Patient Modesty: Volume 74
Throughout the entire discussion about the issue of patient modesty there is one issue that still hasn't been resolved. That issue is: within the "doctor-patient relationship" is there really any balance existing or required between the "needs" of the patient and the "needs" of the physician? Yes, there is imbalance in favor of the physician with regard to medical education and medical/surgical skills and the need to apply this knowledge and skills effectively for the patient. However, since it is the patient who has the illness and who is about to be diagnosed and treated should the balance with regard to "needs" be loaded on the patient's side because it is the patient who is ill and because the patient should have the primary interest and concern which then includes all matters of modesty? The physician's "needs", such as facilitation of time spent with the patient, assistance by others (which might include gender other than that of the patient) during interaction with the patient or other physician professional but self-interest demands, should bear far less weight on balance than the patient's modesty needs. On the other hand, shouldn't the goal be an attempt to balance the "needs" to provide a safe and effective outcome of any doctor-patient relationship? And, yes, in that balance some matters of patient modesty might be affected. I speak as the blog moderator and not as a physician as I present this issue of balance for discussion. ..Maurice.
Graphic: Balance--from Google Images
NOTICE: As of March 14 2016, Volume 74 is now CLOSED to further Comments. Go to "Patient Modesty: Volume 75" to continue posting.
posted by Maurice Bernstein, M.D. @ 8:34:00 PM
168 comments
168 Comments:
Thank you Ray for your wisdom. The unfortunate part of the hospital setting is that one is vulnerable. Whether medicated, asleep or confused and in pain, one has little power to control others' actions. Furthermore, the flow of information (i.e. patient requests) may or may not be consistent - "Oh. We didn't get that memo". And, or course, there are those that take a personal affront to any requests of this nature. I thank you and your wife for being compassionate. I wish the word could be spread to others in the medical profession. Thank you.
RS
Ray, you asked "But, do you test students in your course over the materials studied?". The answer for the "Introduction to Clinical Medicine" course is a "no". There is no written testing by me but simply observation of how each student behaves as they interview a patient and how they behave when they examine their colleagues or their patients. They are then promptly informed of what I observed as well done or what I observed as needed improvement. Attention to patient modesty is stressed not only by me but is a specific part of the checkpoint list of the course which the students are expected to adhere to. ..Maurice.
RS,
I am not in the medical profession. Neither is my wife; she is a retired nurse. Most of my knowledge about health care comes from scholarly publications, textbooks, personal experiences, and empirical research conducted by me and students in my classes. Regarding personal experiences, I seldom give up the change to employ qualitative methods to gather data in my role as patient (the role expectations of which I sometimes deliberately violate). My studies gave me the foundation to intermittently instruct students in courses about health care, at least at the social psychological and sociological levels.
With reference to your statement about the “personal affront to any requests,” I’ve written and spoken at professional meetings on the subject (1996. “The Sense of Entitlement and Professional Identity as Sources of Ethical and Normative Violations among Nurses who Deliver Intimate Cross-Gender Care.” Paper read at the Midwest Sociological Society. Chicago).
Ray
Maurice,
I see. That’s what I thought. Of course, clinical techniques do not necessarily preclude grading. I and my classmates were graded our counseling approaches to clients, nursing students in our BSN program are graded on their nursing care approach, and I and my classmates were graded by professors on speeches we gave. I know it’s more difficult to quantitatively score qualitative variables than to measure variables that lend themselves to quantification such as blood pressure, pulse rate, etc, but it’s done every day.
I spent 20 years in the home of osteopathic medicine and had frequent interactions with students at what is now A. T. Still University. Students derisively referred to courses in which grades were not given as bedside-manner courses, dummy courses or dumbed-down courses. They did not take them seriously and considered them to be of worthless value in the “real world.” I had even more exposure to students and faculty in a BSN program. The students tended to take clinical courses seriously, probably because they were graded on their performances. A few actually failed and had to repeat courses or were expelled from the program. But alas, just as with med students, whatever they learned tended not have a lasting effect because, as many of them reported, “reality set in.” The reality was that they were thrust into a parallel world, a counter culture, or a set of total institutions in which niceties practiced in the outside world were turned on their heads.
What about that research idea I proposed, Maurice?
How about giving us more about your opinion regarding balancing the needs of physicians and patients? From where are you coming?
Ray
Maurice,
Why to you house “needs” between quotation marks? Use of quotation marks in this context suggests that you are not using the concept as intended, using it more or less broadly than it is usually used, directing it at people who use the concept “needs” when they mean something else (e.g., desire), etc. Before I can respond to your questions, I need to know why you are housing the concept between quotation marks.
Human beings (including physicians) have a need for good health. I assume that most U.S. citizens who visit physicians (including physicians) do so because they believe that physicians control the resources that help us satisfy the need for good health. Here I’m using “need” as intended so it needs no quotation marks as it does in this sentence. So, what’s your intent?
Ray
Do you know what the difference is between God and physicians? God never claimed to be a physician. (See, Samuel Shem, “The House of God”) :)
A sociologist is someone who goes around the world kicking down doors that are already open. :)
Ray, "needs" are in quotes because the word, to some, may be ambiguous as expressed for both the physician or the patient. After all, what is needed, at times, may only be in the eyes of the beholder.
As I mentioned in Volume 73, I have under my wing only 6 students and I am not in a position to authorize any survey for the first year medical school class of about 180 students. Such a number of students would be necessary to achieve a result of some statistical value. ..Maurice.
Maurice posted *** "you asked "But, do you test students in your course over the materials studied?". The answer for the "Introduction to Clinical Medicine" course is a "no". There is no written testing by me but simply observation of how each student behaves as they interview a patient and how they behave when they examine their colleagues or their patients. They are then promptly informed of what I observed as well done or what I observed as needed improvement. Attention to patient modesty is stressed not only by me but is a specific part of the checkpoint list of the course which the students are expected to adhere to. ..Maurice."***
Do you use actors / volunteers to "play" patients at first, or throw the students in with real patients?
If it's "play patients", then it should be fairly easy to add an "unofficial" ethical test to your lessons... make sure the female students are otherwise occupied, have a female patient ask the male student if they could have a female "doctor", (and do it in reverse for the female students) and see if they make any effort to trade patients with their other students.
Do that near the start of your teaching the group of students, and again near the end and see how many try to accommodate both times, the first time but not the last, or not the first but the last.
Jason.
Jason, we actually don't "throw" the first students into "real" patients but yes their first patient and each throughout the year (up to 15) will be a hospitalized patient to relate to with history taking and progressing though elements of the physical examination as they sequentially learn how to perform. They get only one exercise with a "standardized patient" who provides to the student "feedback" with regard to the student's performance.
As far as gender selection by the student with regard to the hospital patient or gender selection by the patient with regard to the student, that absolutely does not occur. Gender does not decide which student interacts with which patient, selection is arbitrary but, of course, always with the specific permission of the patient. Rejection of a student visit is rare and I never observed myself or heard from a student that the rare objection was said by the patient to be based on gender. This is another reason why on starting this Patient Modesty blog thread back in 2005 and at that time after 20 years of this teaching experience, having not heard about refusal because of "gender", I was (as I repeatedly written here) surprised by the gender-modesty concerns beginning to be expressed on this thread and continuing. And, in addition, as I have repeatedly stated I received no input regarding modesty issues from patients in my medical practice experience (by the way, including up to the present. ..Maurice.
Hello again Ray,
Is your submission, The Sense of Entitlement and Professional Identity as Sources of Ethical and Normative Violations among Nurses who Deliver Intimate Cross-Gender Care, available on-line? I'm amazed that you wrote something of this nature almost 20 yrs ago and little progress seems to have been made.
RS
Maurice,
You are incorrect regarding the need for 180 subjects or so “to achieve a result of some statistical value.” First of all, my proposal was not for a survey, as you suggest, but for an experiment. Experimental studies with statistically significant results in medicine, the natural sciences, and social sciences usually have fewer than 180 subjects, a number which is considered quite large by every psychologist I know. Depending on the design, as few as 30 subjects can be legitimately used. There are, in fact, formulae that can be employed to determine the number of subjects one needs to obtain any particular level of statistical significance. Of course, it is true that with an increase in sample size comes a decrease in sampling error, but it doesn’t follow that one needs large samples to “achieve a result of some statistical value” (e.g., p< .05). Indeed, each semester for six years, I collected data from 24 to 34 students and found statistical significance at below the .01 level or .05 level in 11 of the 12 times the study was conducted.
Second, far fewer than 180 experimental subjects are sufficient for conducting analyses using parametric statistics including regression analysis, analysis of variance, etc. without violating the assumptions required (e.g., normality of distribution). If the number of subjects is few, one can use nonparametric statistics (e.g., Chi Square) which do not require satisfying all the assumptions of parametric statistics.
Third, many experiments are conduced over long periods of time – one subject here, six subjects there, another two subjects later, thereby leading to large sample sizes (e.g. experimental research to test the effects of Polyheme, an artificial blood product). I used 24 to 34 students each semester for six years to gather data. You might ask, “What about the effects of contagion (subjects at time 1 telling subjects at time 2 about the experiment). There are ways of dealing with that problem.
So, using a low “n” as a reason not to conduct an experiment doesn’t hold much water. Neither does not being in a “position to authorize any survey.” I and every other researcher I know must ask those in authority for permission to conduct research and then get a research proposal approved by an IRB. The only authorities that have turned me and my students down have been in medicine and always for specious reasons, if they give a reason at all. However, when I, students, and a colleague in the medical field have together submitted research proposals to authorities in health care organizations, we have never been turned down.* I can only speculate about the reason for this differential response.
Now, it’s a different matter if you don’t have the authority to try to get permission from authorities to conduct research. That type restriction put on scientific scholarship is hardly admirable in institutions of higher learning. I’d be inclined to quit such an establishment and seek employment at a place that valued scientific exploration.
* The Harvard Medical Study was an impressive example of cooperation among physicians, nurses, other health care professionals, social scientists, attorneys, statisticians, among others. It answered a lot of questions and forced us to consider new ones. It has been cited thousands of times in scholarship since it was completed in the 1990s.
Ray
Maurice,
After all the data and information made available to you since you began this blog, I am surprised that you continue to be baffled by why in your professional career you have “not heard about refusal because of ‘gender.” Surely you can venture some hypotheses and, if you are so inclined, test them.
Distribute an anonymous questionnaire to boys, girls, men, and women and ask them about their gender preferences for intimate examinations. Based on past research, I would predict you’d find a large minority of adults (30% to 40%) who would prefer same-sex providers. I’d posit an even larger percent for young people. The percent in either case, would vary according to certain demographic and personal traits of respondents. One variable that seems not to be correlated with preference, however, is prejudice; preference for same-sex provider tends not to be founded in prejudice (e.g., belief in the inferior abilities of the opposite sex) but in the desire to preserve one’s dignity. In spite of this desire, however, not all those who prefer same-sex providers reject or complain about being assigned to an opposite-sex provider for intimate exams. What are the reasons for the disparity between preference and acceptance? As Hamlet proclaimed, “that is the question.”
Ray
Dr. Bernstein,
The statement: And, in addition, as I have repeatedly stated I received no input regarding modesty issues from patients in my medical practice experience (by the way, including up to the present. concerns me.
Since you are an Internal Medicine doctor, I assume many of your female patients do not have any intimate exams done by you and that they go to a gynecologist for breast / pelvic exams and pap smears. Many women do not have intimate procedures / exams done by an Internal Medicine or family practice doctor. Can you please tell us what a percentage of your female patients have never had any intimate procedures done by you? Most people do not care about the gender of their doctors / nurses for non-intimate health issues.
It is likely you have male patients who have had prostate / rectal exams done by you, but would not want a female doctor.
Misty
RS,
The paper is not on-line. There was no “on-line” when I read it at the Midwest meeting and I don’t presently have the ability to put it on-line. In the paper, I address just about everything that has been discussed regarding cross-gender care in this blog, including some health care providers’ surprise when they discover that many patients who have experienced cross-gender care preferred same-gender care but said nothing about it. I write about, among other things, the techniques nurses use to get resistant patients to submit to nurses’ intimate ministrations against their will and their own interests and the different modes of adaptation used by patients to deal with this intrusion.
I became interested in the subject when I read in the popular literature about a lawsuit brought by Nurse Backus against Baptist Medical Center for gender discrimination. Baptist’s policy was to provide same-sex intimate care unless it was not possible or unless patients expressed the opposite preference. The policy naturally led to gender discrimination in labor/delivery. My first knee-jerk reaction was, “The hospital is screwed.” The decision, however, was just the opposite of what I expected. The judge decided against Backus and in favor of Baptist; being female was a bone fide occupational requirement, she concluded. Backus, ANA leaders, and nurses around the country responded with outrage and moral indignation. I read the decision; it made sense if one accepted the judge’s premises which were based on precedent. I decided to conduct a content analysis of articles published in nursing journals about the decision. After discussing the case in the paper, I report on that analysis. What tended to bother nurses the most was their perception that the decision was a threat to nursing as a profession. Patients’ rights were of secondary importance. Using this analysis as a foundation, I conducted a more exhaustive study of same-sex and cross-sex care combining the knowledge gleaned from past publications and from my own research.
If anyone is interested in getting a copy of the article, I can send it via e-mail after I edit it a bit. Just post your e-mail or, if you feel uncomfortable with that, I’ll post mine and you can contact me.
I can use what I learned from this blog to expand on what is in this paper and in its sequel – “Mortification of the Self in a Total Institution – The Inpatient Hospital.” This latter expands on the first paper and puts the phenomena of study into a theoretical framework – in particular, Erving Goffman’s dramaturgy. Neither paper allows for a full understanding of what is studied. That paper will come later.
Ray
Maurice,
You write, “As far as gender selection by the student with regard to the hospital patient or gender selection by the patient with regard to the student, that absolutely does not occur. Gender does not decide which student interacts with which patient, selection is arbitrary but, of course, always with the specific permission of the patient.”
I recently posted that those in medicine tend to exist in a parallel universe, a counter culture that sports a set of values, beliefs, norms, and behavior patterns at odds with the greater society. Your very words confirm what I’ve written. When Kinsey conducted his research on sex, he deliberately sent women to interview women and men to interview men. Today, researchers for the Kinsey institute and others who conduct surveys on sexuality continue to do the same. The norm at airport security is to use women guards to frisk women passengers and men to frisk men. Female cops are expected to search female suspects and male cops are expected to search male suspects – etc., etc., etc. Outside of health care organizations, were there a dearth of one sex over another, you can bet your bottom bootie that prior affirmative consent for opposite-sex personal/intimate treatment would be the norm; those in authority would not expect those without authority to object before backing off. That physician-educators thumb their noses at this norm is telling. It is also telling that the only institutions in the U.S. other than the health care institution where this norm is eschewed are custodial facilities where people are involuntarily incarcerated and locked out of the “normal” world. I won’t insult anyone’s intelligence by explaining why this is.
Can anyone tell me what the hidden curriculum revealed by the practice described by Maurice is? What covert messages does this practice send to medical students about patients, physicians, and their relationships?
Horace Miner wrote a satire directed at ethnocentric anthropologists in 1956 (American Anthropologist) http://www.sfu.ca/~palys/Miner-1956-BodyRitualAmongTheNacirema.pdf. This classic piece is entitled “Body Ritual among the Nacirema” (“American” spelled backwards). Most students think they are reading about a “primitive” culture – even when Miner introduces the reader to the Nacirema’s originator and “cultural hero” Notgnihsaw who chucked “a piece wampum across the river Po-To-Mac” and chopped down “a cherry tree in which the Spirit of Truth resided” – and are bored out of their gourds. Miner inadvertently alludes to the deviant culture of the “latipso” (“hospital spelled backwards without the “h”) and its effects.
The supplicant [patient] entering the [latipso] is first stripped of all his or her clothes. In every-day life the Nacirema avoids exposure of his body and its natural functions. Bathing and excretory acts are performed only in the secrecy of the household shrine [bathroom], where they are ritualized as part of the body-rites [brushing teeth, toiletry, combing hair, etc.]. Psychological shock results from the fact that body secrecy is suddenly lost upon entry into the latipso. A man, whose own wife has never seen him in an excretory act, suddenly finds himself naked and assisted by a vestal maiden while he performs his natural functions into a sacred vessel . . . Female clients, on the other hand, find their naked bodies are subjected to the scrutiny, manipulation and prodding of the medicine men.
Ray
My last post was with students observing or participating in cross-gender intimate procedures in mind and not non-intimate procedures. Where I conducted my studies, osteopathic students and nursing students are “arbitrarily” assigned to patients irregardless of whether or not intimate care is involved. I believe that if a reasonable person would find it offensive and a privacy intrusion to have opposite-sex students observe or practice intimate procedures on them, then not only should patients’ permission be secured prior to the examination but they should also be warned that an opposite-gender students may be assigned to them so they can make an informed decision. An unintended positive function of institutionalizing this approach is that it would automatically take care of problems that might arise when patients are of Middle-Eastern descent or from other cultures where body exposure to the opposite sex outside of marriage is taboo.
Ray
Ray,
This is my take:
1. Participation by a student has no benefit for the patient - the benefit is for the student only.
2. The patient's specific prior consent should be obtained before a student is allowed to observe or participate in any exam or procedure. This consent should be obtained without the student present.
3. In the event the exam or procedure involves intimate exposure, the patient should also be informed of the gender of the student, i.e., "I have a female student with me today - is it OK for them to observe?". Again, this should be done without the student present.
Hex
Some responses.
To Misty: I have always and would continue to perform pelvic exams, if the clinical issue is appropriate, with the attendance of a female chaperon with permission from my patient.
Ray: To be open and honest on my blog thread, I can tell you and the others here that at our school we never teach our students that they cannot examine a patient of an opposite gender, either in "sensitive" or "non-sensitive" anatomic areas of the body. All patients are to be informed as to what is to be performed and give informed permission (consent) prior to
the examination. That request for consent by the student has always been acceptable to patients and as I have previously mentioned, gender of the student relative to the patent has never become an issue brought to our attention or on my direct observation. Patients, in general, are pleased with my student, irrespective of gender, and tell me that when I enter the room after the student has left as I directly talk to and thank the patient. You would have to be with me to recognize what I tell you now is truthful, but unfortunately you can't. Sorry.
Hex, I would disagree with you relative to #1 benefit to the patient. My first and second year students pick up history or physical findings not noted by the patient's physicians and the physicians are then notified. As part of their 60 or 90 minute interaction with their patient, they spend far more time communicating then the patient's own hospital physicians and some of the communication is permitting the patient time to ventilate their concerns or the student encouraging the patient to follow health matters about which the student is already knowledgeable. Also, often the patients express to me a sense of "altruism" to be a participant in the medical education of a first or second year student. Your #2 is correct and #3 is hopefully correct though first and second year students do not perform or watch these exams on real patients, though second year students spend one session performing the genital exams on male and female teacher subjects where the students get correctional feedback from their subjects.
..Maurice.
Dr. B,
OK, I understand they're students and probably being slow and meticuluous, but 60-90 minutes? What in the world could take them that long?
Hex
The first year medical students are learning to relate to the patient and take a complete medical history and then over the two years learning how to perform a physical examination as they progress in learning serially from one anatomic system to another.
By the end of the second year, they are able to perform a complete history and physical in about an hour. This is no 15 or 7 minute office visit. I regularly, myself, attempt to visit the patients after the student leaves to personally thank them for their participation in such an important educational activity. Despite all the computer programs now being developed and currently available to simulate a patient interview and physical examination, nothing will ever simulate the unique communication with a real patient or the "laying on of hands" upon a real human being. And the only "payment" these patients who volunteer for this is the real attention and concern of the students to whom they consent to be the "student's patient". ..Maurice.
Since we are here delving into medical student education, perhaps you would be interested to contribute to a new thread I just put up on this blog. It is titled "Pimping": Not About Sex--About Medical Education
It is about whether this teaching technique provides needed education to medical students, interns and residents or is it harmful and attacks the dignity of these "learners" only to the self-interest motivation of the teachers and the profession. Also if this "pimping" type of questioning is applied to patients themselves is that a technique to destroy the patient's own dignity? It will be interesting to read your comments. But please write them on that new thread and not simply here. ..Maurice.
I do this post in 3 parts…
Ray et al,
In regards to gender, patient dignity,etc., the focus of healthcare has always been primarily about healthcare. Patients are secondary. Just like the medieval guilds, healthcare sought narrow regulation of the industry in order to restrain competition against encroachment from outside competition. (Source: A Tale of Two Theories: Monopolies and Craft Guilds in Medieval England and Modern Imagination)
The first AMA Code of Ethics, is all about the patient’s duties to the doctor, not what the doctor owes the patient. To see more how healthcare view the patient in its inception, read Victorian medical ethics and the subordinate patient.
Society granted physicians status, respect, autonomy in practice, the privilege of self-regulation, and financial rewards on the expectation that physicians would be competent, altruistic, moral, and would address the health care needs of individual patients and society. This "arrangement" remains the essence of the social contract.
