friends to come over and take turns with her, since that's no different then med students being filed in for a hospital gang rape.
Someone gets to close to you, just punch them. There was implied consent by them getting within striking range.
Something you like in a store? is it chained down or locked up? then that's just an invitation to take it.
A door to someones home not locked? sounds like consent to let yourself in to me...
Feel free to explain the difference to me, since you CANNOT claim it's in the patients best interest to have their unconscious body as a teaching tool without permission... unless you're going to claim that it's a common occurrence that the doctor missed something, but the 3rd ... 7th .... or even 15th+ student caught it.
(and no... signing the waiver doesn't count, since people brought in for emergencies don't usually sign them)
Jason K
Banterings
Four states now by law require consent for pelvic
exams on women under anesthesia. Considering the
behavior of Dr. Sparks with her performing genital
exams on her male patients one would think New
Mexico would have, should have passed such a law
to protect male patients. Or is that just sexist not to?
PT
Banterings:
The article about the man being forced to have a rectal exam against his will is very sad. Why in the world is a rectal exam necessary for a head injury? The rectum is not in the head. It is scary to think about what can happen to patients in ER. I think it is odd that a female doctor claimed that she did not do a rectal exam on him even though she put her finger in his rectum.
I think it is wrong when a doctor demands that a male teenage athlete must submit to a genital / hernia exam before he can be cleared for sports physicals. As you have seen in Dr. Sherman’s article about sports physicals, hernia exam is not necessary to ensure safety of playing sports. A boy can easily examine himself for a hernia and if he has any symptoms or lumps, he can go to the doctor to have them checked out. It bothers me when doctors hold patients hostage by threatening them that they cannot play sports if they cannot submit to a hernia exam or refusing to prescribe birth control pills for a woman unless she has pap smear / pelvic.
One of the biggest goals of Medical Patient Modesty is to encourage patients to stand up for their rights to maximum amount of modesty and same gender intimate care if they wish. It has been a joy to see some empowered patients who got their wishes successfully.
PT: I agree with you that New Mexico should have passed a law to require consent for genital exams on male patients. In fact, I wish it was applicable in all 50 states. Male patients deserve the same protection as female patients.
Misty
I do this in 2 parts:
Misty,
In some instances a spinal cord injury affects the tone of the rectal muscles. It had been thought that this was just another "symptom" to confirm or rule out a spinal cord/vertebrae injury. it is also to look for the presence of "red" (fresh) blood that may indicate internal bleeding. Of course this is just more Voodoo medicine.
After the Brian Persaud case, a scientific review found that the rectal exam in trauma very rarely changes the diagnosis or adds any additional information. What they did find is that the exam itself is very humiliating and traumatic for the patient so it was dropped from guidelines in the ATLS (Advanced Trauma Life Support) manual.
What drove a review of the procedure? Lawsuits and public opinion. What it came down to was ritual, it was not known if it was beneficial or not. The looming threat of lawsuits caused the review with the admission that this added nothing.
PT,
It is sad that only 4 states protect WOMEN from PELVIC EXAMS while under anesthesia, rectal exams on men and women are free game! That is the reason this continues to happen. (See the 2012 article by Shawn Barnes.) It is my opinion that med schools are producing sociopaths. There is no other way to explain how students can go along with these practices.
I also think that there is a greater aspect to the physician suicide problem that is not acknowledged (if it is even known); The conflict with what they were taught was acceptable comes into conflict with what they know to be acceptable. For instance pelvic exams on anesthetized women. How can anyone justify this? Then as a physician you look in the mirror and realize that what you had done is paramount to rape (especially after Peter Ubel's original article).
What about the OR technician, nurses, or physicians, that worked with Twana Sparks for years watching her abuse patients? How do they feel when they look in the mirror? What about the the defense witnesses (physicians) that defense witnesses (physicians) that defended Dr. William Ayres?
You are either a sociopath with no conscience so it doesn't bother you, you self medicate with drugs and alcohol (another common problem among physicians), go insane, or "check out" (suicide). It is the same as the issue of suicide among veterans (especially of the recent middle east wars). Although those who commit suicide do not say the reason, friends who served with them many times point to the horrible things they did to other human beings. This was very common among Vietnam vets.
--Banterings
...Continued...