...The professions arose in the guilds and universities of medieval Europe and England. They had little impact on society until science made health care worth purchasing and the industrial revolution provided sufficient resources so that society could afford it. Some means of organizing health care was required and society turned to the preexisting concept of the profession. This occurred in the middle of the 19th century, when licensing laws were passed granting the medical profession a monopoly over the use of its complex and expanding knowledge base, thus establishing the basis of the modern social contract. (Source: AMA Journal of Ethics)
continued...
Part 2
Let me demonstrate another example of "guilds" looking out for their own self interest at the cost of human dignity:
PREA is the acronym for the Prison Rape Elimination Act. After decades of societal indifference to prison rape, Congress, in a rare show of support for inmates’ rights, unanimously passed the Prison Rape Elimination Act in 2003.
The law describes prison rape as epidemic. It refers to“the day-to-day horror of victimized inmates, and of the need for Congress to protect the constitutional rights of prisoners in states where officials displayed deliberate indifference.
It took almost a decade for the Justice Department to issue the final standards on how to prevent, detect and respond to sexual abuse in custody. And it took a couple of years more before governors were required to report to Washington, which revealed that only New Jersey and New Hampshire were ready to certify full compliance.
What took so long? Resistance was coming from (and still is) from many correctional agencies. The 52 standards for prisons and jails apply to everything from hiring and staffing levels to investigation and evidence collection to medical treatment and rape crisis counseling.
With the second annual reporting deadline, advocates for inmates and half of the members of the National Prison Rape Elimination Commission (a bipartisan group charged with drafting the standards) say the pace of change has disheartened them despite pockets of progress.
“I am encouraged by what several states have done, discouraged by most and dismayed by states like Texas,” said Judge Reggie B. Walton of United States District Court for the District of Columbia, who was appointed chairman of the now-disbanded commission by President George W. Bush.
continued...
Part 3
Some commissioners fault the Justice Department for failing to promote the standards vigorously. Others blame the correctional industry and unions for resisting practices long known to curb “state-sanctioned abuse,” as one put it. All lament that Congress has sought to weaken the modest penalties for noncompliance, and that five governors joined Governor Perry last year in snubbing the standards. The other renegade states, as advocates called them, were Arizona, Florida, Idaho, Indiana and Utah.
But states face only a small penalty, the loss of 5 percent of prison-related federal grants, if they opt out of the process entirely. There are a lot of carrots in PREA, and not enough sticks.
Texas’ opting out was considered especially significant, however, because it has the largest prison population in the country and by far the most reports of sexual assault and abuse. Texas had three and a half times as many allegations as California in 2011, when California still had more inmates than Texas (according to the federal data).
Texas state officials found some standards particularly intrusive. Governor Rick Perry protested that limitations on cross-gender strip searches, pat downs and bathroom supervision would force Texas to discriminate against its female officers.
Read more at The National PREA Resource Center
One of the lessons of The Third Wave experiment (conducted by schoolteacher Ron Jones's which he created a proto-fascist movement amongst his high school pupils in Palo Alto, California, in 1967) was that organizations are self serving of their own best interests.
By the latter part of the 20th century, however, many social scientists concluded that the profession had abused its privileged status and public trust, and that its regulatory procedures were seriously flawed. (Source: AMA Journal of Ethics)
If healthcare really cared about the dignity of patients, then Tuskegee would not have happened, pelvic exams on anesthetized women would not have occurred and we would STILL been having that conversation in 2012.
—Banterings
Hello Ray,
I'd be happy to read your 1996 paper and your new one. Please indicate your e-mail so that I might contact you for a copy.
Thanks.
RS
Maurice,
You write, “. . . we never teach our students that they cannot examine a patient of an opposite gender, either in “sensitive” or “non-sensitive” anatomic areas of the body.”
You missed my point 100%. I never suggested that you do or should teach your students such a thing. My major point was that people in health care belong to a counterculture. If you never teach your students “that they cannot examine a patient of an opposite gender,” if this description is typical across first and second year med. school programs, and given what I wrote about “polite”* society are correct then one can only conclude that resocialization into the health care counterculture begins early in students’ tenure as students.
I noted in my post that in “polite” society, consent is obtained before opposite-sex individuals are assigned to perform intimate procedures. I write, “That physician-educators thumb their noses at this norm is telling.” What does it tell us? It tells us that physician-educators (and you in particular), rightly or wrongly, are involved in helping to create the health care counterculture about which I have written on several posts. It is a fact that in “polite” society males are assigned to males and females to females when intimate procedures are involved. That’s a social norm characteristic of the culture of “polite” society. It is a fact that in health care organizations (including teaching hospitals) providers are assigned “arbitrarily” to patients, without consideration of sex or any other variable. That’s a social norm characteristic of the health care counterculture (as well as custodial facilities in the U.S.).
Again what you have done is provide evidence that socialization of medical students into the health care counterculture begins early in their career as students. Put another way, you have, in effect, provided evidence of a countercultural practice and given me an idea of when in students’ lives countercultural socialization begins. I thank you for your contribution to my understanding.
Please, I invite you to critically evaluate what I have written; give me something useful – something I can use to modify or expand on what I have written. Give me evidence that challenges my notion that health care constitutes a counterculture.** But please, don’t attribute to me beliefs or ideas I don’t possess.
* When I write about “‘polite’ society,” I am referring to the prevailing societal values, beliefs, norms and behavior patterns – the values, beliefs, norms, and behavior patterns in the greater society.
** I actually know of some thoughtful retorts to my theory. But I also know of thoughtful retorts to the retorts.
Ray
Banterings,
I skimmed your post. At first glance, it looks like a good historical/structural analysis. I’ll sit down tomorrow and read it more closely. It’s a pretty long post. So is mine that follows.
Maurice,
If we’re going to discuss “needs” without agreeing what is meant by the concept, then we’re bound to talk past each other. Talking past each other is a common occurrence on CNN, MSNBC, and FOX. I’ve seen, for example, a guest speaking about institutional racism to Bill O’Reilly who insists that it does not exist any more. O’Reilly then goes on to give an example of institutional racism as conceived by his guest. The two spoke past each other because each understood institutional racism differently. Unless we come to some agreement regarding what we mean by “needs,” I think we’re destined to do the same.
It’s not likely that my following words will put the issue you introduce to rest but it may serve as a starting point for discussion.
I’ll begin with the assumption that physicians and patients have the same needs. These needs have been listed by many scholars, the best known of whom is Abraham Maslow who differed from earlier writers of human needs in that he identified a needs hierarchy. At the bottom of the hierarchy are physiological needs which must be met in order to survive as biological organisms and at the top is self-actualization the satisfaction of which allows us to be all that we can be. Society dictates the range of behaviors that are acceptable for fulfilling these needs; there are boundaries beyond which people in any particular society are not supposed to go in their efforts to meet these needs. I conform to social norms when I remain within these boundaries; when I go outside of these boundaries, I can be said to have deviated from the social norms and may be labeled a deviant for doing so.
I desire good health because good health helps fulfill my need for safety. I may know exactly what I need to ensure my good health but may be compelled by social norms to seek help from physicians because they control access to many of the things I need to be healthy, at least I believe that to be the case. When I visit physicians, I expect them to see to my health needs as best they can without compromising my other needs – physiological needs, other safety needs, need for love and belonging, esteem, and self-actualization. I do not visit physicians to satisfy their needs any more than students attend my classes to satisfy my needs or clients visit attorneys to satisfy their needs. However, just as I believe that students should behave in ways that do not undercut my needs, I consider myself obligated to extend the same courtesy to physicians.
Therein lies the rub. Sometimes health care providers behave in ways that challenge some of my needs while they concomitantly seek to satisfy my need for good health – e.g., they may behave in ways that undercut my need for esteem including self-respect and show of respect from others. I can “take it like a man” or I can question the propriety of their behaviors. If I question the propriety of their behaviors, they are likely to perceive me as challenging their authority and thereby their need for esteem. One likely consequence is that I lose trust in the physician because I believe s/he has “gone too far” or has deviated from social norms and, if the physician refuses to compromise, I leave the health care facility and plan never to return. Some health care providers will take my response in stride and agree to see to my need on future visits. Others, because I have acted like a “bad patient” by challenging their authority, will lose trust in me as a patient and order me to seek health care elsewhere.
Ray
CONTINUED
CONTINUATION
Now, let’s make another assumption. Let’s assume that the documents (HIPAA, promise to pay, promise to treat, conditions of admission, patients’ rights and responsibilities, etc.) which are almost always given to patients before they receive treatment, are, in the aggregate, designed to meet or at least not compromise the needs of patients and all parties involved in their treatment. Who is most likely to violate societal norms in a manner that challenges the needs of the other? Are such norms more likely to be violated by those who have been resocialized in a counterculture or are they more likely to be violated by those who are part of “polite” society?* The question is, of course, rhetorical and the answer is true by definition.
Here is an example. Every provider I’ve visited as of late hands out a “Patient Rights and Responsibilities” document to the patient. When read, the document would make any uncritical patient feel all fuzzy and warm inside. You’re told that meeting your health care needs in an environment that protects all your other needs and rights is the facility’s number one concern. Then you read about your responsibilities designed to meet the needs of those who work at the facility. Easy enough, you say. All I have to do is treat others as I would want to be treated, be up front and honest with providers about my illness and knowledge of it, follow doctors’ treatment plans and accept responsibility for things that happen if I don’t, pay what I owe, and follow the facility’s policies. Fair enough, you say. Maybe not. What you’re not told is that the facility’s policies that you’re expected to follow trump the very rights about which you just got all fuzzy and warm inside. You were promised “considerate and respectful care” and “full consideration of your privacy.” You were promised that you would be “treated with dignity, respect, and consideration” and that “your cultural and personal values will be respected.” But one of the facility’s policies requires that a nurse “ALWAYS be by the patient when they [sic] are in the PACU (post-anesthesia care unit) – your back should never be turned to the patient.” That means that you are required to stand naked in front of a nurse while she watches you dress and if you must urinate, it must be done while a nurse watches, even over your objections, entreaties, and expressions of shame. There are no options or exceptions to the rule; everyone is treated the same, no matter their personal or cultural needs.
Ray
CONTINUED
CONTINUATION
You did your part; you met up to all your responsibilities, including following the rules but the provider was not transparent; you were not informed that the rules you were expected to follow permitted providers to violate the very rights you were promised. The result was friction between you and providers, depression and anger, a belief that you had been duped, an undermining of your trust, a feeling of powerlessness and frustration, negative physiological reactions (e.g., soaring blood pressure), increased suspicion of health care providers’ motives, a reduction in your likelihood of seeking health care when needed in the future, bad press for the health care facility, a pledge never to return for health care at the offending facility, etc. You find that efforts to bring about change via filing complaints with higher authorities is about as likely as seeing a platypus climbing the Empire State Building which aggravates your frustration, feelings of powerlessness and impotence, sense of hopelessness, and ultimately fosters cynicism. It’s not a pretty picture.
* If you recall, in an earlier post, I recognized that people in health care move back and forth from their counterculture at work and into “polite” society when they’re not at work. I also recognize that not all health care workers get caught up in the counterculture and if they do, not all behave in ways that compromise patients’ needs. A provider in a clinic, for example, may believe that s/he and other providers are entitled to open closed doors behind which intimate things are taking place without knocking,
Ray
I must do this post in 5 parts:
Ray et al,
You state:
I would predict you’d find a large minority of adults (30% to 40%) who would prefer same-sex providers. I’d posit an even larger percent for young people. The percent in either case, would vary according to certain demographic and personal traits of respondents. One variable that seems not to be correlated with preference, however, is prejudice; preference for same-sex provider tends not to be founded in prejudice (e.g., belief in the inferior abilities of the opposite sex) but in the desire to preserve one’s dignity. In spite of this desire, however, not all those who prefer same-sex providers reject or complain about being assigned to an opposite-sex provider for intimate exams. What are the reasons for the disparity between preference and acceptance? As Hamlet proclaimed, “that is the question.”
You are on to something that I have found in my studies that has been largely ignored. I think that you identified it in the statement, "the desire to preserve one’s dignity".
The AMA Journal of Ethics alludes to there being something other than gender in Patient Requests for a Male or Female Physician. It refers to a study published in Pediatric Emergency Care in 2005 entitled "'Doctor' or 'Doctora': Do Patients Care?" One of the study survey questions was:
"If you had a choice, would you prefer to have a male doctor, a female doctor, or the doctor with the most experience?"
This throws in to the mix another trait; qualification. Those who defend the gender neutrality of healthcare (on this and other blogs) usually say something to the effect, " I don't care if the doctor is male or female, I just want the most qualified."
So I ask, if by the nature of having initials after your name (MD, DO, RN, PA, NP, etc.) negate patient choice, why should qualification (or what we perceive as qualification, like intelligence, education, experience, etc.)? Remember the old joke, "Q: What do you call the person who graduates last in his class from med school? A: Doctor."
Why should all patients, even those in in the healthcare field, NOT just accept the first doctor or surgeon available?
Studies of the effects of physician gender on patient care have been limited by selected samples, examining a narrow spectrum of care, or not controlling for important confounders.
...Physician gender potentially affects the physician-patient relationship and its outcomes in a variety of ways. Physician gender differences in personality and attitudes, especially with regard to gender roles, might influence interactions with both male and female patients. Patients also may have differential expectations of their physician based on gender. For example, they might expect the female physician to be more supportive and empathic and, thus, to disclose more information. Another way in which physician gender might be important is in the status relationship between patient and doctor. As gender is a substantial component of social status, same-gender physician-patient dyads may be closer in social status (greater status congruence) than opposite-gender dyads.
Source: Physician Gender, Patient Gender, and Primary Care
...continued
Part 2:
And where does perception come in to all this? Sociologists and social psychologists have long known that there is a widespread perception shared by many people that physically attractive people are more intelligent and competent, as well as hold many other desirable characteristics.
A large number of experiments over the years have shown that, when asked to rate the intelligence or competence of unknown others, people tend to rate attractive others as more intelligent and competent than unattractive others. (Source: Psychology Today)
So competence is associated with attractiveness. Then the inverse is that people who are less attractive (or creepy) are perceived not as qualified (and not the best doctor).
To further the concept that there is more than gender, why do we not see physicians with visible piercings and tattoos? Answer; dress affects people's perception of physicians. See "Preferences of parents for pediatric emergency physicians' attire" and "Effect of doctor's attire on the trust and confidence of patients.."
But should it? Should patients not just have trust in a physician because they have initials after their name? Is that not what patients are told about gender.
Creepiness is very real. Our “creepy” reaction is both unpleasant and confusing, and according to one study (Leander, et al, 2012), it may even be accompanied by physical symptoms such as feeling cold or chilly. The little bit of research that was at all relevant focused on how we respond to things such as weird nonverbal behaviors, and being socially excluded. These studies did not use the word creepiness, but their results implied that our “creepiness detector” may in fact be a defense against some sort of threat.
...continued
Part 3:
So, what is creepiness?
A recent study (currently under review for publication) by Knox College social psychologist Francis McAndrew and his student Sara Koehnke takes a stab at unpacking exactly what creepiness is.
Creepiness universal human response related to the “agency-detection” mechanisms proposed by evolutionary psychologists. These mechanisms evolved to protect us from harm at the hands of predators and enemies. If you are walking down a dark city street and hear the sound of something moving in a dark alley, you will respond with a heightened level of arousal and sharply focused attention and behave as if there is a willful “agent” present who is about to do you harm. If it turns out to be just a gust of wind or a stray cat, you lost little by over-reacting, but if you failed to activate the alarm response and a true threat was present, the cost of your miscalculation could be high.
We evolved to err on the side of detecting threats in such ambiguous situations. Creepiness is anxiety aroused by the ambiguity of whether there is something to fear, and/or by the ambiguity of the precise nature of the threat—sexual, physical violence, or contamination, for example—that might be present.
Gender plays a role:
Note the rating of traits of creepiness, in this chart of the study results (Likelihood of a creepy person to possess certain characteristics), include gender (opposite 4.01, same 2.41).
95% of survey participants thought creeps were more likely to be male than female — a perception that was equally held by both male and female survey respondents. Women were also more likely to perceive a sexual threat from people they deemed creepy.
See a visualization of creepiness in "The Lonely Island's" song "The Creep."
...continued
Part 4:
As to every study done on gender preference of a physician (or other healthcare provider), they are ALL flawed! The flaw simply asks for the preference of a male or female physician. There are so many other variables that affect the decision beyond just gender. Here are examples:
In the study, "The role and impact of gender and age on children's preferences for pediatricians," the sample was taken when coming for an outpatient visit to a university-sponsored, urban pediatric practice. This is a population that is are regular patients at selected practices. These patients are already conditioned (or have developed coping mechanisms to deal with that as a traumatic event).
Data from students participating in the Commonwealth Fund 1997 Survey of the Health of Adolescent Girls, only asks the question of preference of the physician (provider) gender, but NOT necessarily for an intimate (genital) exam.
The study, "PHYSICIAN Gender Preference in Adolescent Males within an Inner-City Youth Population," does ask preference of the physician gender, for a genital exam. The problem is that there is an assumption that a GE is absolutely required, the patient has granted informed consent (including knowing that it can be refused without retaliation).
Note: The only absolute indication for a genital exam is a specific genital complaint. Even then, many diagnostics do not require direct genital examination. Many genital conditions can be diagnosed through urinalysis, blood tests, self-collected specimens (swabs), self-exams, imaging, etc. They are not necessary for "mandated" wellness exams (just as wellness exams are no longer necessary).
One example is a guidline for testicular cancer from "Teaching the TesticularExam:AModel Curriculum From“A”to “Zack”" which states:
"Patient preference would then determine whether these men would be screened by physician examination and/or TSE."
This is like the situation where somebody is wronged erroneously. The wronged person asked the one who committed the infraction, "Head or stomach?" (The inference is that to "make things right," the wronged party is going to give the perpetrator a "punch." They are being polite in letting them choose the "correction.")
One can study this situation and conclude that a certain percentage of people prefer to be punched in the head and a certain percentage prefer the stomach. Let us hypothetically say 80% prefer the stomach. I can then use this to justify me punching people in the stomach. This is what healthcare has done with gender and intimate exams.
...continued
Part 5:
In AAP publications dealing with genital exams, their guidelines all state:
"Routinely examining the genitals from childhood through adolescence can help the male patient understand the routine nature of this examination component." (Example: Male Adolescent Sexual and Reproductive Health Care
Note in the study "Shoe Size Changes - Layman's Marker of Onset of Puberty," 23% of the children refused the SMR exam.
To properly study this question the first question should be: "When going to the doctor, for a genital exam I:
C.) would refuse a genital exam
B.) prefer a male doctor
C.) prefer a female doctor
D.) have no preference if the doctor is male or female
E.) would make my choice on some other factor
An ongoing issue in healthcare is the failure of physicians to acknowledge that these situations are humiliating, can have severe negative side effects, let patients know that they can refuse them without retaliation (whether recommended by guidelines or not), and follow guidelines that call for omitting them.
Discussion about sensitive topics and sexual organs can be uncomfortable for both physicians and patients. If not appropriately addressed, this discomfort can result in inadequate patient education about self-examination of sexual organs, with failure to detect early warning signs of cancer. Discomfort may also result in patients feeling physically and psychologically exposed and humiliated, increasing the possibility of withholding important information or even avoiding the physician completely,1 which could potentially delay cancer screening and/or early diagnosis. Source: Teaching the TesticularExam:AModel Curriculum From“A”to “Zack”
Finally, this humiliation can be the source of many frivolous lawsuits. Consider this conclusion from one of the best articles that recognizes Shame and humiliation in the medical encounter:
I believe that most patients who are angry at their physician or at the medical profession are responding to perceived experiences of shame and humiliation. The specific complaints are not that the doctor makes mistakes, misses the diagnosis, causes too much pain, or charges too much. The complaints are that "the doctor does not listen to me," "the doctor tells me I am too fat," "the doctor seems too busy for me," "the doctor treats me like a piece of meat," "the doctor is sexist," "the doctor insults my intelligence," "the doctor thinks my problem is all in my head." Underlying these complaints, I contend, are the emotions of shame and humiliation.
Maurice,
You write, “Patients, in general, are pleased with my student, irrespective of gender, and tell me that when I enter the room after the student has left . . . You would have to be with me to recognize what I tell you now is truthful.”
I don’t question the veracity of what you write; I question the method by which you draw your conclusions. In addition to teaching Evaluation Research for 33 years, I was the program evaluator for an umbrella agency (Pima Alcoholism Consortium) that monitored a set of alcoholism treatment facilities. I worked with program directors to identify agencies’ goals, measurable objectives, and instruments to assess the extent to which objectives were achieved. When data were available, I would rigorously test the effects of programs on the achievement of objectives. There was one exception – a physician-run facility. His facility was not subjected to rigorous test. His conclusions about program effectiveness were based on casual observations of the sort you make, Maurice, rather than systematic analysis. Consequently, there was nary a recommendation that came out of our agency regarding how to improve his program – e.g., recommending techniques for increasing how pleased clients were with students’ performances or suggesting strategies for improving families’ access to life-saving services. When I quizzed our program director about the propriety of treating the physician with kid gloves, he gave me a puzzled look and replied, “Why, he’s a doctor.”