...Continued Part 2:
Read what the VA (Veterans' Administration) says about "moral injury" as a cause of suicide:
However, even in optimal operational contexts, some combat and operational experiences can inevitably transgress deeply held beliefs that undergird a service member’s humanity. Transgressions can arise from individual acts of commission or omission, the behavior of others, or by bearing witness to intense human suffering or the grotesque aftermath of battle. An act of serious transgression that leads to serious inner conflict because the experience is at odds with core ethical and moral beliefs is called moral injury.
More specifically, moral injury has been defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009).
Read the words of Iraq war veteran Daniel Somers, who committed suicide following an arduous battle with post traumatic stress disorder (PTSD) that was caused by his role in committing “crimes against humanity,” according to the soldier’s suicide note.
Then again, healthcare is in denial about what they do to patients being traumatic, so "moral injury" could never be the cause of physician suicide...
--Banterings
In relation to my last comments, I just found this recent post on KevinMD:
How to protect physicians from themselves
Banterings
Dr Bernstein, why do you consider Sarah's comments relevant to this discussion? Other than the standard "boilerplate" provider ethics comments we've all heard ad nauseam, she launches into a ludicrous college rape rant like that's somehow related!
Ed
Ed, Sarah is using the rape as an example of a "bad" and how to punish the perpertrator and to prevent further "bad".all that Sarah is saying is what we have been saying for years now "speak up!" She is emphasizing the "speak up" both for the professional who observes bad or criminal behavior and also for the victim to do the same. She feels this would be more effective for change in professional behavior than simply lecturing medical student and doctors "don't do it".
Perhaps, this suggestion doesn't fit well with many or most of my visitors here because of the concept written here that it is ALL of the medical profession who are thoughtless of the patient or "more worse'. Well, if that is the final conclusion here then, of course, Sarah's comments sound like a rant.
But I have to say that I disagree with the assessment that ALL "medical professionals' are unhumanistic creatures out there only for their self-interest whether it be monitory or sexual or anything else. Yes, there are some.. and it is up to the other professionals and the patients to "speak up" if they witness or experience a "bad" whatever it may be. ..Maurice.
I am going to do this in 2 parts:
Maurice,
I totally disagree with the statement :
"But I have to say that I disagree with the assessment that ALL "medical professionals' are unhumanistic creatures out there only for their self-interest whether it be monitory or sexual or anything else."
The problem is not the deviants but a system that accepts the same actions as normal behavior that anywhere else would be considered deviant.
Providers assume that it is OK for them to view the body of any patient which is a total fallacy. The "doctor-patient" (and all other providers-patient relationship) should be thought of more like romantic relationships. I think nobody would support the notion that a person could have an intimate relationship with any person.
There are preferences, learned behaviors, past traumas, sexual preferences, etc. If that was the case, rape and molestation would not be crimes. Providers should approach the patient thinking that "I need to win this person over to trust me," "I need to ask permission," and "I know that I am not everyone's preference." The sense of entitlement needs to be removed.
There will be providers that patients will choose for that bond (like a marriage) and there will be some that they will tolerate (like a one night stand). There will also be the person that is just plain "creepy" and we would never want that person touching me, Everyone has experienced a person like this when dating.
Jason's example is a perfect description of the problem:
"Just think... you have friends over for drinks, and a lady friend crashes on your couch instead of driving, you can claim assumed consent because she's spending the night at your place and force yourself on her. Call some friends to come over and take turns with her, since that's no different then med students being filed in for a hospital gang rape.
"
So what do we teach our children? Not everyone feels the same way that you do, some are going to reject you, ask permission, treat people with respect, NO means NO, don't stare (look), etc.
What are med students taught? This is a teaching hospital so there is implied consent (Shawn Barnes 2012), you are a professional so it is OK, etc.
The THINKING is WRONG, the ASSUMPTIONS are WRONG, and the TRAINING is WRONG!
--Banterings
...Continued...
Part2:
I thank Kevin for pointing this news story out to me:
Nurses Forced to Strip Naked During Drug Testing
From what I read so far, the supervisors were female (same gender as the nurses) licensed healthcare providers (nurses), had a chaperone (2nd supervisor) present (alsofemale licensed healthcare providers), the nurses had the right to refuse, were tested individually (not in a group), it was according to the facility guidelines and what was deemed [sic] medically necessary.
So why the problem with the 4 nurses tested? They were afforded more considerations than most patients. Why would the supervisors not assume that they could witness the collection procedure, after all they were nurses...
The nurses knew drug testing policy when they were hired, and there was an eminent danger of missing pharmaceuticals. The enhanced methods were necessary because their training would allow them to cheat a drug test easier than the average person.
I am NOT condoning what happened here, I am simply trying to illustrate my point.
*** Warning *** The following is me further illustrating my point using a sexual situation:
In a single's bar, should I as a man assume that I can feel any woman's breasts (that I am attracted to) until she says "NO" or should I ask permission first?
What if the patient with ambiguous genitals asked the med students (who were there to see a unique case) asks to see what normal genitals look like?
Why is it assumed OK for the students to look but not the patient? I argue there is a therapeutic value in the patient looking.
Please do not fall back on the "outliers" argument, we are beyond that now.
--Banterings
The female nurse said
" We're all professionals here. You have nothing we haven't seen before.
It's not sexual, it's clinical. It's no big deal. The full nude foldouts from
Playgirl magazine that we covered the staff bathroom walls with doesn't
count because since its in the hospital, it's clinical."
PT
Clean of the body’s hair,
I lie smooth from breast to leg.
All that was special, all that was rare
is common here. Fact: death too is in the egg.
Fact: the body is dumb, the body is meat.
And tomorrow the O.R. Only the summer was sweet.
What you just read was one section of a poem "The Operation" by Ann Sexton, poet, 1928-1974. You can read the entire poem here.
I am referencing the poem here because it does enlighten the reader of this "confessional" with some of the very concerns of being a patient and attended to by "those starchy ghosts" which have been repeatedly described on this thread.
I am not arguing that what Ann Sexton writes represents a statistical outlier. What I have repeatedly said is that most patients will accept a certain degree of "indignity" (if that is the correct term) for diagnosis, treatment or hopefully a cure.
I also want to say that I think the vast majority of doctors and nurses do understand the dignity sacrifice that patients are accepting to accomplish an overall "good" with regard to their health.
And I want to emphasize again, that in August when I start again with my group of six first year medical students, in the first week of their trip to become a doctor, that every bit of Ann's feelings will be one of the first things they are going to learn as we start them learning to take a history and perform a physical exam.
Don't fret. I am starting them all off with concern about patient dignity and the importance of attending to those concerns. And that conversation about their patient' concerns about them and the system is primary in developing a relationship with the patient. "The Operation" by Ann Sexton will become an addition to my introducing the students into medicine and becoming physicians. ..Maurice.
To add to Banterings comments on the nurses who had to strip for drug testing.
The nurses were essentially subjected to what their own patients endure daily - except they were afforded same gender care. But somehow they found it traumatic and humiliating? How is this different than them holding a urinal for an invalided man? The solipsism is sickening but not surprising. Them vs. us mentality.
Has anyone mentioned "The Doctor" a William Hurt movie form '91? A surgeon has to go through the medical system as a patient and has an epiphany in terms of his own care of patients. It is loosely based on Dr. Edward Rosenbaum's 1988 book, A Taste Of My Own Medicine. The experience changes the surgeon forever. When he returns to work, he begins to teach new medical interns about the importance of showing compassion and sensitivity towards their patients, which in turn will make them better doctors. He puts the interns in patient gowns, assigns them various illnesses and orders all the tests for them to "feel" the experience that they will soon put their patients through.
Another article about the unnecessary exposure and how patients feel;
http://news.nationalpost.com/health/the-dreaded-hospital-gown-described-as-health-cares-prison-jumpsuit-often-imposed-on-patients-needlessly-study
A study which examined the effect of patient nudity/dehumanization in hospitals due to the omnipresent gown - examines the way that standardized nudity affects quality of care and psychological well-being.
Kevin
i found a problem to the link on the video: "Nurses Forced to Strip Naked During Drug Testing"
here is the link: https://www.youtube.com/watch?v=oDgm2VicX7E
--Banterings
I just read a truly disturbing article on bioethics in The Boston Globe. Although it is focussing on research and technological advancement, I believe this is the prevalent attitude in healthcare:
...the primary moral goal for today’s bioethics can be summarized in a single sentence.