When the state monitored us, we had empirical evidence of changes and improvements made in other agencies but when it came to the physician-run facility, we had nothing to give the state except the impressions of the physician-director. Furthermore, directors of other programs were, understandably, put out and embittered by the differential treatment. Consequently, they resisted efforts at compromise and negotiation, subverted efforts to monitor their programs, sought to put our agency out of business, and used those of us who had to work closely with them as whipping boys. Eventually, the director of our umbrella agency was terminated and the physician-directed agency was scrutinized using the same rigorous standards adopted to evaluate other agencies. The physician-director responded with moral indignation, quit, and was replaced by another physician who was amenable to program evaluation and the consequent program development. I and some of his staff worked together and in no time at all we came up with ways to measure program objectives and success. We carried out an evaluation study and found where the strengths and weaknesses were. Some of the weaknesses were glaring and would have resulted in provisional accreditation by the state if they were not dealt with in a timely fashion. The data collected pointed to ways of ameliorating the problems discovered. We implemented those ways, tested their effects, and were pleased with the outcome; so were state authorities.
Ray
CONTINUED
CONTINUATION #1
Here’s what it was like working with the first physician-director. What follows is historical fiction. The account is fictional, but the process leading to the scientifically-based assessment of a social service program is historical fact.
Me: “Dr. Physician-Director, tell me what your program objectives are.”
Dr. Physician-Director #1: “Well, one objective is to make sure that clients are pleased with the students who are assigned to them.”
Me: “That’s a noble objective. What do you think is a good way to determine how pleased patients are with their students?”
Dr. Physician-Director #1: “I already do that.”
Me: “Wow, ‘you’re a better man than I, Gunga Din.’ What do you do?”
Dr. Physician-Director #1: “I enter the room after the student has left [and] I directly talk to them and thank [them].”
Me: Do you directly speak with them about how pleased they are with students – that is, do you solicit a response to a question such as, “Were you pleased with the student?” or do you wait for them to offer their opinion?
Dr. Physician-Director #1: “I make a mental note when a patient says something about the student. Patients, in general, are pleased with my students.”
Me: Did you keep a record of this?
Dr. Physician-Director #1: “Of course not, I have better things to do.”
Me: “You may very well be correct; patients may indeed be pleased with the students assigned to them, but we’ll need something more than just your impressions based on casual observations.”
Dr. Physician-Director #1: “I don’t understand why that is. Why can’t you just accept my word?”
Me: “I don’t at all question your sincerity. I truly believe you’re being open and honest and sincerely believe what you say is correct. Unfortunately, casual observations are open to unintentional errors of inquiry. For example, casual observations are susceptible to overgeneralization, selective perception, and illogical reasoning. It’s also true that people who have vested interests in a program may inadvertently and unintentionally see and hear things – usually positive – they expect to see and hear about their program. Furthermore, in your case, you’re not speaking to people in a neutral environment; the authority you carry as a physician can influence what patients say.”
Dr. Physician-Director #1: “I don’t know anything about all that. I see no way to deal with the problems you’ve identified. I think what you call casual observations are as good as anything else. What is superior to making casual observations? People have been doing it for eons and we’ve gotten along okay.
Ray
CONTINUED
CONTINUATION #2
Me: “Scientific inquiry is superior to casual observations. Unlike casual observations, scientific inquiry is systematic and deliberate; it involves the creation of demonstrably valid and reliable instruments to measure variables, the use of certain generally accepted methods to collect data using these instruments, a systematic analysis of the data, and the drawing of conclusions based on patterns uncovered by the analysis. When all this is done, the likelihood of the common errors associated with casual observations diminishes. I should add that those who evaluate our evaluations help keep us honest, too. They like nothing better than to catch us in a methodological snafu.”
Dr. Physician-Director #1: “But, you would have to be with me to recognize what I tell you now is truthful. Patients may think your presence is intrusive and they may as a result not be as pleased with their experience. I don’t like that idea.”
Me: “Neither do I. My presence there with you when you speak to patients might also augment the influence of authority on their behaviors. There are other more unobtrusive procedures for gathering data. We can conduct a survey of patients soon after they leave your facility using an anonymous questionnaire, telephone interview, or even the internet.”
Dr. Physician-Director #1: “Well it sounds like a lot of work for something I don’t think would be very fruitful. What would be the benefit?”
Me: “That’s a good question. It may not be beneficial; it may not tell us anything or anything we don’t already know. That’s why we need to deliberately create measures, test our beliefs about what’s going on, and add to our knowledge about what’s going on. I and my colleagues will do the bulk of the work. Your major job will be to approve or recommend changes in what we do.
Let me ask you this. You told me that patients are pleased with students. How pleased are they? Are some patients more pleased than others? If so, what are the characteristics and experiences at your facility of those who are more and those who are less pleased? Would answers to these questions have any utility? Maybe answers to these questions could provide you with information about how to increase patients’ satisfaction with the students assigned to them.
Dr. Physician-Director #1: “You have an answer for everything, don’t you? I’m tired of your jiggery-pokery and I’m satisfied with what I’ve found. If patients say they are pleased then they must be pleased and that’s good enough for me. If you and those jackanapes at state want more, you’ll just have to do it yourself without my help. Hey Mildred! Show this guy out.”
Ray
CONTINUED
CONTINUATION #3
The replacement physician-director has been through evaluations of programs before and found them useful for program development. He assigns a staff member to work with me and report back to him. We create a multidimensional measure of “patient satisfaction with medical student” and establish its level of validity and reliability. We distribute this instrument to a random sample of patients who had medical students assigned to them and they rate their level of satisfaction on each of several dimensions (e.g., satisfaction with demeanor, satisfaction with communication skills, satisfaction with empathy shown, etc.). We score each subject on each dimension and on satisfaction level in general.
We don’t have any hypotheses to test regarding who will be more or less satisfied so we do some data dredging. That involves correlating satisfaction scores with 52 variables (e.g., race, age, sex of patient, sex of student, years of schooling, type of procedure, outcome of treatment, etc.) to see if any patterns pop up. We find considerable variation in satisfaction depending on the dimension measured. For example, we find that patients tend to be significantly more satisfied with students’ demeanor than with their communication skills. We also find statistically significant relationships between different dimensions of satisfaction and some of the 52 variables and a statistically significant interaction among sex of patient, sex of student, intimacy of examination, and overall satisfaction; patients who receive intimate exams tend to be significantly more satisfied when they are assigned same-sex students than opposite-sex students. This is surprising, given Dr. Physician-Director #1 insistence that patients’ satisfaction does not vary according to sex of patient/sex of student, even when intimate examinations are involved.
Given that we found a correlation and correlation is not causation, we decide to conduct a randomized experiment after getting IRB approval. Experiments are best for determining whether or not a causal relationship exists between or among variables. We use our findings to hypothesize that patient satisfaction will be greater if patients are allowed to choose the gender of the student before an intimate examination than if they are not. We randomly assign patients who are to receive an intimate examination to an experimental group. Patients in this group are approached and told the following: “There is a medical student accompanying the physician today. May we have your permission for the student to be in here with the physician?” If the patient assents, s/he is asked, “Would you prefer that a female student or a male student accompany the physician or doesn’t it matter to you?” Control group patients are simply asked if they will consent to a student accompanying the physician.
Ray
CONTINUED
CONTINUATION #4
An anonymous questionnaire to measure satisfaction with medical student is sent to patients involved in the experiment after they leave the office. The data they provide are analyzed. It is found that patients in both the experimental and control groups tend to report favorable experiences with students. However, those in the experimental group are significantly more likely than those in the control group to report favorable experiences and their satisfaction tends to be greater than the satisfaction of control-group patients (p <.05). The recommendation – To increase the satisfaction of patients who consent to the presence of medical students during intimate examinations, ask them if they prefer a male or female student or if they have no preference. The new practice is implemented and patients’ satisfaction with students is compared to their satisfaction before the implementation of the new practice. It is found that the aggregate satisfaction of patients is statistically higher after than before the new procedure and this difference is due to the greater satisfaction of patients getting intimate procedures who are given a choice of student gender.
So, again, Maurice, I don’t question the veracity of what you write; I question the method by which you draw your conclusions. It takes more, a lot more, than casual observations to convince me that something is true or false. It takes something akin to what is described in my historical fiction.
I believe that you earnestly believe what you have inferred from casual observations. At the same time, I also believe that you are as susceptible to the errors associated with casual observations as I am. When anyone – doctor, lawyer, or Indian chief – posits a hypothesis based on casual observations, I have learned to take it with a grain of salt. Indeed, I could teach an entire course on Science, Pseudo-Science, and the Layman’s Conundrum about the disparities among scientific findings, pseudo-scientific findings, and beliefs that arise from casual observations, common sense, tradition, misuse/abuse of authority, and other non-scientific sources of information. In short, I’m from Missouri; you’ll have to show me partner and it takes a lot more than conclusions based on casual observations to do that.
Ray
Maurice, Ray, et al,
Let me use historic example: Pelvic exams on anesthetized women during surgery.
I am sure that every surgical director at these facilities would say that patients are satisfied with the students involved with their care…
Since 2003, when Dr. Peter Ubel first exposed this practice in his article, "Don't ask, don't tell…” in the American Journal of Obstetrics and Gynecology the practice has continued through 2012 when Dr. Shawn Barnes confirmed in the journal Obstetrics and Gynecology that the practice continues. If past performance is any predictor of future performance, I can say with complete confidence that it continues today.
The practice continued (through 2012) despite; states outlawing the practice, associations (reluctantly) produced guidelines against it, bad publicity in media outlets (like ABC News), and so on…
WHY? I ask why?
Note: I am not directing the following at (you) Maurice. I am about to become brutally honest in an attempt to stimulate critical thinking.
I do not know which is more troubling, the practice continuing despite the fallout of the 2003 revelation, OR the fact that physicians did NOT know (or care) that the practice was morally and ethically wrong in the first place.
…and after the Nuremberg Physician trials, and Tuskegee.
Is this sociopathic behavior, hubris, or both?
Even the AMA acknowledges that medicine has broke it’s social contract with society:
Social scientists argued that medicine had abused its monopoly to further its own interests, had self-regulated poorly, and that its organizations were more interested in serving their members than society.
Source: AMA Journal of Ethics, "Professionalism and Medicine's Social Contract with Society"
...By the latter part of the 20th century, however, many social scientists concluded that the profession had abused its privileged status and public trust, and that its regulatory procedures were seriously flawed. Standards were considered to be weak, variable, and inconsistently applied, and physicians were further accused of using collegiality as a means of shielding poorly performing peers. Medicine was further criticized for its lack of openness and transparency in regulatory procedures and for the absence of public involvement in them. In short, the system appeared to lack accountability, and it was suggested that an informed public should participate in medicine's regulation. Many of these criticisms proved to be accurate and had an impact on both public policy and on the level of trust that the profession enjoyed.
...Since the medical profession's rights to self-regulation are delegated by society via federal and state legislation, society can, if it becomes dissatisfied with the performance of the profession, alter the terms of the social contract and reclaim some of these powers. Following major lapses in self-regulation and a consequent decrease in trust, society has already diminished the scope of medicine's powers (eg, the Office of the Inspector General's new guidelines for physicians' relations with industry)
Source: AMA Journal of Ethics, "The Medical Profession and Self-Regulation: A Current Challenge"
Perhaps asking for patient input long ago would have prevented the state healthcare is in now.
--Banterings
Hex,
On your Sunday, 12/13/15 12:12 pm “take” you give three opinions. The first is that only the medical student benefits from teaching subjects. Maurice outlined some ways he believed patients could benefit. I can conceive of how patients may sometimes benefit from interaction with students. Maurice should consult with the AMA and give its “Code of Medical Ethics” more substance by adding to what it writes in “Opinion 8.087 – Medical Student Involvement in Patient Care: . . . Patient and the public benefit from the integrated care that is provided by health care teams that include medical students.” If you sacrifice yourself, if sacrifice it be, for the common good, you and yours will reap the rewards of integrated care.
I kept a record of what occurred during 32 occasions when I was used as a teaching subject. I was never asked my consent and on only one of the 32 times was the student an active participant in my treatment. On no occasion was a student introduced nor was the status and function of the student explained to me.
Were I to overgeneralize from my own experiences, which I will not do, I would take exception to Maurice’s and the AMA’s claims. I would take exception because, in part, the ethically proper protocol identified by Maurice was not followed during the 32* occasions in succession when I was used as a teaching subject. In 31 of those occasions, I was used as a visual aid; my prior consent was never solicited, I was never introduced to students, students’ status as student was not communicated to me, and the role and function of students in my health care was never mentioned. Students merely shadowed the physician, sat down on a chair, and observed the proceedings. They never said a word to me or the physician and neither I nor the physician said a word to them. They may as well have been invisible, but they weren’t because they were intruding on my privacy. I got nothing positive out of the experiences and I imagine the students, in many instances, didn’t either. Indeed, the students involved were more objectified than I was; at least the physicians spoke to me.
On the remaining occasion, I was used as a teaching tool, again without my consent. I made an appointment to receive a synvisc injection for osteoarthritis knee pain relief. The student entered the examination room, introduced herself, and proceeded to practice on me, performing procedures without explaining their relationship to a synvisc injection. The attending physician entered the room, engaged in a little small talk with me after which he injected the synvisc. If I benefited by my interactions with the student in the ways suggested by Maurice, nobody told me. Oh, by the way, after all that, I experienced no knee pain relief.
I was used as a teaching subject (either as a visual aid or teaching tool) dozens of times before and after collecting the data on my 32 visits. I cannot say that I realized any benefit from a single one. I do know I was objectified as providers instructed students in whatever medical art they were teaching and I was subjected to gratuitous physical pain when students practiced certain pain-producing maneuvers on me that were repeated by the physician. Nevertheless, in spite of my personal experiences, I can still imagine that some patients could benefit in ways described by Maurice, but I personally do not intend to hold my breath.
* I have been used as a teaching subject many more times but I took notes on only 32 visits to physicians in health care clinics.
Ray
Hex,
Your second of three statements is, “The patient’s specific prior consent should be obtained before a student is allowed to observe or participate in any exam or procedure.” I’ve argued elsewhere that prior consent to participate as a teaching subject is ethically obligatory. It is an ethic that has been, at least partially and not unambiguously, recognized quite recently by the AMA (but never by the ANA) in its “Code of Medical Ethics” and followed by some (but not all and possibly not a majority of) physician-educators, including Maurice. In “Opinion 8.087,” the code reads, “Patients are free to choose from whom they receive treatment. When medical students are involved in the care of patients, health care professionals . . . should ensure that they are willing to permit such participation.” This opinion implies, with some ambiguity, that prior consent be obtained from patients who will serve as teaching tools but not those who are used as visual aids as occurred to me in the 31 cases I describe in my last post.
Ray
Ray, first, we never use the expression "teaching subject" to identify a patient. (If the expression "teaching subject" is to be used it is used to identify those teachers of medical students who educate the students in genitalia exams on themselves. We also can use "teaching subject" to mean "standardized patients" who are actors and are used to provide standardized history to the students and allow physical examination. Both groups are well paid. Real patients are identified only a "patients".
I feel very sorry for any patient such as you, Ray, to have been treated in the way you described with either one student or multiple students present. Our students are identified as "medical students" and in no way identified with the terms "doctors" or "student doctors". "Shadowing" is not done without permission of the patient. Every single time that I go into a patient's room to demonstrate how to detect abdominal ascites (for example) to the entire group of 6 students, the student who has spent an hour communicating with the patient asks the patient permission for me and the rest of the class to enter and then, if given the permission, I go in alone to ask the same question after identifying myself and my activity. It is only then after the patient accepts both requests, that the students all enter. And, after I demonstrate detecting the "fluid wave" and testing for "shifting dullness", it is only with the continuing approval of the patient that permits each student to practice briefly on the patient. All the while, I watch for any signs of distress by the patient and if found would terminate the practice session. And, yes, the patient and each student do communicate during this activity.
Ray, I don't know what type of institution you had your experiences but obviously it was not like mine. And you should have "spoken up" unless this was your research project and not part your protocol. ..Maurice.
Hex,
You recommend that prior consent by patient to serve as a teaching subject “be obtained without the student present.” You also suggest, “In the event the exam or procedure involves intimate exposure, the patient should also be informed of the gender of the student [and] . . . this should be done without the student present.” Correct me if I am wrong, but I assume that you believe it is preferable that the attending physician secure the patient’s consent, or do you believe someone else should do it (e.g., receptionist, nurse, etc.). Can you be more definitive and offer an argument: Who do you believe is the most suitable candidate for obtaining patients’ consent. Why is it the person in this status preferable over someone else? Why is it not preferable for the student to obtain consent?
Ray
Maurice,
I am quite aware that your approach to delivering health care varies from what I and other posters have described and I appreciate your efforts to lead students in the “right” direction. If all medical instructors of 1st and 2nd year medical students take the same approach to teaching students as you do, and if all of these students recognize the desirability of this approach, then something is going on between year three and when I and other posters have had the experiences on which we have reported in this blog. I, no doubt, sound like a broken record, but I’ll repeat myself for the umpteenth time What is going on after year two is the resocialization of students and providers into a system that is maintained and becomes increasingly entrenched by a set of countercultural values, beliefs, norms, language, and behavior patterns. I suspect that the students who go through your program are as vulnerable to this resocialization as students who go through other 1st/2nd – year programs.
Speaking for myself, what I described that happened during those 32 visits were also at variance with what I usually experienced. Usually, no student was present and things went quite smoothly. But had there been a student present, I suspect the same ethically questionable protocol I described would have been used. It was, if you will, standard operational protocol practiced across physician-educators in the community where I lived. As I’ve reported in the past, the research conducted by students and me suggested that men were more likely to experience this protocol than women.
I brought what I found on those 32 visits and from the survey research I and students conducted to the attention of local authorities including hospital and university administrators. One hospital administrator was skeptical until he interviewed a few hospital administrators he knew who confirmed what I told him. He brought what he found to the attention of the quality improvement officer (QIO) at the hospital who took the position that prior consent was not a right but a privilege. A human right is something that is accorded a person because s/he is a human being; it needn’t be demanded, requested, purchased, or otherwise earned; that would be a privilege. According to the QIO, demand is exactly what a patient would have to do if s/he did not want student involvement. More specifically, s/he would have to put a request in writing and submit it to the physician-educator. The physician-educator had the authority to award the patient the privilege of not serving as a teaching subject or s/he could reject the request. If the patient and physician-educator did not see eye-to-eye, then, according to the QIO, “services will not be rendered . . . except in emergency situations.”
Ray
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I brought my concern to the head of nursing at the university who argued that prior consent was not needed at a teaching facility. By virtue of choosing to seek services at the local teaching hospital (the only hospital within 36 miles) or its affiliate clinics, a patient was automatically (ipso facto) agreeing to be subject to student care and observation. She also defended here position by proclaiming, “Research shows that patients benefit from the care given by nursing students.” I had studied the research; methodologically, it wasn’t the best I’ve read but it was okay. It showed that patients “tend” to benefit from nursing student care. But, it doesn’t matter because her argument was based on the introduction of a red herring; even if it is true that patients tend to benefit from student nursing care, it doesn’t follow that it is not ethically obligatory to get prior consent.
The fourth community leader with whom I corresponded about my findings was the president of the local university where a Nursing Department was located. He commented in writing about my concerns. He indicated in his letter to me that he was satisfied that no patient rights were being violated when nursing students were involved in the health care of students. The source of his information was the head of nursing.
Ray
Maurice,
Regarding your comments about use of the term “teaching subject”: It was used by every health care provider to whom I spoke on the subject (no pun intended) during the time I was doing my research. It was also used in hospitals’ “Conditions of Admission” forms. Teaching subjects were those of us who were observed by (thus my use of visual aid) or cared for (thus my use of teaching tool) by students. I don’t know if the concept is still used.
I use “visual aid” and “teaching tool” metaphorically to signify the objectification and dehumanization of the patient. Some people may consider their use to be hyperbole or dysphemisms. I’ve read publications in which authors have criticized the use of “subject” (e.g., research subject, teaching subject) as itself carrying impersonal and objectifying connotations. I can’t quibble with that, but in a sense the use of “subject” may be considered a euphemism because it does not have the specificity of nor does it carry home the message as poignantly as “visual aid” and “teaching tool” do.
When you wrote that “teaching subject” is used by medical school instructors “who educate the students in genitalia exams on themselves,” I was reminded of a video that was played over and over all day long in a patient waiting room at the Mayo Clinic in Rochester. It was a good ½ hour tape of a young man checking himself for testicular cancer. What would possess hospital administrators at one of the most prestigious hospitals in the world to approve such a thing – in a patient waiting room of all places? (I think I answered my own question earlier.)
Ray
Ray,
In answer to your question of "why not the student?", it's the same reason the student should not be present when consent is requested: intimidation factor
Some people are intimidated or may feel guilty of offending the student if they say no with the student present, even though they are very uncomfortable with the idea of the student observing or participating. Quite often afterwards they will be upset and feel guilty for not standing up for themselves. Keeping the student out of the consent interaction eliminates these potential problems.
The MD, PA or NP are the licensed practicioner, the student's actions are their ultimate responsibility. There should be only one primary point of contact with the patient with respect to obtaining informed consent and that should be the responsible practicioner. Forcing the patient to deal with multiple people for various consents can be extremely confusing and misleading to the patient. In the words of an old English idom, they should be allowed to "Speak to the organ grinder, not the monkey."
Hex
Hex, the medical student is the "organ grinder". It is their job not only to obtain a history and perform a physical but much more and that "more" is personally interacting with the patient from the outset and throughout the relationship. That is why we have the students obtain the consent from the patient at the outset and sequentially what follows. The student is the one who has to deal with being rejected or being accepted by the patient. And, by the way, though most patients will accept the student to begin the interview, it is not rare that at some point the patient "speaks up" to the student and terminates the interview or examination with one explanation or another. The student then thanks the patient for their participation and leaves without trying to get the patient to change their mind. The students doesn't feel "rejected" since they are aware that the entire session is dependent on the patient's consent and as we tell the student, it is the patient who is voluntarily assisting in the patient's learning. Now, remember, I am writing about first and second year students. In the 3rd and 4th year clinical clerkships when the students are learning not in a classroom but on the hospital wards, the relationship with the patient is a bit different since at times the student may be directly contributing, under supervision, to the medical management of the patient even though the the patient's own MDs are the responsible parties. I can only detail intimately what goes on in the first 2 years, since that is my work. ..Maurice.
Hex and Maurice
Thanks for sharing your rationale with me, Hex. It introduces some interesting empirical questions.
I personally would be pleased if anyone would secure my consent before I provide any unremunerated service to others. I have frequently given unremunerated services to people and organizations, including serving on boards of health care facilities. My consent has always been obtained (sometimes in a way that bordered on begging) and the recipients of my “largess”* have always expressed their gratitude in a number of ways, including saying “thank you.” By contrast, in the counterculture of health care and in my status as patient, my consent has never – not once – been obtained before I provided my services as a teaching subject – not by physician-educators, medical students, nurse-educators, nursing students, ultrasonographer-educators, ultrasonographer students, and right on down the line. And never – not once – when I have stayed mum and “graciously” allowed students and provider-educators to “exploit their good fortune,” I have never – not once – been thanked; not even a simple “thank you” has been extended to me. Why is that? I think I have a partial explanation for my experiences. They don’t think I’m doing them a favor; they think they are doing me a favor. That is the claim made by the head of nursing whom I mentioned on an earlier post. However, it can only be a partial explanation because some provider-educators, such as you Maurice, and those responsible for “Opinion 8.087” of the AMA’s Code of Medical Ethics express the belief that patients benefit from student participation but, at the same time, demand that prior consent be obtained. If I had the authority, Maurice, I would require every health care student and every health care provider who believed s/he was entitled to treat patients in the way I just described to be reeducated by you and by other provider-educators who take your approach. However, I am skeptical that it would do much good because there are more important factors than belief that students’ presence benefits patients which determine the behavior I’ve described. I cover some of them in my “Sense of Entitlement” paper.**
So, Hex, I have no personal interest in who asks for my prior consent as long as someone asks. I write this as a preface to my response to your last post because I want you to know, I have no vested interest in taking one position over another. My intent is to go where the evidence lies, which I will do in a later post.
* I use quotations marks when, among other reasons, I am writing “tongue in cheek.”
** By the way, Maurice, I sent you my e-mail so that those who are interest in getting my paper can e-mail me. I don’t see it posted. Did I miss it? It is ss50@truman.edu.
Ray
Hex and Maurice,
Hex, the AMA agrees with your belief that it is the physician who should ask, but it gives no rationale; I suspect that its rationale is the opposite of yours. In the AMA’s Code of Medical Ethics “Opinion 8.087” it is stated, “Patients and the public benefit from the integrated care that is provided by health care teams that include medical students. . . When medical students are involved . . . health care professionals should relate the benefits of medical student participation to patients and should ensure that they are willing to permit such participation. GENERALLY, ATTENDING PHYSICIANS ARE BEST SUITED TO FULFILL THIS RESPONSIBILITY.”
Hummmm! Given the history of medicine, I am inclined to believe that the AMA is most interested in creating a situation that lends itself to as many patients as possible giving their consent. I’m skeptical that it is not most interested in encouraging the modest to listen to the little internal voices that instruct them to say “no” – to cave in to what some, if not most, in health fields believe is an “irrational” desire for privacy?
I believe what I’ve written is correct for two reasons. First, for most of history, medicine’s code of ethics did not recognize prior consent for using patients as teaching vehicles to be an ethical requirement. Banterings wrote in an earlier post about the focus of medical “ethics” in the early years. Furthermore, until around the turn of the century, the AMA’s Code of Medical Ethics was more a code of etiquette governing the relationships among physicians and with other health care providers than a code of ethics governing the treatment of patients (Kathleen Fenner. 1980. Ethics and Law in Nursing. Nostrand Reinhold.). I don’t know all the factors that compelled the AMA leaders to expand its codes and to recognize rights that had never been recognized before, but, to their credit, they did. However, to deny the past as some do and suggest that the AMA’s motive suddenly morphed from utilitarian to altruistic makes little sense to me.
Second, the AMA Code of Medical Ethics extends legitimacy to a questionably ethical practice (see Appendix) – trying to persuade resistant patients that they SHOULD give consent for student participation in their health care, sometimes over their better judgment. By using “should,” the Code does not just permit but makes it an ethical imperative for physician-educators or attending physicians to convince, cajole, inveigle, if not compel resistant patients to allow student participation in their health care. The Code recognizes, correctly, that it is the “attending physician” who is “best suited” to do this rather than anyone else, including medical students – best suited, not ethically, but best suited in the sense that the authority MD or DO credentials carry have far greater potency for securing patient compliance to physicians’ wishes than the authority carried by any other credentialed (e.g., physician assistants) and non-credentialed (e.g., medical students) individuals in health care. I won’t cover the evidence that Banterings and I have offered on this blog regarding the effects of authority, including the authority that accompanies the title “doctor,” on human behavior. To do so would be like “beating a dead horse.” The only thing I have left to offer are some choice anecdotes which I can provide if asked.
Ray
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CONTINUATION #1
By contrast, Peter Ubel and gang (of pelvic exams on anesthetized women fame) side with Maurice. They believe that students should be the ones that secure patients’ prior consent without physician-educator attendance. By so doing, they argue, it helps them become comfortable with getting consent, something they will be compelled to do in many different situations when they become physicians. Indeed, maybe if medical students were trained more thoroughly than they presently are in securing informed consent from patients, we would not have a basis for the complaints regarding informed consent that I have read about in earlier volumes of this blog. This possibility remains an empirical question as far as I know.
Forward to your argument, Hex. You write, “In answer to your question of ‘why not the student?’ it’s the same reason the student should not be present when consent is requested: intimidation factor.” If a physician accompanies a student who asks consent, there is, indeed, likely to be an “intimidation factor.” Research by Stanley Milgram and others would lead one to hypothesize that the “intimidation factor” is likely to be high if a physician seeks patient consent without the presence of the student; the presence of the student, however, would not add to the effect of the “intimidation factor,” whether it is the physician or the student who seeks consent. It is the authority associated with the status of physician that is most important in determining the “intimidation factor.” One would induce from past research that if the student sought patient consent without the presence of the physician, the “intimidation factor” would be less than if it were done while the physician were present. Again, whether or not I am correct is an empirical question. But, if I am correct, then, all things being equal, there should be fewer patients who consent to serving as teaching subjects if students without the presence of physicians seek consent than if physicians without the presence of students seek consent.* One would surmise from what I’ve written above that the AMA would be most interested in the former than the latter outcome.
Your next hypothesis is that if the student seeks consent, the anticipation of feeling guilt for offending the student might compel patients to consent over their better judgment. Let’s call this the “guilt at offending student factor.” Your statement implies that if the physician seeks consent, the anticipation of feeling guilt for offending the student is less than if the student seeks consent. Plus, you don’t consider the possibility that the patient will anticipate feeling guilt for offending the physician by denying student participation in his or her health care and for that reason will not consent. Let’s call this the “guilt at offending physician factor.” (I’ve offended physicians by rejecting student participation, as noted in an earlier post.) Under which of the following conditions will patients most likely consent when they really don’t want to: 1) when they are concerned about feeling guilt for offending students but not physicians; 2) when they are concerned about feeling guilt for offending physicians but not students; 3) when they are concerned about feeling guilt for offending both students and physicians? These too are empirical questions to which, at the moment, your guess is at least as good as mine.
* Maurice could easily test this hypothesis thereby adding to our knowledge of patient-provider social dynamics.
Ray
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Your metaphorical use of “Speak to the organ grinder, not the monkey” is interesting. I don’t remember ever hearing that expression before, even though as a kid in Manhattan I had frequent exposure to organ grinders and their little critters. Having been exposed to organ grinders’ routines, it seems that your metaphor breaks down quickly. You recommend that the physician (organ grinder) speak to the patient about consent, not the other way around. The only role the patient has in the interaction is to assent or not to assent. If I remember correctly, the organ grinder never spoke; he was too busy playing his organ. He let his monkey (medical students) do his “speaking” for him by doing tricks and running around with its money cup begging for coins. Some people, especially kids, thought they were giving coins to the cute little buggers rather than to the not so attractive organ grinders. Their magnanimous gesture made them feel good; all warm and fuzzy inside maybe due to endorphins raging through their bodies. Therein lies another possible factor that affects patients’ decision to consent when they otherwise would not. – call it the “altruism factor.” However, I doubt if people who consent because of altruism are as likely to kick themselves for consenting as people who consent because of the “intimidation factor” or the “guilt factor.”
By way of summary, as I’ve written, personally, I’d be happy if anyone would seek my consent before students participate in my health care. For patients in general, if the choice is between physician asking and student asking, I believe the “intimidation factor” is less if the student without presence of physician asks than if the physician asks with or without presence of patient. Some patients when asked to give consent by a student may experience a “gush of altruistic fervor” and consent when they would otherwise not do so. The effect of this “altruistic factor” may help mitigate the effects of the lower “intimidation factor” when students ask than when physicians ask, but probably not by much. I’ve nothing to cling to when it comes to predicting outcomes of the “guilt factor.” I’m inclined to believe that it has little effect one way or another.
So, there’s my take. Given the available evidence, it is reasonable to hypothesize that if one is most interested in maximizing patients’ freedom to say “no,” or put in another way, if one is most interested in reducing the inhibition of patients to decline participation by medical students, it is the medical student without the presence of a physician-educator who should seek prior consent. This option should have the effect of minimizing the potency of the “intimidation factor.”
Ray
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APPENDIX
Every profession has a code of ethics. They all recognize, either directly or indirectly, the universal ethical principle of “respect for persons,” a principle that is paramount in every internationally accepted code of ethics such as the Belmont Report. According to Belmont, this ethical principle “incorporates at least two ethical convictions” one of which is “that individuals should be treated as autonomous agents. An autonomous person is an individual capable of deliberation about personal goals and of acting under the direction of such deliberation. To respect autonomy is to give weight to autonomous persons’ considered opinions and choices while refraining from obstructing their actions unless they are clearly detrimental to others. . .” There’s the rub – “refraining from obstructing their actions unless they are clearly detrimental to others.” The Belmont report addresses the latter. The principle of respect for persons requires that researchers and practitioners conform to the requirement of informed consent. “The consent process can be analyzed as containing three elements” one of which is “voluntariness.” It is ethically obligatory to CLEARLY INFORM INDIVIDUALS OF BENEFITS AND RISKS THEY MAY ACCRUE FROM THEIR PARTICIPATION. “Even when some direct benefit to them is anticipated, the subjects should understand clearly the range of risk and the voluntary nature of participation.” Voluntary participation requires that participants not be subject to coercion, undue influence, or unjustifiable pressures. According to the Belmont Report, “Unjustifiable pressures usually occur when persons in positions of authority or commanding influence . . . URGE A COURSE OF ACTION FOR A SUBJECT” THAT THE SUBJECT MAY OR MAY NOT WANT TO TAKE.
There you have it. Maurice follows this ethical principle almost to the tee while the AMA Code violates it on several fronts. Maurice makes room for patients to change their minds about student participation at any time. When this occurs, students are required to permit the patient to leave “without trying to get the patient to change their mind.” The only thing missing is “clearly” informing patients of risks and benefits they may accrue from their participation. Bravo, Maurice! You follow ethical guidelines that, unfortunately, are absent in the AMA’s 8.087 Opinion but inherent in international codes of ethics, such as the Belmont Report. If you haven’t communicated this to students, you might consider doing so. I and medical researchers are obligated to follow these dictates. If we did not, our research proposals would not pass IRB scrutiny. Given that ethical principles are universal, they must transcend professions and if they must transcend professions, then health care practitioners are obligated to conform to the same ethical guidelines as researchers.
For “Opinion 8.087” to meet the ethical standards of Belmont, it would have to require what Maurice requires in addition to informing patients not only of the benefits of patient participation (which is obviously meant to influence patients’ decision to give consent) but also the risks of participation.
Ray
Ray, no risk to patients from being interviewed and examined by first or second year medical students. They pose no potential harm to any patient including even patient modesty harm. In fact, as I have noted on this thread many times over the years, I even have to remind the students to have the patient remove stockings before the student begins the neurologic and vascular status and simple inspection of the patient's feet. You can't imagine how many times I have seen a student "examine" the patient's feet but with the socks still present. Many. In terms of emotional "harm" in history taking, the student's regularly explains to the patient that they are about to ask "sensitive" sexual history and look for the patient's permission or rejection before asking.
In the later years of medical education and experience, yes, informed consent should include "risk" since procedures are carried out and a procedure either by a student or by a doctor might carry some risk (perhaps trivial) but some risk that the patient should be aware and either accept or reject. ..Maurice.
Dr.B,
My comments were in context to the clinical medicine environment, not the 1st/2nd year medical student interactig with volunteer patients in a classroom environment. They are very different situations.
Ray,
"Speak to the organ grinder, not the monkey" is an old English idom that has been around for a very long time. It simply means, speak with the person in charge, not the subordinate.
Hex
Hex, although the process is one of learning or experiencing, the environment in where the students are interacting with patients is in the patient's hospital room environment. Hopefully, the experience will provide some benefit also to the patient: longer attention to the patient and their concerns then the patient's own physicians and finally, as I previously noted, a good feeling of altruism: participating in the creation of a new physician. ..Maurice.
Maurice,
According to Belmont, risks may be of “psychological harm, physical harm, legal harm, social harm and economic harm” to the patient, client, research subject, etc. One of the points of my post which, I believe, is worth reiterating was that the AMA Code imposes the expectation that the attending physician inform patients of the benefits they may accrue by agreeing to allow students to be present during or participate in their health care. This expectation opens the way for physicians to abuse their authority by trying to inveigle or “twist the arm” of patients to consent. Requiring attending physicians to couple an analysis of benefits with an analysis of risk provides balance. This balance is required by federal fiat for every internal review board (IRB) in the country through which human subject research proposals are rigorously screened. This balance is not required by “Opinion 8.087” of the AMA’s Code, a double standard the justifications for which are poorly conceived.
Health care providers with whom I have had confrontations have a myopic view of risk; they think only of physical risks to patients to the exclusion of other risks and that’s true even among those who claim to be holistic in their approach to treatment and care. Second, they tend not to think probabilistically but either categorically or, at best, in dichotomies. This makes it difficult if not impossible to judge the relative weights of risks versus benefits. Third, they express the belief that their statuses entitle them to decide for me what the risks and benefits are rather than treat me as though I were an autonomous human being with a brain.
The risk of psychological/emotional and social harm to patients who give consent for student involvement can be high, especially in small communities. If it is the attending physician who is assigned to get consent, it is ethically obligatory that s/he speak to patients about possible psychological/emotional and social risks as well as benefits so patients can make informed decisions about whether or not to allow students to be present during examinations. As autonomous humans who are entitled to enjoy the right of self-determination, it is the patient and not anyone else who has the authority to decide what’s best for him or her.
Ray
Hex,
I had had never heard the idiom before, but I did know its meaning. I simply did not see its relevance given the issue we were addressing. If we wanted to answer a question such as, “To whom should patients speak if they want the best answers to questions about their health care, the organ grinder (physician) or the monkey (student)?” the idiom would have been apropos and the answer would be the organ grinder. But that’s not the question we were addressing. Our question was, “Who should speak to the patient about giving consent to serve as a teaching subject, the organ grinder (physician) or the monkey (student).” As I tried to demonstrate, the answer to that question is more ambiguous than the answer to the first question.
Ray
Ray, to be clear, there is no risk to the patient who agrees to be interviewed and examined by a first or second year medical student and the communication and request for permission and the periodic checking for continuing consent by the student alone is felt to be sufficient. I would say that in the 3rd and 4th years, patients should be informed by their physicians about the role and procedures which are to be performed by the student and, yes, this informed consent must be obtained and not avoided because "this is a teaching hospital".
Again, as we do with all "diseases", it is important to find and understand the underlying pathophysiology before developing a cure. So, I again want to thank Ray and Banterings and the others who have changed the tone of this blog thread from "moaning and groaning" about patient modesty and patient dignity to a more constructive and hopefully more productive approach to that "cure". ..Maurice.
Maurice,
In your 12/20 8:36 post, you suggest that “there is no risk to the patient who agrees to be interviewed and examined by a first or second year medical student.” The bulk of what you write suggests that first and second year students are privy to confidential information about patients, observe intimate procedures performed on patients (except genital exams), and perform intimate procedures on patients (except genital exams). If what I have written is correct, then there certainly is a “risk to the patient who agrees to be interviewed and examined by a first or second year medical student,” although we may agree that the risk is low. If there were no risk, why would it be less than “rare . . . that at some point the patient ‘speaks up’ to the student and terminates the interview or examination with one explanation or another,” why would you get “continuing approval of the patient” for student participation, and why would you “watch for any signs of distress by the patient” that would warrant termination of “the practice session.”
One possible risk to patients, especially to those who share personal information with students or are subjected to intimate examinations, is discomfort and embarrassment. International ethical criteria require that patients be informed in advance about such risks followed by the reassurance that they can decline at any time to continue as teaching subjects without any efforts to change their minds or ill feelings on the part of providers. I and other researchers must do this even when we plan to distribute what, at first blush, appears to be an innocuous questionnaire. If, for example, I ask subjects on an anonymous questionnaire about what they believe to be morally right and wrong, I must inform them in advance of the possibility that the questions may cause them stress (given that many people have not thought much about this subject) and assure them that they are free to terminate the questionnaire without fear of repercussions. Without the warning and reassurances, my research proposal would not pass IRB inspection. Unfortunately, there is nothing comparable to an IRB at universities to screen protocols for vocational students in health care clinicals.
You believe that “periodic checking for continuing consent by the student is felt to be sufficient.” I actually would not quibble with that. In fact, it is far superior to what is demanded by the AMA’s Code of Medical Ethics and may even be superior to what is required by international documents. It might be considered even more superior were you to inform patients in advance of the risk, slight though it may be, and patients’ right to terminate participation at any time. However, I don’t know whether that would reduce the risk of discomfort or embarrassment over what you currently do. That is, again, an empirical question.
Ray
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I propose that the risk of, among other things, discomfort and embarrassment to patients with whom students wish to interact is low precisely because of your insistence that students conform to the ethical principles demanded by international codes of ethics upon which at least some parts of professional ethical documents are founded. You tell us that students obtain prior consent from patients; the consent is informed; there is no effort on your part or the part of students to convince, cajole, or inveigle patients to consent; you and/or students check with patients intermittently to make sure they are amenable to continuing participation; patients are free to break off participation at any time without negative repercussions or efforts to persuade them to continue (voluntary participation), you watch for signs of stress in patients and break off participation if it is detected; and both you and the students thank patients for their service.
I have sought health care services from Maine to Arizona and have been with family members as they received services from FL to CO. In the modern era, never has any one of us been treated with the respect you demand of yourself and your students.* Indeed, never has any of us been exposed to the first step in the process – getting prior consent, whether informed or not. My point – it is a mistake for anyone who is so inclined to overgeneralize or make hasty generalizations (https://en.wikipedia.org/wiki/Hasty_generalization ) from your approach to obtaining patient consent to other first and second year medical training programs.
In my experience, some hospitals and clinics put on a show of gaining consent that rivals that of the most skillful of legerdemainists. One way used by physician-educators is to introduce student physicians to patients as “Doctor so-and-so.” The physician-educator, in effect, defines the situation in a manner that does not require consent; by introducing students as physicians, the physician-educator communicates to patients that all those present are indispensable contributors to patients’ wellbeing. If patients truly believe that “all these people” are indispensable contributors to their wellbeing, they are unlikely to object to their presence.
* In the 1950s, Dr. Zagraniski made house calls. He was a guest in our home. We treated him as a guest and he behaved as one would expect a guest to behave. Today, we are hospital guests or guests in physicians’ clinics. However, I and members of my family have rarely been treated as one would expect a guest to be treated.