Get out of the way.
A truly ethical bioethics should not bog down research in red tape, moratoria, or threats of prosecution based on nebulous but sweeping principles such as “dignity,” “sacredness,” or “social justice.” Nor should it thwart research that has likely benefits now or in the near future by sowing panic about speculative harms in the distant future. These include perverse analogies with nuclear weapons and Nazi atrocities, science-fiction dystopias like “Brave New World’’ and “Gattaca,’’ and freak-show scenarios like armies of cloned Hitlers, people selling their eyeballs on eBay, or warehouses of zombies to supply people with spare organs. Of course, individuals must be protected from identifiable harm, but we already have ample safeguards for the safety and informed consent of patients and research subjects. (Source: The Boston Globe, The moral imperative for bioethics)
This attitude when applied to patient dignity explains things like "I am a professional," gender doesn't matter, being completly naked (under a gown) for ALL surgery, etc.: "get out of my way (A.K.A. efficiency). This attitude fails to recognize the harm and suffering it causes:
But now, reducing patient suffering — the kind caused not by disease but by medical care itself — has become a medical goal…
Or loss of privacy...
"These are harms," Dr. Sands said. "They elicit suffering. They can be long lasting, and they currently are largely unquantified, uncounted, unrecorded." (Source: NY Times, Doctors Strive to Do Less Harm by Inattentive Care)
As I stated previously, being a healthcare professional does NOT give the provider the right to attend to the patient and for the patient to TRUST the provider, what being a professional DOES DO is give the the provider the right to ASK to PARTICIPATE in the patient's healthcare ONLY to the level/point the patient wishes, AND to EARN the patient's trust.
--Banterings
Banterings,
what being a professional DOES DO is give the the provider the right to ASK to PARTICIPATE in the patient's healthcare ONLY to the level/point the patient wishes, AND to EARN the patient's trust.
I fully agree: nothing more and nothing less. That is exactly the way I have practiced medicine all these years and this is the what I teach my students from the very first day (coming up on August 18) of their medical education with me.
..Maurice.
Banterings - great articles - especially the NY Times ending with this quote.
“Every patient visit is a high-stakes interaction,” Dr. Thomas Lee says he has learned. “It is a big deal for the patient and it is a big deal for you.”
Maurice: Earning trust is a huge part of the patient/healthcare experience - but I am sure it falls way down the list - ranking well below the disease. I'm sure most physicians see trust as implicit due to their MD and do not try to earn it.
I avoided an unnecessary surgery once as my orthopod wasn't listening to me and I demanded an MRI - it proved that I had nerve rather than tendon damage. He said that in med school a prof had told him that once in a while a pt will argue with you - and you should listen. He had so concentrated on a (false) ultrasound that he wouldn't listen to me. His arrogance would have led me to getting cut open for nothing; and fear of malpractice would have kept him quiet - only the surg staff would have known. As we learned in the case of Twana Sparks - what happens in the OR stays in the OR.
Physicians take an omniscient purview - know all/see all - yet not that very long ago you would have bled me. Increased specialization, special interest groups (assoc.s/unions) have carved out turf but have fragmented the system and it seems no one is steering the ship sometimes - more like twelve hands on the wheel and the direction generalized. Where does the buck stop? In the old days wasn't that with the doc?
I see a doc socially right now - have brought up some of my own (biased) views of men and healthcare - the doc hadn't even considered that modesty may play an important role why men are avoidant. Considering the doc has an MPH and is a research chair there was a definite 'face-palm' moment for me.
Kevin
Kevin, trust is not "way down" a list, it is primary requirement in both directions. Trust is essential in the patient-doctor relationship and our first and second year medical students are repeatedly made aware of this essential. That is why they get permission from their assigned patients before starting a history and they explain to the patient what and why they intend to do as the physical exam progresses. And they are taught to observe for patient rejection of any part of the history or examination and to accommodate the patient.
Of course, I have no control what happens in the students' later years except for the guidance I provide them in the first two years. If circumstances later in their careers put efficiency, emergency, personal interest and more ahead of trust then unless they become demented, they still should remember what I had taught them about trust in those first two years. ..Maurice.