Ray
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A second form of wizardry that I have experienced occurs when providers redefine what is meant by consent. If a patient doesn’t dissent, then s/he must be consenting, the reasoning goes. This non sequitur is vigorously defended by some providers who assume that if students are introduced to patients as students and patients don’t dissent, then that constitutes evidence of patients’ consent. This reasoning is an example of an informal fallacy called “argument from silence” – a conclusion based on silence or lack of evidence to the contrary.**
Chicanery used by providers to secure patients’ “consent” also occurs when hospital or clinic receptionists ask patients to sign a “Conditions of Admission” form without explanation or with a truncated explanation of its content. If an explanation is verbally offered, it is invariably of the following sort: “Signing this form gives the physician permission to treat and to release information to your insurance company.” Nothing is said about the condition which requires patients to submit to the ministrations and scrutiny of students. Usually this condition is “hidden” beneath the heading “Consent to Medical and Surgical Procedure” and consists of one or two lines, typically something similar to the following: “The undersigned do hereby acknowledge that sometimes functions as a teaching institution. Patients may participate as teaching subjects in various education programs.”
By way of summary, in my lifetime, I have visited dozens of health care organizations around the nation in which I have regularly been the teaching subject of many health care students, some of whom I permitted in and some of whom I expelled from examination rooms. Never once was I and my loved ones [and, for that matter, most people I interviewed on the subject over the years] treated with the respect and dignity you require of yourself and your students. Never once has a medical student, nursing student, or their mentors even requested my or my loved ones’ consent before using us as teaching subjects. Some, however, make a duplicitous show of securing consent by 1) introducing students as “doctor” so-in-so, 2) introducing themselves and assuming that consent is given if there is no dissent, and 3) hiding consent to serve as teaching subjects on “Conditions of Admission” documents.
** “Argument by silence” is quite common, although I’ve encountered this logical fallacy – evidence that patients assent is that they don’t dissent – among health care providers more frequently than among people of any other occupation. I have also seen it used quite effectively by people who are driven more by ideology than by fact. For example, Dinish D’Sousa was able to publish an entire book founded on this fallacy. The book’s title is “The Roots of Obama’s Rage.” The evidence D’Sousa uses that President Obama is full of rage is that he never shows or “lets on” that he is full of rage.
Ray
Maurice,
In your last post, you suggest that “as we do with all ‘diseases,’ it is important to find and understand the underlying pathophysiology before developing a cure.”
Using your concepts metaphorically, the “underlying pathophysiolog[ies]” of the “diseases” described in this blog cannot be known unless interested people are able to study them. Unfortunately, studying them requires an interest of and cooperation between people within the health care system and people outside of this system. As I’ve mentioned before, the Harvard Medical Study is a good example of such cooperation. Unfortunately, I and others have found great resistance among health care providers and medical researchers to collaborate in conducting critical research in health care, research that tests critical theories, and research the findings from which hold promise for making institutional changes. For example, I and nursing students in a scientific methods course hypothesized that if osteopathic medicine is more holistic than allopathic medicine, as its proponents claimed, then one should find that osteopathic students would be more likely than allopathic students to agree with holistic principles and the gap between them would increase from first to fourth year. Not a single physician in our area – allopathic or osteopathic – was interested in testing this hypothesis, although different positions had been bandied about with nary a shred of evidence for one over another.
I discouraged students from pursuing their interest without support from people in medicine but they pushed me to let them try, which I did. Before creating the research proposal, we got permission from friendly faculty at the medical school to use students in their classes as subjects. Once this was accomplished, we created the proposal which was approved by an internal review board (IRB). Then we found out that a single physician-administrator at the medical school had nixed the project because he unilaterally decided that the demonstrably valid instrument we were using was not valid at all. So we decided to change our data collection method; we chose a random sample of residents at the medical-student dormitories and communicated with them via e-mail. Because of this change in method, we were compelled to go through the IRB again. As I feared, the students who conducted the research ended up with a small, non-random sample. Most of the medical students did not answer the questionnaire at all. Others, instead of answering the questionnaire, took umbrage at people other than medical researchers conducting the study by, for example, writing, “Nurses shouldn’t be doing research like this. Only physicians should be doing it.” Others questioned the motives of the student researchers with, for example, “Whoever is doing this research has a hidden agenda. I think they just don’t like doctors.” Ironically, the data that were collected indicated a pattern in the direction hypothesized. However, because of the small sample (n < 30), the findings were not statistically significant.
Ray
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Although the “underlying pathophysiolog[ies]” of the “diseases” described in this blog are not known, there are plenty of theories and plenty of research studies conducted which help us understand why people commit acts of the sort described in this blog and why others do not, but the subjects of theories and studies have tended to be powerless segments of the population. For example, countercultural theories have been used to explain the deviant behaviors of gang members and the high rates of illegitimacy among the poor. Nobody, however, has thought to explain the deviant behaviors of health care providers of the sort described in this blog using countercultural theories, probably because such deviance has been considered so rare that it can be better understood as the consequence of character defects. We can, in short, use already existing theories and knowledge gleaned from testing these theories in settings other than health care to understand the “diseases” or “pathological conditions” that show up in the health care institution.
Fortunately, we can study the countercultural behavior patterns and lingo in health care using qualitative research methods such as participant observation and by conducting surveys of citizens who have had experiences with health care providers. Unfortunately, it is much more difficult to study the countercultural beliefs, values, and norms adopted by providers because that requires conducting research using health care providers as subjects. We know from publications such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” (Rosemary Gibson and Janardan Prasad Singh) that heath care providers tend to close ranks when faced with the possibility of litigation. They also tend to close rank when researchers from outside of health care try to understand the disparity between ideal and real norms and between image and reality in health care.
So, I agree with you, Maurice, “it is important to find and understand the underlying pathophysiology [of the disease] before developing a cure.” But, how can we hope to “understand the underlying pathophysiology” of the “disease” we’re interested in curing without the help of health care providers and health care researchers of conscience?
Ray
Ray, much to respond to your commentaries! First, I want to comment on your concern about risk to the hospitalized patient by a first or second year student taking a history or performing a physical examination. Compared to all potential risks which a hospitalized patient may encounter during a hospitalization, there is virtually no risk to be interviewed and examined by those students. Whatever one considers the risk of emotional or physical discomfort by what the student asks or examination the student performs, it is mitigated by the students attention to the patient's emotional and physical comfort by communication and observation.
With regard to getting the valid data to understand patient-doctor or patient-institutional dysfunction or injuries, this will require more than participation by an single physician, instructor but will require participation by the larger components of the medical system such as the medical schools themselves or the hospitals or the medical organizations.
In this regard, I would like to help you to "spread the word" of your concerns and the methodology of attempting to begin to get an understanding of the "pathophysiology" of the problem so that a mitigation or even a "cure" can be devised.
I will be glad to put up onto the medical educators listserv sponsored by Michigan State University, to which I am a subscriber and participant, your written concise definition of the issue and approach for research for which you would advise for medical school program officials to consider. Perhaps we will get important feedback as well as interest from these medical school officials which will lead to the essential participation which you will need. Let me know what you think about this offer. ..Maurice.
Maurice, Happy New Year to you and all other readers/posters.
On your last post to me, you indicate a wish “to comment on” my “concern about the risk to the hospitalized patient by first or second year student[s] taking a history or performing a physical examination.” I believe I did not express “concern” over your approach. Indeed, I wrote that I “would not quibble with” your assertion that “periodic checking for continuing consent by the student is . . . sufficient” and expressed skepticism that adding a prior warning about the possibility of discomfort or embarrassment, as recommended by international documents such as Belmont, would reduce the risk of these negative feelings more than what you are already doing. The focus of my concern was demonstrably over those first and second year programs that did not follow your and your students’ lead and the duplicity sanctioned by these programs to secure patient compliance including 1) introducing students as Doctor, 2) defining patient consent as a lack of dissent following the introduction of the student, and 3) “hiding” consent in the “Conditions of Admittance” form.
You continue with, “Compared to all potential risks which a hospitalized patient may encounter during a hospitalization, there is virtually no risk to be[ing] interviewed and examined by those students.” Can you tell me what point you are trying to make here? I see no premise to this statement nor do I see a conclusion that logically follows from it.*
You then suggest that the risk of emotional or physical discomfort by patients who collect confidential information about and perform examinations on patients “is mitigated by the students attention to the patient’s emotional and physical comfort by communication and observation.” I write, “the risk of . . . discomfort and embarrassment to patients with whom students wish to interact is low precisely because of your insistence that students conform to the ethical principles. . .” I then specify what those ethical principles are. Aren’t you communicating the same thing I am communicating, albeit I do so with greater specificity? If not, in what way have you added to what I wrote?
* In my experience, such statements are invidious – e.g., Only conditions that put human welfare at highest risk should be the focus of change; those conditions that put humans at virtually no risk should not get any attention. “Compared to all potential risks which a hospitalized patient may encounter during hospitalization, there is virtually no risk to . . .” Therefore, the former should be the focus of change and the latter should get no attention. I frequently encounter such arguments – e.g., Black people kill more black people than do the police. Therefore, “Black Lives Matter” should focus on changing the former rather than the latter. Another version of this line of reasoning comes from social Darwinists who believe that the U.S. should not use its resources to reduce human rights violations here because “things are worse in other countries such as Cuba.”
Ray
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Did you add to what I wrote in the sense that your intention was to generalize from what occurs with first and second year medical students in your program to all medical teaching programs across the nation? As I have pointed out, my experiences with first and second year students have never measured up to the approach you have described. Yet, I would err (both logically and factually, if what you wrote is correct) were I to generalize to all first and second year medical students across the country. After all, as I have mentioned earlier on this blog, I and students found that prior consent was obtained from some patients some of the time and was more likely to be obtained from female than male patients. These findings occurred in the same community in which my prior consent was never solicited.
Was your intention to defend the belief that “there is no risk to the patient who agrees to be interviewed and examined by a first or second year medical student”? If so, you have introduced a proposition that is not subject to proof. How does one “prove a negative,” or put in another way, how does one provide evidence for what does not exist (e.g., “no risk”). The burden of proof, of course, falls on the affirmative. It’s the impossibility of empirical support for a negative that the state must prove the guilt of defendants rather than requiring defendants to prove they are not guilty. Statisticians make this point as well. We would begin our research with the null (or negatively worded) hypothesis that “there is no risk to the patient [of discomfort, embarrassment, humiliation, or whatever] who agrees to be interviewed and examined by a first or second year medical student.” The analysis of data may lead one to conclude that the null hypothesis is rejected or that the null hypothesis cannot be rejected; one cannot conclude that the null hypothesis is supported or confirmed because that would put one in the untenable position of claiming that s/he found evidence of something that does not exist; i.e., claiming s/he “proved” a negative.
Second, all one needs to do to “prove” that your “no risk” assessment is incorrect is to find one patient among the hundreds to which medical students in your program have attended who experienced discomfort, embarrassment, or humiliation. You claim that it is not “rare . . . that at some point the patient ‘speaks up’ to the student and terminates the interview or examination with one explanation or another.” Is it possible that one of those less than rare patients spoke up because of discomfort, embarrassment, or humiliation? Of course it’s possible, but we’ll never know unless pertinent data are collected using the “double-blind” method in a neutral environment.
Ray
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All that said and done, you have inadvertently introduced what to me is an interesting empirical question that can be presented in the form of a null hypothesis: There is no significant difference between the level of discomfort, embarrassment, and/or humiliation experienced by patients who are exposed to your ethically-based approach to student participation compared to approaches that do not follow ethical guidelines. Why it would take the participation of large “components of the medical system such as the medical schools themselves or the hospitals or the medical organizations” rather than a single physician-academician with approval by an IRB to test this simple proposition seems strange to me. Back in the ‘60s and ‘70s, Robert Leonard and James Skipper, in collaboration with individual nurses and with the approval of university/hospital IRBs, or their equivalent conducted many studies that tested similar hypotheses. I’ve gone through the same process with medical scientists who are also educators and practitioners when writing grant proposals and conducting research. Neither Leonard, who was one of my graduate school mentors, nor I was compelled to get entire medical schools, hospitals, or medical organizations involved in the research. Indeed, I suspect few physicians, administrators, and other employees at the sites where our research was done even knew about it.
The problem is convincing potential collaborators in health care that critical research is worthy research. To test the null hypothesis proposed above or something similar would also require securing the cooperation of physician-educators whose approaches to student participation in patient care varied. Were I to find a collaborator on “medical educators listserv” and get IRB approval for testing the hypothesis posed above, would we be able to count on you to provide us with the opportunity to gather data given that the proposed methodology met with your approval?
I welcome your help to find someone on “medical educators listserv” with whom to collaborate. How do you propose this should be done? What protocol for soliciting favorable responses would be best, do you think?
Ray
Ray, I can't present any proof in terms of a statistical rigorous study to confirm the "conclusions" I presented. What I "conclude" is simply based on 30 years of active participation in this single medical academic course "Introduction to Clinical Medicine" where students learn how to interact with patients in an ethical and even, yes, compassionate manner with attention to them not as "objects" of the student's learning experience but as sick human beings who at the time are confined to their hospital beds. There are over 30 groups of 6 students each with their own instructor in each of the two years and only based on the frequent faculty meetings, I assume that most, if not all, are following the general teaching principles for this course including the student-patient relationship similar to the what I teach. I have no direct control of my students' behavior later in their academic/clinical training except I warn them now about the possibility of learning behaviors which are not always in the very best interest of their patients as they progress through the "hidden curriculum" of years 3 and 4 and beyond. Hopefully, they will remember the "good" what we have taught them in their early years and will resist the "bad" which may be directed later.
With regard to "spreading your word" to the medical school and graduate program educators: Write a concise description of the issue and your plan to obtain investigative documentation that will provide a valid conclusion and what help from the educators or an educator you are looking for and then provide your e-mail contact address. I will then submit it to the listserv. ..Maurice.
“Compared to all potential risks which a hospitalized patient may encounter during a hospitalization, there is virtually no risk to be[ing] interviewed and examined by those students.”
Let me expand on the self-serving ethics Ray presented. I am sure that all students as well as physicians and nurses use “confidentiality” (as promised in patient rights) as a means to cajole every intimate, embarrassing detail of a patient’s life whether related to the medical encounter or NOT. But does the provider ever tell the patient that while they can’t disclose their information, that by entering their information it is shared with insurance companies, community health organizations, government, CDC, etc.?
Or do they simply justify it that the patient has read the “privacy policy” (which is usually just an acknowledgement that a privacy policy exists and NOT that the patient has even been provided with it)?
This seems to make “confidentiality” an outright lie.
Next is consent. Unlike our Miranda rights, patients are generally NOT told that they have the right to refuse student participation let alone any procedure WITHOUT consequence (this would amount to coercion). I have a citation that consent involves knowing one has the right to refuse, but can not locate it right now. The justification of the Miranda rights should suffice.
The profession has realized that it has betray society’s trust, thus causing the loss of much autonomy. That being said, I am happy with the progress that has been being made in putting a tight leash on the profession. At the current rate of progress, in the next 6 years, physician autonomy will be so dependent on patient satisfaction, that the line will have been crossed to patient paternalism (a progressive trend lasting 150 years, the way physician paternalism lasted).
Patients will soon discover with payments based on community health, the “new lawsuits” will be readmissions for psychological harms caused by modesty and consent issues. Just as with hospital acquired infections, we will see “hospital acquired PTSD” that facilities will be penalized for.
The best thing that we can do as patients is push for more government regulation and more corporate involvement in healthcare.
—Banterings
Banterings, I disagree with "... all students as well as physicians and nurses use 'confidentiality' (as promised in patient rights) as a means to cajole every intimate, embarrassing detail of a patient’s life whether related to the medical encounter or NOT."
First and second year medical students, in my experience, do not "cajole" or trick details from the patients they interview. In fact, sexual or other "sensitive" issues may be occasionally avoided, out of personal sensitivity of the student, despite being clinically important.
As far a the vast majority of physicians' and nurses' use of "cajoling" their patients, do they really have enough time with the patient to even do that? ..Maurice.
Maurice,
I am talking about the whole issue of confidentiality. I am sure that even you (by your own words on this blog) would promise patients confidentiality, yet do you tell your patients that what they tell you is not kept confidential?
No one here would argue that our personal medical information is kept confidential, but just in case, see:
No, Your Medical Records Are Not Private
The Truth about the Modified, Final Federal Medical Privacy Rule
Your Medical Records May Not Be Private: ABC News Investigation
Basic Health Privacy FAQ’s
Your medical information is not private, and it’s sold routinely
Your health records are supposed to be private. They aren’t.
Beyond the HIPAA Privacy Rule
Just read any Patient Privacy Policy (such as this one) OR pick any Patient Privacy Policies searched on Google.
Yet patients are told by providers “I will keep what you say confidential” knowing full well that once they enter the Hx in the system, it is the equivalent of posting the information on “medical Facebook.” Just like all the customs of healthcare (gender; I’ve seen it all), it is intended to make the provider’s job easier by lulling a patient into a false sense of security.
Read any “Patient Rights" statements, they all start out with: “Providing, to the best of your knowledge, complete and accurate information about your health and medical history... AND go on to end with something such as:
...and any other matters relating to your health, including perceived safety risks…
...and other matters pertaining to their health and complete medical history…
…to provide any personal information…
Let me ask, in your statement "sexual or other "sensitive" issues may be occasionally avoided, out of personal sensitivity of the student, despite being clinically important,” where is the importance to the patient that that NOT be disclosed when there is no guarantee of protection? Do the students tell patients there is no guarantee of protection?
See:
Small Violations Of Medical Privacy Can Hurt Patients And Erode Trust
Small-Scale Violations of Medical Privacy Often Cause the Most Harm
Although Often Overlooked, Small Breaches Of Medical Privacy Harm Many Patients
<a href="http://www.seattlechildrens.org/research/initiatives/bioethics/education/case-based-teaching-guides/confidentiality/case-discussion/”>case discussion: confidentiality</a>
– Banterings
Banterings, you write "Do the students tell patients there is no guarantee of protection?" No. My students and myself routinely tell the patient that what the students write or communicate will not be identified by the patient's name and the only person to review the writeup will be their instructor (me).
..Maurice.
Maurice,
So "what the students write or communicate will not be identified by the patient's name and the only person to review the writeup will be their instructor” (you), then that means that what the students learn is NOT added to the patient records and there is NO benefit provided to the patient from the student interaction (only a benefit to the student)?
Ray,
As to your comment: By contrast, Peter Ubel and gang (of pelvic exams on anesthetized women fame) side with Maurice. They believe that students should be the ones that secure patients’ prior consent without physician-educator attendance…
I always thought that Ubel pushed that the physician get the permission, but the students verify that permission was indeed granted. In light of "Don't ask, don't tell,” students absolved themselves by saying that the attending told them to participate so they assumed permission was granted. Ethically this is NO excuse.
I have raised this issue here before that when any other person enters the exam/procedure room that they introduce themselves and ask permission to participate in my healthcare.
– Banterings
Banterings, the student's history and physical examination is NOT added to the patient's hospital chart. However, if some clnically critical information is made available to the student which is not in the chart or about which the nursing staff does not yet know, the students are instructed by me to notify the staff. A common example would be that the student observes or the patient says that they currently are in severe pain (vital sign level 8-10) and the patient says the staff is unaware, the student will then notify the staff to promptly attend to the patient.
It is to these rather rate occurrences by which the patient may get a direct "benefit" from the student's involvement. But most of the time, the benefit is psychological and humanistic since none of the staff will spend so much continuous time sitting with and communicating but also listening with the patient, all with the patient's permission. There is "therapy" is this behavior. ..Maurice.
Maurice,
Agreed, there is therapy in listening.
More to the point is that even beyond the student scenario, physicians “promise” confidentiality to patients when we all know that it doesn’t exist.
There have been things that I told my doctor that I did not want as part of my medical record (mostly these dealt with issues of national security), but I told him to have a better understanding of me.
No reasonable person can fault a patient for not disclosing things such as sexual history when it can come back and harm them. As a physician you may argue that is relevant to the doctor-patient relationship and the medical encounter, BUT what if a patient’s disclosure of proclivities leads to them losing their job (down the road)? Is there NOT harm there as well?
Whether the disclosure is due to hackers breaking a secure system, a rogue employee violating hospital policy (and the law), from legally disclosed data (government, community health, public health dept., etc.), or the purchase of such information legally (credit report showing delinquency in payment to a major cancer center), the repercussions can be devastating for one’s career and can certainly affect one’s health and well being.
Read: The 'Re-Identification' of Governor William Weld's Medical Information to see how Massachusetts Governor William Weld was identified from “anonymous” health data that is legally disclosed. Just look at how Joan Rivers' doctor took selfie, began biopsy before her cardiac arrest.
Again, it is all about the provider. Just as with the “you have nothing I haven’t seen before,” saying “I keep what you tell me confidential” fails to address how what a patient says is disclosed. If a physician was truly protecting a patient, they would purposefully omit certain information from the medical record to protect patients or tell them what really happens with their disclosure (if the doctor even knows).
Just as the profession seized power when it began organizing, government and corporations are seizing power by granting the power to themselves to “reign in” the abuses that medicine has committed in its violation of its contract with society.
Furthermore, the altruistic nature of medicine is the fuel that feeds future physicians. By the fact that the profession argues those are the intentions first an foremost that it holds, it will always continue to attract individuals who want to make a difference (even if their underlying motives are money and power).
It is also this altruistic nature that will foster the change to a patient paternalistic system. The justification will be, “if you want the best for your patients, then you will…” This is the same justification used in traditional paternalism, “ I want the best for you, my patient, that is why… (for example) I am having 10 med students examine you after I do…” [A bit sarcastic, I know.]
Here is a post on KevinMD, "Doctors are not in control. Perhaps this is our greatest challenge.,” that laments the loss of autonomy. Not my comment on the subject matter. Note my comment in the comment section.
Until the profession is ready to be absolutely honest, they are going to be reasoning like a delusional, bipolar, schizophrenic. Just look at what has happened here, on this blog in the last year. What had been presented for almost 9 years and dismissed as emotion and out fliers has been scientifically proven (supported). Most would call these matters common sense, but the profession seemed to ignore such things as the fallacy of gender neutrality.
But what can one expect from a profession that has modern guidelines saying “… despite lack of evidence [organization] recommends [procedure]…”?
– Banterings
Maurice,
I didn’t ask you to provide proof “to confirm the ‘conclusions’” you presented nor even suggest that you ought to do so. I simply pointed to an informal logical fallacy inherent in your statement “there is no risk to the patient who agrees to be interviewed and examined by a first or second year medical student” – viz., the fallacy of proving a negative. If it is impossible to “prove” a negative or to provide evidence for what is not, then how can anyone “conclude” that a negative (“there is no risk”) exists? Second, by insisting that you have “concluded” that there is “no risk,” you have put yourself in the unenviable position of challenging an empiricist to find only one example of someone who had a negative experience in spite of your efforts to prevent it thereby “disproving” your “conclusion.”
Use of absolutes – all, none, every, etc. – are commonplace, but I find it disturbing when used by people who occupy positions of authority. For example, back when Ted Koppel was anchor for “Nightline,” he interviewed Dr. James Meserow, who was a big shot at Rush Presbyterian-St. Luke’s hospital and St. Joseph’s hospital in Chicago, about his efforts to convince the IL appellate court to force Tabita Bricci to undergo a cesarean section against her will. I’ll never forget how angry the man looked when he shouted that he was 100% certain that if Mrs. Bricci’s pregnancy was brought to term her child would die. Not even the most knowledgeable scientists can be 100% certain that their predictions or prognoses will pan out – they may be 95%, 99%, or 99.9% certain, but 100%? – No way. It takes someone chock full of hubris to abuse his or her authority by making such a claim.
In spite of Dr. Meserow’s efforts, the court overruled his demands. As reported by Daniel Kennedy (1994. “A Public Guardian Represents Fetus.” ABA Journal (March): 27), “On Dec. 29, Tabita gave vaginal birth – without complications – to a boy.” Indeed, the child’s Apgar readings on each of five criteria (appearance, pulse, grimace, activity, respiration) were reportedly higher than average.
Ray
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CONTINUATION #1
Were I to challenge your “conclusion,” I would not ask you for “proof.” Logician/philosophers speak of “proof,” as do mathematicians.* I’ve read hundreds if not thousands of scientific articles published in journals and books across disciplines. I have yet to read one in which the authors write of “proof” except in the context of logic or mathematics. They instead write about confirming/supporting or rejecting theories, propositions, or hypotheses. The problem with misusing the word “proof” in the context of scientific probabilities, according to Earl Babbie, is that it can foster what he calls “the premature closure of inquiry.” Consequently, I would ask if you had “evidence” – not “proof” – to support your hypothesis. I asked that question last spring and you answered it. You needn’t repeat your answer again for my sake; I understood it the first time around.
Speaking of hypotheses and their more abstract kin (propositions and theories), they tend to be the consequence of induction – gathering data, recognizing patterns, and inducing hypotheses, propositions, and theories from those patterns (the reasoning is from data to theory). Such research can be quantitative or qualitative.
David Takeuchi (1974. “Grass in Hawaii.” M.A. thesis, U. of Hawaii) gives us an example of the former (inductive/quantitative). He found that coeds, Asian students, students living at home, and students who attended religious functions “religiously,” were less likely to use marijuana than male students, students who did not live at home, non-Asian students, and students who seldom or never attended religious functions. Then Takeuchi reasoned inductively by looking at what was common among coeds, Asian students, etc.; what was common among men, non Asians, etc.; and what was the difference between the two sets of groups. Eureka! Women differ from men, Asian differ from non-Asians, etc. to the extent that the first of each pair are subjected to greater social restraints than the second of each pair, an observation that led Takeuchi to formulate a set of propositions that made up his “social restraint” theory designed to explain why some people violate social norms and others do not.**
* Of course, so too do people in law, but they are using the concept “proof” very loosely.
** Takeuchi followed in the footsteps of Frenchman Emile Durkheim who, in the 1890s, gathered data from secondary sources to help him understand why suicide rates vary from one population of people to another. He found that men, Protestants, the wealthy, and the unmarried were more likely to commit suicide than women, Catholics, the less wealthy and the married. From his findings in developed a theory of social integration. The more socially integrated into society a people are, the lower the suicide rate. His theory was put to the test and confirmed many times during the 20th century.
Ray
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CONTINUATION #2
An example of a qualitative study where induction (induction/qualitative) was used comes from “Tearoom Trade” by Laud Humphreys. Humphreys induced a number of theoretical propositions from this research, one of which was the following: “The greater the network of friends, the less severe the aging crisis.” One might think Humphreys’ research was conducted with people who had retired or people whose children had grown up and left home, but it wasn’t. Humphreys collected his data systematically using the qualitative method of participant observation in a “tea room” at a St. Louis park where men went for impersonal homosexual sex. (Here’s his study, if anyone is interested: https://is.muni.cz/el/1423/podzim2013/GEN107/um/HUMPHREYS.pdf)
Maurice, your “conclusion” comes from observations most similar to the latter method. You might notice that neither author of the two studies mentioned above drew conclusions; they induced hypotheses, propositions, or theories from patterns found in the data collected and observations made. The theories, propositions, and hypotheses must now be tested. This requires deduction (from theory to data), what most of us know as the “scientific method of investigation” – rigorous, quantitative, and narrow in scope. From theory we deduce propositions; from propositions we deduce hypotheses; we create instruments to measure variables in our hypotheses; we choose a research method (experimentation, survey, quasi-experiment, analysis of existing data, etc.); we implement the method; we collect data; we analyze data and make note of patterns that confirm, reject, or modify the hypotheses; we draw conclusions from the patterns about the theory.
Ray
CONTINUED
CONTINUATION #3
In short, Maurice, based on what you have written, I submit that your method leading to what you call a “conclusion” falls somewhere between casual induction/qualitative and semi-systematic induction/qualitative. This method may legitimize the formulation of theories, propositions, and hypotheses but it hardly warrants the drawing of conclusions. To draw unwarranted conclusions prematurely, as you have done, closes scientific inquiry prematurely. The drawing of conclusions requires that one test hypotheses using the scientific method which, by your own repeated admission, you have not done.*** Therein lies the reason I proposed the null hypothesis, “there is no significant difference between the level of discomfort, embarrassment, and/or humiliation experienced by patients who are exposed to your ethically-based approach to student participation compared to approaches that do not follow ethical guidelines.” You implicitly proposed the hypothesis, I merely formalized it. I then asked, “Were I to find a collaborator on ‘medical educators listserv’ and get IRB approval for testing the hypothesis posed above, would we be able to count on you to provide us with the opportunity to gather data given that the proposed methodology met with your approval?” You did not answer this question. You also did not answer my question regarding the mitigating effects of following ethical guidelines on patients’ risk of emotional and physical discomfort: “Aren’t you communicating the same thing I am communicating . . . ? If not, in what way have you added to what I wrote?” Nor did you attend to my questions, “Did you add to what I wrote in the sense that your intention was to generalize from what occurs with first and second year medical students in your program to all medical teaching programs across the nation?” and, “Was your intention to defend the belief that ‘there is no risk to the patient who agrees to be interviewed and examined by a first or second year medical student’?” Is there some reason or reasons you did not answer these questions, especially the first one regarding your amenability to participating in scientific research to test the effects of your approach to teaching compared to approaches that do not use the level of ethically-based instruction that you use? It seems to me that professional journals such as “Medical Education” and “Clinical Teacher” might be interested in what is found.
I will try to write something up within the month that meets the criteria you have proposed. Without a collaborator, I can only be concise up to the point of recommending hypotheses/propositions for testing. Methodology and measurement requires knowledge of health care settings I don’t have; thus, the need for a collaborator. Also, if an “issue” lends itself to moving from data to theory, “valid conclusions” will not be the outcome; the formulating of theory, propositions, and/or hypotheses will.
*** Think of the distinction between scientific induction and scientific deduction this way. Although I’m not very fond of sleuth fiction, I do watch Sherlock Holms and “my dear Watson” every so often. I noticed that when Watson commends Sherlock with “good deduction, Sherlock,” he really should be saying “good induction, Sherlock” because Sherlock skillfully puts together the data he systematically collects in a way that allows him to recognize patterns and induces from these patterns “who done it.” The rest of the film is taken up with Sherlock testing his theory – e.g., setting up the suspect or otherwise fooling him into revealing his guilt – and, ultimately, drawing a conclusion regarding “who done it.”
Ray
Banterings,
In what ways are the ethical principles I espouse “self-serving?” Do you really mean to suggest that these ethical principles reflect an interest in meeting my own needs and not the needs and interests of others? The ethical principles I embrace (e.g., self-determination, do no harm, autonomy, nonmaleficence, beneficence, privacy, etc.) are, as I suggested, founded in international laws and international documents (I mentioned the Belmont Codes). I also suggested that internationally recognized ethical principles (many of which were the consequence of Nazi atrocities) are the foundation for the ethical guidelines I must follow as a researcher, and rightly so in spite of their inconvenience. They form, at least in part, the basis for the ethical standards of professional organizations such as the AMA and ANA. These ethical principles were obviously not codified for me personally; they were meant to apply to us all, including you.
Many activities in health care that I have labeled ethically questionable are highly unlikely to affect me. For example, I am 100% certain that I will never have a pelvic exam of the sort experienced by women while I am anesthetized without prior consent, yet I consider such action to be ethically questionable. I doubt very much that, without my consent, I will be filmed by a commercial enterprise in an emergency room as I’m stripped naked and catheterized, yet I consider such action to be ethically questionable. And, I could give a fat rat’s bananas if I’m used as a teaching tool or visual aid without my consent, yet I consider such action to be ethically questionable. Outside of health care, it is highly unlikely that I will be subjected to racial discrimination, ethnic segregation, police violence, etc., yet I consider such actions to be ethically questionable. Furthermore, I will defend as best I can the rights of people not to be treated in these manners. What, pray tell, is self-serving about this?
Ray
Ray, you wrote: "I submit that your method leading to what you call a 'conclusion' falls somewhere between casual induction/qualitative and semi-systematic induction/qualitative. This method may legitimize the formulation of theories, propositions, and hypotheses but it hardly warrants the drawing of conclusions."
I should have been more specific and use the words "impression" rather than "conclusion" since what I write about my experience with my group of 6 students is not based on research but represents only that of my professional "impression". I would expect folks with your skills in sociological investigation to get a better understanding of the relationship between medical students and patient in publishable format. However, as I have stated previously, I have appreciated the current "pathophysiological dissection" of the conflict disorder between medical professionals and their patients. Again, this is much better then simply repetition of the "symptoms" because often "symptoms" alone do not lead to the correct diagnosis. Often more history and investigation beyond "symptoms" are necessary.
With regard to a formal study with my group of first year students, if that is what you are writing about, I would need to know the final details and obtain permission from the leader of our ICM course.
--------------------
Finally, to our other thread readers and I know that you are there, I hope you will also participate in bringing up your impressions and suggestions with regard to what you are reading here. ..Maurice.
Banterings,
You may be correct regarding what Ubel, et al. wrote in “Don’t Ask, Don’t Tell . . .” My memory may be off some; I see the words on the last page of the article but the letters are all fuzzy. I should have a copy of the entire article somewhere. I’ll see if I can find it and get the authors’ exact words.
I wholeheartedly agree with your words, “When any other person enters the exam/procedure room . . . they [should] introduce themselves and ask permission to participate in my healthcare.” It is also advisable that they describe their function vis-à-vis your care, if any. I have argued elsewhere that these actions are ethically obligatory as well as matters of proper etiquette and common decency. Regarding explaining one’s function, an added incentive may be a legal one. Here’s an 1881 case on which later cases were based that explains why. http://faculty.uml.edu/sgallagher/DeMay.htm
If everyone or even a majority of patients did what you do toward examination room intruders, we’d probably experience a turnaround in some “standard operational procedures.”
Ray
Banterings gives examples of macro-level confidentiality breaches including breaches due to policy and computer glitches. Micro-level confidentiality breaches by health care providers are also commonplace. What can one expect when hospitals and clinics – including privately owned hospitals and clinics – allow children and young adults, many of whom cannot even define the words “ethics” and “confidentiality,” shadow physicians and nurses? Whether prior consent is obtained or not, to expect them to keep the “juicy” things they see and experience to themselves (even at the behest of providers in positions of authority) is like expecting a teenager to “kiss but not tell.”
Many adult providers violate confidentiality both deliberately (e.g., nurses nicknaming male patients after the shape of their penises and spreading their “humor” around town to their girlfriends) and irresponsibly (e.g., talking about patients in public places within earshot of laypeople), yet administrators of and providers in many, if not most, health care organizations threaten to augment the problem of micro-level confidence breaches by adding children and young adults to the list of people who have access to personal information about patients who may include their neighbors, their teachers, their classmates – you name it. Were one to study the classic works on social, personality, and ethical development written by Sigmund Freud, Jean Piaget, Lawrence Kohlberg, Alfred Adler, Erich Fromm, etc. and the research findings of those who confirmed their theories, s/he would reasonably conclude that the likelihood of children and young adults submitting to the temptation to violate confidentiality (especially at the urging of peers) would be much greater than the likelihood of adults (who are more likely than children to have firmly embedded ethical values) doing the same. It seems that as legislators pass laws with the intention to close the doors to confidentiality breaches in health care, providers conjure up new and more creative ways to circumvent those laws.
Ray
Maurice,
Thank you for the clarification. I’m pleased that you are not closed to social scientific inquiry. Regarding the imprecise use of words, I’d like to think that I have a sufficient grasp of English that I never use words imprecisely, but nothing could be further from the truth, especially when I write about things outside of my areas of expertise.* Thus, it would be presumptuous and hypocritical of me to project onto others the foible in myself. When I use words imprecisely, I hope you and other contributors to this blog will bring it to my attention.
When I was teaching, my colleagues and I would correct each other’s word usage when needed. Sometimes it was with, “Is this what you mean?” Sometimes it was less subtle, “I think a better word to use in the present context is ‘sesquipedalian’” On one occasion I talked to students in class about the Jolo Serpent Handlers and noted that a serpent was, by definition, a poisonous snake. A student approached me after class and diplomatically pointed out that the correct word was “venomous” not “poisonous.” She was correct.
* In fact, on this blog, I have sometimes deliberately used the word “hypothesis” more broadly than it was intended to be used in science.
Ray
Banterings,
You wrote:
"I always thought that Ubel pushed that the physician get the permission, but the students verify that permission was indeed granted. In light of "Don't ask, don't tell,” students absolved themselves by saying that the attending told them to participate so they assumed permission was granted. Ethically this is NO excuse."
How soon we forget...
"I was only following orders"....and then the boxcars came.....
Hex
Hex,
I like your imagery! So on point. One could say that analogy is very relevant in light of accusations that physicians assisted the CIA with torture of detainees…
Ray,
Your reference to “John H. De May and Alfred B. Scattergood v. Alvira Roberts” was the perfect prelude to Hex’s comment of "How soon we forget…”
Maurice et al,
In keeping with the turn this blog has taken to a more scientific view of patient modesty (dignity), I find that the following events are contributing to the ongoing problem.
Recently I have had 3 of my comments deleted from KevinMD on the posts: The problem with shared decision-making in appendicitis, This is why patients cannot be customers, Physicians aren’t burned out. They’re abused., and Doctors are not in control. Perhaps this is our greatest challenge..
My comments dealt with the topics addressed in the original post and in the comments’ section. I linked the state of the current healthcare system to medicine’s betrayal if society’s trust and society’s response to impose external regulation to protect its members. I reference 3 articles in the AMA’s Journal of Ethics (along with others) that support my position and demonstrate how medicine has betray its social contract. Those references are Reevaluating the Social Contract in American Medicine, The Medical Profession and Self-Regulation: A Current Challenge, and Professionalism and Medicine's Social Contract with Society.
My posts are factual, ethical, and to the point. To many providers, it is a bitter pill to swallow and they find the truth insulting. My style is the same as I post here, which most of you are familiar with. I invite and engage in discussion, will admit when I am wrong, and will not back away or back down from controversy. Yet, moderators delete my posts.
This refusal to accept that the profession has caused the problems that it faces today is also what prevents it from solving those very problems. Just like the addict or alcoholic that refuses to acknowledge that they are the cause of their own problems and continue to blame others, they are never going to get better or enjoy life. Just as with addiction, medicine needs to hit rock bottom, which it has not yet.
Since KevinMD does not want to hear the truth, I am crafting a post on my blog about both issues. I will update here when I publish that post.
“...and then the boxcars came…..”
– Banterings
Mea culpa, mea culpa. I found Ubel and gang but couldn't find where he addressed who should get consent. Now I'm thinking it's in his contribution to Dr. Sherman's blog but I've not been inclined to track that publication down. You make a good point, Hex. If the students are required to get consent, then they can't fall back on the excuse, "I thought the physician got permission on my behalf."
Ray
Banterings,
What you may have run into is a physician who considers any information that is inconsistent with conventional medical wisdom a heresy and physicians who promulgate it heretics. John and Sonja McKinlay addressed this idea in a 1977 publication in which they very clearly demonstrated that the reduction in the aggregate of infectious disease mortality rates during the 20th century due to medical intervention (inoculations) was less than 4% -- a far cry from what physicians had been telling people. It matters little to these people what the scientific evidence reveals; if the facts are inconsistent with self-serving theory, rather than alter the theory they dismiss the facts. It would be interesting to find out what factors distinguish between physicians who are "heretics" and physicians who are "conventional wisdom defenders."
Here is some of what the McKinlays wrote:
“The modern ‘heresy’ that medical care is generally unrelated to improvements in the health of populations is still dismissed as unthinkable in much the same way as the so-called heresies of former times. And this is despite a long history of support in popular and scientific writings as well as from able minds in a variety of disciplines. History is replete with examples of how, understandably enough, self-interested individuals and groups denounced popular customs and beliefs which appeared to threaten their own domains of practice, thereby rendering them heresies (for example, physicians’ denunciation of midwives as witches, during the Middle Ages). We also know that vast institutional resources have often been deployed to neutralize challenges to the assumptions upon which every day organizational were founded and legitimated (for example, the Spanish Inquisition).”
Ray
Ray,
You are absolutely correct and allude to the answer of your own question. Medicine is more of a cult than a profession (complete with “white robes…”). Just look at the similarities; the initial altruistic nature and goals to attract candidates, the selection process that ensures the candidates are “programable,” the boot camp style breaking down and building up, the hierarchy of power, the memorization of sacred texts, the grilling of questioning (A.K.A. pimping), the exemption from many societal norms and mores (like the separation of church and state), etc.
Then you, I, and others come along and espouse the teachings of Copernicus that the physician on Earth is NOT the center of the universe. How dare we speak blasphemy when it will damn our souls, our health, and the signature of our school physical exam form.
There is science involved, just as there was science in the practice of alchemy, but the core is based upon blind obedience. This cult mentality that fosters blind obedience is why the profession has a poor record of self regulation (Reference: Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1984, Freidson E. Professional Dominance: The Social Structure of Medical Care. Chicago, Ill: Aldine de Gruyter; 1970, Larson M. The Rise of Professionalism: A Sociological Analysis. Berkeley, Calif: University of California Press; 1977). This is the foundation of the “white wall” (like the blue wall of police).
The mistake that the medical profession has made is the same as the church; believing that they can best police their own ranks. Just as the church, medicine has paid the price. The loss of power, trust, and autonomy. Unlike the church, society has intervened with more regulation than the church.
They stick to doctrines that remain unscientific. Look at the issue in the news of mammograms just yesterday. Still, organizations and sects put out guidelines that continue to say; “…despite lack of evidence [insert group name] recommends that patients receive [insert unproven procedure here]…”
The cult of medicine also expects that patients offer their BODIES, minds, and souls on the alter in the exam rooms. That is the only way to achieve health.
This is the healthcare of the Nacirema!
Yes, this has elements of sarcasm and parody, but it also has elements of TRUTH.
– Banterings
Maurice,
Do NOT take this comment as an attack on you. If anything, you ARE an outlier in respect to patient dignity.
In previous posts you affirm this commitment to training your year 1-2 students with awareness and sensitivity to the topic. There are many reasons why people do not believe providers when faced with our experiences first defend themselves as compassionate, aware and professional. Next they defend their profession and finally dismiss our experiences as outliers or that we suffer from some (delusional) mental illness.