Dr B said And they are taught to observe for patient rejection of any part of the history or examination and to accommodate the patient.
But you've also said (to the effect of) you've NEVER seen anyone express concern undressing in your practice.
I'm curious what you tell the students to look for if you yourself have never seen it.
Jason K
Maurice:
My first experience with a physician lying to me was at ten years old. I had an emerg appendectomy and had awoken during the procedure - (I realize that pediatric anesthesia can be problematic). I remember the intubation and someone performing the plantar reflex. During rounds he totally denied it happening. Thing is I had no idea what intubation was but remembering thrashing about choking. I saw a show years later (ER?) where this pain stimulation was administered to evaluate consciousness - also had it (plantar reflex) again during a more recent meniscectomy when I told the surg that there was no anesthesia from the epidural and he was ready to wield scalpel. (He grudgingly gave me a local while sneering at the anesthetist). He was already behind sched so was a little pissed already - in his haste he then sliced through my Ramis articulares (white hot sword through my knee), ended up leaving about 500ml of saline inside my knee as he had a golf game or something to go to and couldn't be bothered draining it. I 'sloshed' around for a few hours after.
I REALLY hope I am an outlier. As Yoda would say; my trust docs have not earned.
Kevin
Jason K, to answer your question directly, I tell them after they explain to the patient what they are going to ask (for common examples: "I am going to ask you some sensitive questions about your sex iife but it will remain confidential" or as part of the physical exam "I want to listen to your heart under your gown to find any abnormal sounds"). In the case of the student, if the patient rejects the offers, I find that the sexual history is missing and the cardiac exam is recorded as not thorough in the writeup the student presents to me) This is what I always did in my practice and, yes, I have never had a rejection after I had presented patients with an explanation of what should be done and without some sign of rejection, I continued my work..
This is why what has been written on this thread from the onset about patients rejecting care based on modesty was a surprise. But, maybe that was because I didn't directly tell the patient to "speak up" and assumed without a "yes, go ahead" or a "no" that the patient accepted what I said. I certainly have been, in recent years because of this thread, speaking to my students more about encouraging patients to voice their concerns. ..Maurice.
Maurice,
You do realize that confidentiality is a joke!
You may or may NOT be aware of this. Unless the patient pays with cash, the insurance carrier routinely requests a copy of notes. The justification is that if a physician is ordering regular HIV and hep tests, the insurance company wants to know why. Oh, I see Mr. patient says he is bisexual...
Now with EHR, all that is transmitted to the insurance company, "community health concerns," the federal government, etc. Read SUMMARY OF THE HIPAA PRIVACY RULE and note:
The Privacy Rule permits use and disclosure of protected health information, without an individual’s authorization or permission, for 12 national priority purposes. These disclosures are permitted, although not required...
Read all the exceptions!
Workers' compensation cases also routinely request doctor notes as well.
Don't believe me, go in to the billing office and ask how routinely doctor notes are requested by 3rd parties.
So do you teach your students to tell the patient "I as your physician will keep your information confidential but our practice will disclose it to everyone"? Is ignorance of such disclosures an excuse for the physician? Patients electronically sign these disclosures on admission and do not even get a paper copy. There is NO informed consent. That is NOT an excuse for any physician OR student to promise confidentiality!
Anyone would be a fool to fully disclose or NOT to lie to their doctor today.
Ubel's paper showed that what is taught 1st and 2nd year is thrown in the trash in regards to modesty, consent, etc.
Read the comments on this story onKevinMD, "A patient secretly records his colonoscopy. It cost this doctor her job." All the physician commenters say the doctor was in the wrong but argue that $500,000 is excessive.
Here is the point they miss: do not comment fraud (medical records in this case), treat patients with dignity, and you will NOT have to pay such penalties. Basically what they are saying is that do NOT think that abuse of patients and fraud ARE serious.
"The only thing necessary for the ABUSE of PATIENTS to occur is for good PHYSICIANS to do nothing."
--Banterings
Dr B - so you basically tell them to ask, then if the patient hasn't been whipped into submission and refuses, to just skip the questions / part of an exam. So.... no mention of body language or anything the patient might display if they really don't want to answer / consent but feel obligated to, or just as a sign of general embarrassment / discomfort?
Jason K.
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