Many do not believe these claims of sainthood because the problem is systematic. The same way that airport screening makee people who don't fly on a regular basis feel safe, so too do these claims that healthcare abuse is nonexistent. Look at this from a scientific point of view, as such in the turn this blog has taken.
I have previously referenced the PubMed article "Pelvic examinations and access to oral hormonal contraception" in which 33% (one third) of clinicians surveyed admit that they require pelvic examinations before provision of oral contraceptives, despite guidelines indicating they are unnecessary and research suggesting they can pose a barrier to contraceptive access.
I add that that is the number that “admit" to the requirement. There is other research that shows the number to be significantly higher. Furthermore, the fact that there are so many articles that reaffirm the correct guidelines, Oregon and California legalizing pharmacist prescribed hormonal BC, and the attitude of so many providers as to the necessity of a PE for hormonal BC on Internet forums (read comments; 2015 on Reddit, "Denied Access to Birth Control upon Refusing Pelvic Exam & Pap Smear"), it shows this is a significant problem (still).
Is there a culture of acknowledging what is scientifically (evidenced based) correct and doing what the profession “has always done [this way]?" Is that also not the hallmark of a cult; acknowledging the beneficence of God while practicing harmful rituals and holding harmful beliefs and espousing them as beneficent? The AMA JOE of ethics addresses this in the line, "...turning of "preventive screening" from science into religion…" (Source: Informed Refusal)
The article on PubMed, "Survey shows that at least some physicians are not always open or honest with patients", seems to allude to an attitude of “do what we want, evidence be damned." As Maurice stated, he is only responsible for years 1-2 of his students’ medical training. The AMA JOE addresses the hidden curriculum and what happens between years 1-2 AND years 3-4 here in its February 2015 issue: The Role of the Hidden Curriculum in “On Doctoring" Courses and Professional Socialization in Medicine.
Perhaps the problem is that the problem has NOT been addressed:
Unfortunately, these data are not that dissimilar from a survey of ethics education in ob-gyn residency programs performed more than 20 years ago. In the report by Cain et al. [6], the average amount of time for ethics training for residents was only four hours; faculty members lacked training in medical ethics; and the method of teaching was generally lacking in structure. Source: AMA JOE September 2015 ,"Designing an Ethics Curriculum in Obstetrics and Gynecology")
– Banterings
Banterings, I, too, worry about what is happening to our students as they move from our (not just me) teachings in "Introduction to Clinical Medicne" in years 1 and 2 into the final 2 years of medical school. Your links to the AMA Journal of Ethics articles is very appropriate to the current discussion of the "what" and "why" of professional behavior and "misbehavior". ..Maurice.
Maurice,
The most important link is Survey shows that at least some physicians are not always open or honest with patients. Scientific proof, physicians lie, and on a regular basis.
I think part of the problem is rooted in the paternalistic fallacy of “doctor knows best.” The problem arises when a patient’s goals don’t accord with the physician’s judgment about what is in the patient’s best interest. The ethical concern is the conflict between autonomy and beneficence. In a Machiavellian justification, the physician’s choice of end justifies the means.
Edmund Pellegrino, MD, chair of the President’s Council on Bioethics and elder statesman of the discipline, argues that the proper focus of autonomy, the reason it is owed, is the principle of beneficence. Paternalism is not synonymous with physician beneficence, nor is it compatible with either autonomy or beneficence. Beneficence means acting in the patient’s biomedical, subjective, personal, and ultimate well being.
(Reference: Pellegrino ED. The four principles and the doctor-patient relationship: the need for a better linkage. In: Gillon R, Lloyd A. Principles of Health Care Ethics. New York, NY: John Wiley & Sons; 1994.
Pellegrino ED. Moral choice, the good of the patient, and the patient’s good. In: Moskop JC, Kopelman L. Ethics and Critical Care Medicine. Dordrecht, Netherlands: D. Reidel; 1985.)
– Banterings
OK..now for some specific input from my visitors to this thread relative to my medical teaching responsiblities:
Specifically, how (what words with what associated actions-behaviors) should a medical student or a physician use in order to obtain a sexual history from a patient (adolescent/adult)?
Should NO sexual history be obtained from any patient in an initial hospital admission if no symptoms appear related to the genital organs? What if the symptoms appear related to the genital organs?
Should sexual preference and sexual response be asked the patient? Should the number of sexual partners be asked? Should protection against pregnancy be asked? Should oral and rectal sex be asked about?
All these questions have potential clinical significance. But if you are concerned about maintaining patient modesty and patient dignity and yet also maintain the ability to provide diagnosis and treatment presently and in the future, what words and what behavior should be part of the medical interview?
I am pleased to have the visitor resources on my blog thread to be able to provide an answer to these these medical practice but also for me as "teaching issues". ..Maurice.
”Hello Mr. Bernstein. I am Dr. Banterings, and I a resident here at Truth or Consequences Medical Center. I am not your attending physician, but I am doing some of the preliminary work for your attending.
Do you know the difference between a resident and an attending? If not I will explain each.’s role.
[Appropriate, honest explanation if necessary…]
May I continue to take care of you?
Yes, thank you very much.
Even though you signed a consent form when you came in, I would like your permission to participate in your care. You may refuse my participation and we will find someone else you would be more comfortable with. You can also choose the level of service that you receive from me, that is you may only feel comfortable answering my questions and not comfortable with me examining you.
You may not only refuse my participation, but any other person as well.You may refuse to provide specific information, answer certain questions, or specific parts of any exam or procedure.
You will also be asked permission and introduced to other members of our team who will take care of you before they actually begin your care. You will also be told their position, explained their function and how it fits in to your healthcare. At any point, you may withdraw your permission.
If at any point, you wish to withdraw consent, you can ask to speak to me or any other person that you are comfortable with and you can do it privately. If you become uncomfortable with any request, please let us know and we will accommodate you.
I am sure you have heard of HIPAA and medical privacy. That prevents us as individuals from disclosing anything that we learn or that you tell us from people not directly involved with your healthcare. Once we do enter your data into our computer system, your information is dispersed, not by me personally, but by the corporation that owns us to the federal government, community health organizations both government and privately owned, our regional accountability organization, the guy who sells subs across town, the CIA, the NSA does not technically receive your data, the do COLLECT it, your insurance company, and more sarcastic institutions [reflecting my humor]…
First, some questions so myself and others here do not make any assumptions that may offend you. If we do make any assumptions, please let us know so that we may address you properly.
First, how do you prefer to be addressed?
Do you consider yourself male, female, both, or neither, and what pronouns do you prefer?
I want to ask you why are you here. I see that you [what ever lead to this]. Please tell me in your own words.
Now I would like to get your history, starting with medical, then social and finally family. Again, you may refuse to answer all or any specific question. This should help us diagnose what is going on here.
Now I am going to ask you some personal questions that may seem embarrassing. Again you can refuse to answer or if you prefer we could have a different person ask or you could fill out a form. All these questions have POTENTIAL clinical significance. You have to decide what you are comfortable disclosing.
Have you ever had a bad or traumatic experience with receiving healthcare, if so how bad would you rate it, what happened, and how can we prevent it from happening again?
Do you have a gender preference for those who take care of you?
I would like to ask you about your sex life.
...yes, your insurance company will see the answers. OK, we can skip these.
I would like to review your systems. Let us start with your head...
Is there anything else that I need to know about you or your care?
Thank you for your answers and letting me participate with your care. Next I would WANT to…”
Note: I said “WANT,” the only things that we need to do are pay taxes and die (at least once).
– Banterings
Dr. B,
In response to your questions it is my opinion that unless they are directly relevant to the reason for hospitalization, the sexual history and related questions you itemized should not be asked of any patient, ever. It is absolutely none of the physician's business.
If the questions are directly relevant, then they may be asked, but it should be done in a completely private environment and in a sensitive and caring manner. The patient should be told ahead of time the nature of the questions that will be asked and why they are relevant, so they don't feel blindsided. They should also be informed that they have the absolute right to decline to answer any question that they are not comfortable answering or they feel is too invasive. Students shoud not be involved without the explicit prior permission of the patient.
Regardless of assurances to the contrary, repeated breaches have shown that EMR's are anything but secure. There are also far too many loopholes as to who may access the information in them to provide any remote semblance of privacy.
Banterings and Hex, great responses!
Banterings, a patient "filling out a form" but without any subsequent verbal communication between student (or doctor) and patient may miss an important diagnostic or important health related condition or habit which would be of clinical importance to discuss and/or further investigate. Your description of the student's communication with the patient is exactly what they have been taught and what they do. (I sit with them at times and I hear exactly what they are saying to the patient.)
Hex, there is history that should and can be obtained which though at first appears to be unrelated to the reason for hospitalization may, with further detailing and investigation, actually be related or represent a concurrent separate issue which was not known immediately at the time of admission. For example there is a heuristic error in clinical reasoning which is termed "triage cueing" where, for example, in the emergency room a diagnosis is made and if followed up as "the diagnosis" may be in error until later, on the ward, after further history taking, for example, it becomes clear that an entirely different cause and thus different diagnosis was the basis for admission. That is why additional history taking, perhaps of a "sensitive" nature (sex, drugs, smoking, alcohol as examples) may yield a correct diagnosis. ..Maurice.
Dr. B.,
I understand your point - that is why I said if directly relevant. It is my contention that the number of instances where the patient's sexual history and related questions might be relevant is a very minuscule percentage of hospital admissions. How would they be relevant to something like appendicitis, a fracture reduction, joint replacement, or hundreds of other medical conditions commonly requiring hospitalization?
Certainly OTC and recreational drugs, smoking and alcohol use are more likely to be relevant as they can directly interact with or increase the risk of various treatments or procedures such as antibiotics, anesthesia and pain control, but that was not the question you posed. In that situation I have no issue with relevant questions being asked, but you still need to tell the patient why they are relevant.
As to concurrent separate issues, why not just ask the patient if there any other problems they might want to discuss and proceed based on their response.
Hex, you write "Certainly OTC and recreational drugs, smoking and alcohol use are more likely to be relevant as they can directly interact with or increase the risk of various treatments or procedures such as antibiotics, anesthesia and pain control.." and yet syphilis and HIV have also their affect on presentation and complication of other diseases or may simulate other diseases.
Yes, we teach students to ask "open-ended" questions such as "do you have other problems?" and then the student responding to that. But a "no" or something else to "other problems?" may not be sufficient to reveal clinically important disorders which can be unambiguously asked in the form of asking a "direct question" such as "have you ever had or have been treated for syphilis or HIV?"
There is a lot of subtleties to taking an effective clinical history and we have to teach that to our students. ..Maurice.
I do this in 2 parts:
Maurice,
A paper answer is definitely better than “let’s skip those questions."
A flag on the paper may lead to ask a relevant question in a non-sexual context. For example; “have you ever participated in receptive anal sex" AND “is there a chance that you have ever been exposed to the HIV virus" answer a question of significance for the clinician the latter does not carry certain implications to one’s masculinity or dignity.
Let me touch on another aspect of the transition from student to doctor. It is potentially a source for “medical hubris" and infractions on patients’ dignity. It is also a potential risk for future physicians. From “invading" (sorry, best word I could come up with) patients’ bodies unrestricted, being unquestioned in their decision making, leads them to a “god-like" complex and normalizes situations that are normally taboo or prohibited.
It has been applied to teachers that have inappropriate relations with students. It is thought that the teachers being in control and exposed to every aspect of their students creates an alternative “norm" where they then apply “regular" societal norms and thus see their students as a pool for romantic and physical encounters. Please note that these differ from serial predators where a “normal" person’s mores are distorted by means of exposure to a certain subculture or group.
Michael Jackson was thought to offer from this. By missing out on a “normal" childhood, being pushed by Papa Joe to achieve as an adult, he regressed to being a child in his adult years. Hence, he surrounded himself with playmates, and IF sexual impropriety did occur, it was the result of his adult social norms (sexual expression) being applied to the children’s social group that he internalized.
There has been speculation that this has been the root cause of physicians that behave improperly with children. Again, these are NOT predators that go in to medicine, these are normal people who have their norms and mores altered by their environment. (Please note this is a very simplistic and rudimentary explanation:) By being exposed to the bodies of children, they may normalize them into their pool of potential sexual encounters the way a non-physician would develop their personal preferences from societal advertising and sources of porn (Playboy, Internet, etc.).
Continued...
Part 2:
This is also part of the theory that the abused children go on to become an abusers by the nature of normalizing sexual contact between adults and children (See NIH, "Preventing sexually abused young people from becoming abusers, and treating the victimization experiences of young people who offend sexually", and NIH, "Sexual abuse history among adult sex offenders and non-sex offenders: a meta-analysis".)
I am having trouble finding all my references for these theories and research in my vast notes. I am sure that Ray will have some references to back these. I will post my references as soon as I find the rest of them."
The latest perpetrator of the sexual abuse of patients is the famous Dr. David Newman, Professor of Emergency Medicine, Mount Sinai Hospital. He has published articles such as the one in the Huffington Post, Quiet Fortitude in the ER, written books such as Hippocrates’ Shadow: What Doctors Don't Know, Don't Tell You, and How Truth Can Repair the Patient-Doctor Breach (I love the title in light of recent events...), and even did a TED talk, "Truth That Lasts".
On January 13, 2016, The New York Post reported that Dr. David Newman being sought by police Wednesday for allegedly drugging and sexually assaulting a 22-year-old female patient who’d gone to the hospital due to severe shoulder pain on Monday night. The Gothamist has a more detailed account of what is alleged.
My point is that there are factors that can affect one’s perceptions and make one from being a “therapist" to being “the rapist." There are also chronic and/or acute factors (stressors) that may push someone not normally predisposed to act in such a way to perpetrate such abuse (as an acute, one-time, or limited acting).
– Banterings
…and this just in from The Local, France: "France to ban vaginal exams without consent"
France has moved to ban vaginal and rectal exams on unconscious patients after a study found that many were being performed without patient consent.
It might sound like common sense, but France is set to put an end to the practice of doctors and their students carrying out rectal and vaginal examinations on patients who haven't expressly given their permission.
The reason? It was revealed that some doctors have been using patients under general anesthetic as teaching tools for their students.
While doctors claimed it was simply medical teaching, others were outraged that male and female patients hadn't given their permission.
Among the most vocal were a group of fifty doctors, feminists, and social workers, who wrote an open letter to the French government in February demanding a change to the system.
The group noted that medical directors had been quoted as saying they didn't ask for permission because patients "might say no", or even that it was "preferable" that the patients "don't remember that people unknown to them have 'had a look'".
Women's rights group Osez Le Féminisme said the examinations met the legal definition of rape in that they were “An act of sexual penetration committed on another, either by violence, restraint, threat or surprise”.
One former student doctor told L'Express that she remembered carrying out gynocology exams on unconscious patients at a Paris clinic.
"Before the operation, we were told we could make a vaginal examination when the patient was asleep. We all took turns without asking any questions," she said.
In response to the revelations, Health Minister Marisol Touraine asked for an official report to be carried out by teaching hospital medical deans, who came back with troubling figures.
They said no patient consent had been obtained for for one in three pelvic examinations by first-year students, or one in five such procedures carried out by more experienced students.
Touraine said the report was "very worrying" and "condemned with the utmost firmness these illegal practices".
"The state will be extremely firm against these unacceptable practices which undermine the integrity of the human body and the human rights of patients," she said in a statement.
The minister added that new measures would be taken to ensure no one in France would be examined by third parties if they hadn't given prior permission.
– Banterings
At first I was surprised at the lack of responses about my previous post. Then I just chalked it up to “this is what society expects of physicians (no surprise)” AND "healthcare doesn’t care because this keeps happening.”
I have to question what this is doing to the trust that society has put in the healthcare system in France…
One has to look in our own country and see what has happened to trust in the healthcare system. I just read a NY Times story: In Rural Alabama, a Longtime Mistrust of Medicine Fuels a Tuberculosis Outbreak.
Marion, AL is in the throes of a tuberculosis outbreak so severe that it has posted an incidence rate about 100 times greater than the state’s and worse than in many developing countries…
...“The phrase that every single case uses is, ‘I don’t want nobody knowing my business,’ ” Pam Barrett, the state official who is leading the response…But if you’re doing maybe some things that you don’t want other people to know about, or doing some things you’re ashamed of, you don’t want people in your business, and you’re not going to tell me.”
Others suggested that the history of medicine in Alabama, including the notorious medical experimentation in Tuskegee, was hampering efforts to contain tuberculosis.
“There is a mistrust of government medicine, in the African-American community especially, because of Tuskegee,” Dr. Perkins said. “It dates back to that. We haven’t dealt with the damage of Tuskegee in this state at any meaningful level.”
In 1932, the United States Public Health Service began a study of untreated syphilis that involved 600 black men in Macon County, Ala., which includes Tuskegee. The men, many of them sharecroppers who lived in poverty, agreed to participate in the study and received certain medical services for “bad blood.” But researchers failed to make complete disclosures about their work, and the men were not offered penicillin, which in 1947 became the recommended treatment for syphilis. In 1972, a federal panel found that the study was “ethically unjustified,” and the government ended it that year.
– Banterings
Story coming out of Miami about a fourth year resident Anjali Ramkissoon who tried to kick an Uber driver in the groin. She has
been placed on administrative leave from the hospital. The story has gone viral and you can see the video on line with her bizarre
behavior, but we hear and see disturbing stories associated with residents. My advice, medical students=interns=residents=nursing
students. Stay away from them all if at all possible.
PT
PT, how about staying away from med-surgical techs? ..Maurice.
Maurice,
In previous volumes Ray, Kevin, myself and others demonstrated how medical students experience a learned “sociopathy” (this is how I described the experience, others as a suppression/eradication of empathy…). Couple this with a strong knowledge of anatomy, being a victim of abuse (pimping…), and burnout; now wonder she was behaving like a rabid weasel.
PT may be on to something.
…But I am sure she is very compassionate, empathetic, and gentle with her patients.
—Banterings
From Banterings post Jan 16..
**While doctors claimed it was simply medical teaching....
The group noted that medical directors had been quoted as saying they didn't ask for permission because patients "might say no", ***
I'd love for the people with this mentality to meet other people with that mentality... specifically boxing coaches..
Imagine a doctor walking down the street minding his own business when out of nowhere some random guy.. or group of people... just walk up and start punching him in the face.
I'm 100% sure he'd be OK with it as it's a learning experience for the boxing student, and the reason they didn't ask him to spar was .. well... they "might say no".
Jason K
A visitor today wrote the following to the original thread for this Patient Modesty thread titled "Naked". However, I can't publish it there because there were too many responses and the thread is closed.
However, I want to publish it here as a rare example of a visitor on this subject who actually defends doctors and nurses who have patients undress. And, yes, I agree with one point made: "I don't remember this being an issue 30 years ago". Isn't that exactly what I have been from the beginning repeating here to you guys and gals? ..Maurice.
As a patient in his 50's, I am baffled by this trend of patient modesty and feel it has gone way too far. Having lived in Europe and the Middle East, I could see how bizarre our fixation on modesty seemed to people in other cultures, where undressing for a doctor was considered normal and unremarkable. I think there is something quintessentially American about this issue, one of our many oddities (gun lobbies, laws against abortion). Doctors and nurses need to control their professional space so that they can do their jobs efficiently. If they need us to be naked, it if for a good reason. Why are patients making this difficult for them through this over-emphasis on modesty? Why can't patients be more practical about this? I don't remember this being an issue 30 years ago. Why does it have to be an issue now? What a waste of time and money.
JB
From the post Maurice quoted ***As a patient in his 50's, I am baffled by this trend of patient modesty and feel it has gone way too far.***
Sounds like a doctor / nurse just claiming to be a patient, as the average patient without modesty issues would have no real reason to visit a blog about patient modesty. (I've never visited a blog / forum for people with a crippling fear of the color blue....)
As for their claim " If they need us to be naked, it if for a good reason." ... either they've never read the stories out there, or are the product of brainwashing to be obedient to authority figures.
If nothing is ever questioned, challenged or changed we'd still be in the dark ages.
Jason K.
JB says, “If they need us to be naked, it is for a good reason.”
The problem with this statement is that the evidence has shown us that things like prostate exams, pelvic exams, DREs in trauma, etc. are NOT necessary and potentially more harmful. Physicians have subjected women to pelvic exams for birth control when NOT necessary. So patients have been lied to about these things, we have to question everything.
One lie is enough to question all truths...
I would ask JB what is the good reason for medical students performing genital and rectal exams on anesthetized patients WITHOUT consent?
30 years ago we did not have the internet or 24 hour news, etc. We are in the information age. Anything anyone tells us as a truth can be confirmed on our smartphones in minutes.
This mindset also makes me think of those old sic-fi movies about alien invasions that I love. Those movies are awash in Milgram's obedience to authority experiments. People do not question the police or army because they are wearing uniforms. This is the mindset of what Tom Brokaw termed “the greatest generation.”
Younger generations follow Fox Moulder’s (X-Files) lead; “trust no-one.”
If the police showed up at the office of a physician and wanted to question them, would they freely open up or want to call their lawyer?
The police are in a position of authority (wearing uniforms), and as JB put it, if they want to question the physician, “...it is for a good reason.”
He also talks about “things uniquely American.” Like “FREEDOM.” This is a very unique concept in the world, especially in the 1700s. Our liberty has spread throughout world as the old guard regimes fight to hold absolute control over its subjects. (Sounds a lot like healthcare.)
Would anybody in the United States want the Canadian or British healthcare system here?
What about some other uniquely American things? 30 years ago women were not treated equally as is many places around the world. Does JB advocate for that? I ask, why not then? Why give women equal rights, allow women to fight in wars (when historically) this was a man’s realm? If men don’t want women in war, there must be a good reason.
I know this example is not the exact same as JB’s point about undressing, but there are similarities. The ”way we have always done things" argument is what JB is trying to make, and we disproved that argument a long time ago.
—Banterings
Banterings, be gentle with JB. His comment could not be published on my first thread titled "Naked" and I have no way of contacting JB to let him (I assume the writer is a "his" or a "him") know that his posting is actually on "Patient Modesty: Volume 74" and already commented upon, so that he could respond to your remarks. ..Maurice.
Dr. B,
I don't think that Banterings was directly criticizing JB as much as he was generally taking issue with what he feels (and I agree) is the outdated "Polyanna" attitude it represents.
Hex
Maurice,
JB, himself states; “As a patient in his 50’s...
Hex is correct. I am not criticizing JB, but rather that attitude that does not question authority.
—Banterings
Banterings, you are sharp eyed and picked up the gender clue, I missed!
The reason I wrote "be gentle with JB" was because you specifically identified him in your comment. Somehow, I feel if the writer of a commentary is not available for response to another's critique, it is fairer not to identify but just return with your response. This may just be an "old fashioned" attitude, so excuse me.
Why do you think we don't get responses contrary to what is virtually a 100% unified view over all these Volumes and years? Is it that virtually 100% of all world wide visitors reading these Volumes all hold the same views you all do or that there are many others who are too "shy" to argue against what is written here? Why oh why is there virtually only one "JB"? I, frankly am surprised and puzzled. ..Maurice.
Maurice
The operative word is student. Not sure what you mean by Med-Surgical tech. I can describe
to you numerous bizarre events regarding residents if that helps.
PT
Maurice,
I believe that it is a standard view of healthcare that it tramples patients’ dignity. The only people who defend it are the providers. Look at providers who have been hurt and how their views on healthcare changed (Dr. Edward Rosenbaum). I think the difference of the people who speak up here believe that we can change the world.
I think “patient satisfaction surveys” illustrate this thinking: patients do not just expect to be healed at any cost.
—Banterings
TURNING THE TABLES
So let me ask, is there anything wrong with a physician having to strip from the waist down so a urologist examined his penis to determine if his belly covered it while a nurse observed? Then given a chemically induced semi-erection and assume various positions?
What if he was ordered to not treat female patients of any age or even be alone in a room with them unless an approved female monitor was present, required to keep a patient log book, and have notices about these rules up in the waiting and examination rooms?
What if he disregarded these restrictions and was eventually arrested and charged with sexual assault?
See:
Doc's penis not hidden by belly, disciplinary hearing told
Barrie dermatologist being investigated by college This article contains a picture of the required notice.
Barrie-based dermatologist has medical licence suspended
Accused Barrie dermatologist suspended after breaching conditions
Court appearance for Barrie dermatologist facing sex charges
Was It His Belly Or His Penis? Skin Doc Faces Sex Abuse Allegations
Commentary:
I think that this exam is humiliating. I suspect that he agreed out of desperation. I wonder how long before he calls the exam traumatic and claiming PTSD?
I think that even more troubling is that the Ontario College of Physicians and Surgeons approved such an exam. (At least the nurse was male.)
Note: In the article, Doc's penis not hidden by belly, disciplinary hearing told, Investigator George Reed, who’s also a nurse, acted as an observer stated, once Kunynetz put his pants back on, he noticed “Tenting in his trousers.”
Perhaps Maurice could verify what year students are taught the medical term “tenting.”
—Banterings
***"Why do you think we don't get responses contrary to what is virtually a 100% unified view over all these Volumes and years? Is it that virtually 100% of all world wide visitors reading these Volumes all hold the same views you all do or that there are many others who are too "shy" to argue against what is written here? Why oh why is there virtually only one "JB"? I, frankly am surprised and puzzled. ..Maurice."***
Like I said earlier... "the average patient without modesty issues would have no real reason to visit a blog about patient modesty. (I've never visited a blog / forum for people with a crippling fear of the color blue....) "
Jason K
Small world.... that dermatologist Banters linked to is MY dermatologist. Or was, I guess. I was last there about a year ago. He was one of the few doctors I WASN'T creeped out by. He came off as a slight bit arrogant, but not to the point of being offensive, but other than that he seemed like a nice guy. I didn't read all of the articles, but no... their clinic didn't offer gowns, but they did provide full size bed sheets to cover yourself with, with clear signs in the rooms to leave your underwear on. EVERYONE who worked there ALWAYS knocked before entering, even if they literally just stepped out and had forgotten something and turned back.
As much as I distrust doctors and the profession in general, I'm honestly surprised by this.
Jason K.
JP brushes Europe and the Middle East with a single brush. The desire to protect the integrity of one’s body varies from one European nation and culture to another. While it may be of little importance in Spain and Germany, one might suppose it to be of greater importance to citizens of England. Outside of Europe, the people of Scandinavian nations seem not to be too concerned with exposing themselves while Canada is ahead of the U.S. in its efforts to protect its citizens from unwanted bodily intrusions by healthcare providers.
People of the Middle East, other than Israel, tend to consider the body to be sacrosanct. Exposure of one’s body, even in a doctor’s office and especially for women, tends to be approached with great caution so not to offend. Indeed, I know for a fact that BS nursing students in the program with which I am familiar are taught to respect and how to show respect for people of Middle Eastern extract when it comes to bodily exposure.
In the U.S., people of Arabic descent tend to settle in enclaves where they are treated by physicians who show respect for their cultural idiosyncrasy. This concern for protecting one’s bodily integrity is articulated in The Arab Mind by Raphael Pata, a book which is considered to be the U.S. armed forces’ “bible” for understanding people in Arab nations. What occurred at Abu Ghraib and elsewhere was based on the knowledge of the traumatic effect nakedness has on the people. Women and men have been stripped searched by the opposite sex in public places for the purpose of humiliating them. We are hated not only as occupiers but also for the disrespect we have shown for the value they place on bodily integrity.
As an illustration of the impact of Middle-Easterners being exposed to others, there is a case in the ‘90s of a Saudi man and his wife on an airline. The stewardess dropped coffee on the man’s lap. Over his objections, he was thrown to the floor and his pants removed. He not only sued for the coffee spill but also for the impotence that followed the humiliation of having his pants removed. His wife sued for loss of consortium. They won on all counts.
The author of the piece writes that the “trend of patient modesty . . . has gone way too far” and that there is an “over-emphasis on modesty,” yet, true to form, he does not give an example. I imagine if he did, he’d cherry pick the outliers as indicative of the norm. Since I began participating on this blog, the preponderance of the examples given are of those actions that violate professional ethics (which are founded on international human rights’ documents) and that are outside the law. Is it that the writer has contempt for professional ethics and laws designed to protect unnecessary intrusions of patients’ bodily integrity? It appears so. -- Ray
JB writes, “I don’t remember this being an issue 30 years ago.” He doesn’t remember it being an issue because he probably wasn’t interested enough to find out. The issue was addressed obliquely and in a comedic way in Horace Miner’s Body Ritual Among the Nacirema in 1954. In 1970 Joan Emerson acknowledged its importance in her famous work on pelvic exams. Edward Rosenbaum, a physician himself, addressed it in his book A Taste of my Own Medicine in 1988. The courts even dealt with it in cases such as Backus v. Baptist Medical Center in 1981 and EEOC v. Mercy Health Center in 1982. I conducted a form of qualitative analysis called content analysis on nursing journal publications having to do with the issue in 1986.
JB might defend himself speciously with, “How would I know about these publications?” The answer is, they’ve all been cited in Maurice’s blog. JB simply didn’t bother to study the matter. Banterings is probably correct, issues of modesty – just as issues of paraphilias – have come out of the closet because of the internet and other forms of modern communication technologies.
JB’s comment “Doctors and nurses need to control their professional space so that they can do their jobs efficiently. If they need us to be naked, it if (sic.) for a good reason” suggests that he is a physician himself, as noted by Jason K., or he’s the type of person who, “when a [physician] says the sun don’t shine, tries to hide his shadow.”
Ray
Maurice, I'd like to mention you in a letter to an organization that has a protocol that violates the AMA's Code of Medical Ethics and, possibly, civil law. I make some recommendations for simple changes in their protocol after which I refer the reader to you. I'd like your blessing to mention you in this context. If you think I should add something to what I've written, please tell me what it is.
Let’s assume that TOI chooses the neutral environment option. The following recommendations would satisfy its ethical obligation to patients.
1) When patients enter TOI, they are presented with a document that provides the following: a) informs them that TOI provides a service for high school-aged and college-aged students who want to shadow doctors to find out about how they practice medicine, and provide them with any other pertinent information that would help them make a decision to assent or decline the participation of observers; b) make sure patients understand that the observers are not part of any health care educational program at their schools or elsewhere, but are there only as observers to better understand what doctors do; c) ask patients to check one of two boxes indicating that they either decline or consent to the invitation; d) inform them that if they consent, they can change their minds at any time before or during the examination without negative repercussions; and c) ask them to sign the document.
The following recommendations may not be ethically obligatory but they may be considered because they demonstrate respect for patients and an appreciation for their contribution to young peoples’ understanding of what it’s like to be a physician.
2) Patients who consent can be given a handout with the name of the observer (and with the consent of the observer, a photograph) along with other information that the observer has agreed to share with patients about himself or herself regarding, for example, interests and aspirations.
3) When the physician and observer enter the examination room, the physician can introduce himself and the observer to the patient and thank him or her for agreeing to allow the observer to participate. The patient can then be asked if s/he has any questions about the student or protocol regarding his or her participation.
4) Following the examination, common courtesy dictates that both physicians and observers thank patients for their service. It would be good PR were the clinic manager to send a letter thanking patients for their service. This insures that all parties who benefit from patients’ services express their gratitude.
What I have presented above is a variation of the approach used by Dr. Maurice Bernstein, an assistant clinical professor of medicine in the Kleck School of Medicine at the University of Southern California in Los Angeles. Dr. Bernstein strictly adheres to ethical guidelines advocated by the AMA Codes and rules of common courtesy when he teaches clinical courses, which he does to great success and with little objection from patients to the presence of medical students. If Dr. Bernstein does this with medical students, surely TOI can treat patients with equal success and equivalent respect when teenagers are the observers.
Ray
Ray, you should feel free to express your opinion to a recipient whom you find is in need of such a view. My recommendation is that along with your description of me and my behavior, you should also reference where you obtained that description, such as the written source e.g: Patient Modesty threads, Bioethics Discussion Blog (bioethicsdiscussion.blogspot.com) or more specific links.
I certainly am in favor of requesting informed consent by patients with the information being presented directly by those requesting consent. ..Maurice.
Dr. Bernstein - I’m a returning contributor from a few years ago (now that I have more time to continue advocating for patient rights). For the long time readers/contributors I previously participated under the name CompliancePhD, going with a shorter identifier from now on.
Great discussion in this thread. I have a couple very simple questions related to the med student training and processes at your medical school. Other practicing physicians could answer too. First, my lifelong experience receiving full physical exams from both female and male MDs, in multiple States is the examination of the genitalia, hernia and/or prostate is done last. Is this a universal teaching in medical school - that the intimate part of the adult male exam is done last? If so, why? If not, maybe I’m just a statistical fluke.
Secondly, my experience receiving full physical exams, say in Internal Medicine or other practices needing to perform the full physical, is that I never get a gown to wear. At best it is “take off all of your clothes down to your underpants”. How does your Hospital/practice clinic handle the full physical exam of the male patient in an outpatient setting? Are female outpatients receiving a full physical exam in the same setting getting gowns? Finally, does your medical school teach/recommend to its students whether gowns should or should not be provided to the patient (male, female) for the full exam in the outpatient setting?
I would be interested in others experiences in the order of the physical exam, and the state of undress requested for both males and females, i.e., get a gown or not and/or undergarments or not. Any differences in the approach to males vs females in terms of requested state of undress at start of the exam? Thanks. - AB
Alden, welcome back to the blog and blog thread.
We teach our students to attempt to preserve the patient's modesty but also to be aware that unnecessary large areas of exposure of the body may lead to chilling with unwanted increased in muscular tone and shivering. These physiologic responses impede accurate auscultatory and palpatory examination results. All exposures of the body should be sequential just to expose that specific area to be examined. Out patient exams should be the same, in this regard, as inpatient exams. So, beyond modesty concerns which all students and physicians should be considering, these other bodily responses should be prevented.
So, we expose just the areas of the patient's body which are to be immediately examined. And this dictum is given to all students when they start learning the physical examination. ..Maurice.
Dr. Bernstein,
So is there a taught sequence of examining the body systems or is the rule as long as the student does the same sequence each time to cover all the body systems that is okay? Is their a preferred order of body systems that is taught? I’m just wondering if those physicians that do the examination of the intimate areas last do so because they know this part of the exam can cause patient anxiety and embarrassment?
As for the use of gowns in outpatient clinics my underlying suspicion is room turn around time (patient volume), cost of gowns and laundry (business costs), and assumptions about male modestly vs female modesty (can we cut corners, save time and money with male patients) may factor into how a clinic uses gowns (if at all). Hence why I’m trying to tease more info out of you and others. - AB
AB, yes, there is a taught sequence of a "complete physical examination" with regard to the sequence to examine each and every system. Yes, Head, Eyes, Ears, Nose and Throat begin the exam and yes Genitalia and Rectum end the exam, though the Genitalia exams are not necessarily performed every time and depend on the history and appropriateness with regard to the clinical history and past findings. The Rectal exam should be part of any Abdominal examination.
The examination of genitalia and rectum are to be done at the conclusion of the physical examination purely out of their known emotional sensitivity with regard to the discomfort and modesty. In order to attend to the issues of discomfort and modesty, it is important that the patient, during the prior parts of the physical exam, have become comfortable with the physician's overall behavior (including communication) and skill in examination. Thus the genital and rectal exams should be done last when the patient has had time to develop that comfort.
Use of gowns should not be an issue of time or money but is an essential part of the physical exam for the patient's basic modesty and to keep the patient warm and comfortable. Examining through clothing can severely impair obtaining needed information. All this we teach our students as the learn to perform the physical examination.
Note: Currently, my first year students are learning the physical examination of the abdomen and yes, they are examining their colleague who is wearing a gown, the body below the abdomen covered with a sheet as a standard of practice with only the bare abdomen are exposed. ..Maurice.
Welcome back, AB. I don’t recall your early contributions. You may have preceded my participation in the blog or made contributions during the period of my hiatus.
Thank you for the input, Maurice. I made reference to your blog in my letter. If you have something specific to which I can refer readers, I could include that too. I’m skeptical that they will pursue any reading in an area that makes them question their protocols, but references do give credibility to what one writes.
Now, I have a question for you, Maurice. I have been used as a teaching tool or a visual aid many times, always without prior consent, but was never thanked for my service. What justification do you think physicians and students would give for not thanking patients for providing them with a gratuitous service?
Ray
Dr. B - It sounds like you are teaching your students to examine a patient in a most respectful way. Thank you for that. I’ve never been the recipient of a gown and sheet as an outpatient, and I’ve had comprehensive physical exams at multiple large medical centers throughout the country.
Here is one example that plays out many times a day that illustrates how the care differs in comfort and dignity between males and females - also in the outpatient setting. A female has suspicious findings on her mammogram and must go get a breast biopsy (1 in 8 women will develop breast cancer). She goes to a Women’s Imaging clinic and is escorted to a private changing area and given a gown, and in some centers, she also gets a robe to wear. Then she is escorted into the procedure room and the Radiologist does the biopsy. She then is escorted back to the changing area and gets dressed in privacy. (All staff are female it goes without saying to this thread).
A male (and this is from my personal experience) needs a prostate biopsy (1 in 7 men will develop prostate cancer). He goes to a Urology center and is escorted to the procedure room and told by the (female) MA to undress from the waist down (no gown). Eventually the urologist shows up and performs the biopsy assisted by the MA. The MA remains in the room while the patient gets dressed in front of her.
Aside from the gender issues, there are gross assumptions about dignity here by the same Medical Center. No women is ever asked to undress or dress in the procedure room, and while attended by the MA or tech (of either sex). Women are not asked to go without a gown either. State and national medical ethics codes all suggest patients (as in ALL patients) should be allowed to dress and undress in private. So why do the clinical leaders, physicians, and other clinicians feel it is okay to deny the male patients certain dignities and patient rights? Maybe they need remedial training at USC! - AB
I was recently directed to a YouTube video at the address below.
https://www.youtube.com/embed/gSw4CLV14sQ?rel=0
The fact that it was selected as a finalist in an Australian film festival in 2012 demonstrates just how far we have to go in changing attitudes in order to gain real respect for male modesty in medical situations.
If you watch the video you will most likely be applled by the underlying messages it sends:
1. Male modesty violations and humiliation in a medical setting are not to be taken seriously. In fact they are a source of humor.
2. The double standard is alive and well. Can anyone imagine this film being made with a female patient instead of a male!
3. It’s fine to disrespect patients. The doctor laughs at his problem, the exam room door is left open and a female feels free to just walk into the room.
4. The patient has absolutely no input into what happens to him. This message may be the most dangerous one of all for those who are unaware of their rights as patients. Most of this blogs readers would have told off the doctor, insisted the women leave the room, and sued the institution for various privacy violations but this man just plays the role of the helpless patient who feels he has no control over what happens to him.
Unfortunately, misandry appears to still be alive and well!
(If anyone has trouble with the link, the title of the video is “How Many More Doctors Does It Take to Change a Lightbulb”)
MG
MG
" How many more Doctors does it take to change a light
bulb.". There is a version of a female patient and a version
of a male patient, watch both of them. The female patient
version is a joke and I assure you never happens. The only
time I have ever seen three physicians in the same room
would be during a level 1 trauma or a surgical setting.
Physicians are just too busy to congregate around one
patient like this. I believe this video is just a smokescreen
to distract the inequality male patients are subjected to. I'm
in no way suggesting females are not subjected to behavior
that is considered unprofessional by providers. I'm suggesting
it does not happen in this depicted fashion.
Does it happen in this fashion to male patients, absolutely
but by nursing staff. Intimate care of male patients is best
delivered by multiples of female nurses with doors open and
curtains not drawn. Their staff bathroom may be decorated
profusely with full nude foldouts of males from playgirl
magazines to further remind them after a potty visit that that
male patient is not actually a patient, but a slab of meat.
PT
When is the US gov't gonna step up & start protecting men's healthcare privacy rights. I for one am appalled at the lack of concern by the powers that be. Being a male and trying to get any medical test or procedure done without surrendering your modesty and/or dignity is nearly impossible these days.
I tried out on the east coast setting up a colonoscopy screening as it's that time and the doc is pushing to get one. I am willing to push the appointment out a full two months. All I've asked for is doc that's done it many times, no sedation just pain mitigation if needed, colonoscopy shorts for modesty reasons, or an all-male team to do the procedure.
So far, none of the facilities uses the shorts and not one of the facilities can give me an all-male team. Even pushing the appointment out to give them the time to assemble the team. They can however guarantee me an all female team I'm told all the time.
This is sad.
They wonder why men die young.
Healthcare industry needs to change. They need to hire an equal amount of men and women for healthcare positions. I have a male friend very qualified but can't get a nursing job because these places tell him we are only hiring females for nursing positions. That is discrimination and they should be called on the carpet for doing it.
I've given up on looking for an endoscopy center that would work with me and will settle for one of the at-home FIT tests for now.
Women wanted equal rights & they got it.
Well, men want equal healthcare rights now. What are you going to do about it? Let them keep dying young?
NT.
NT,
I agree with you that it is hard for men to get their wishes for modesty in medical settings respected. If you really need a colonoscopy (I have no idea what your risk factors are), I encourage you to shop around until you can find a medical facility willing to respect your wishes for an all-male team. As for colonoscopy shorts, you could wear boxer shorts backwards or you could look into buying a colonoscopy short for yourself. In fact, you could possibly get some free sample colonoscopy shorts from Prime Pacific Health Innovations. They are inexpensive and most patients would be willing to pay for those shorts.
Medical Patient Modesty helped a man to take steps to ensure that he would have an all-male team for his colonoscopy in New York. Check out the testimony of James who had success in getting wishes for an all-male team and colonoscopy.
Also, check out our colonoscopy article about how you can take steps to ensure your wishes for colonoscopy are respected.
If you need any more help, please email us through Medical Patient Modesty’s web site.
Misty
NT
There are 16 patients scheduled for colonoscopies that were done between the hours of 7:20a and 2:30p. There are only
2 endoscopes. Each endoscope requires 30 minutes cleaning process. You do the math! The endo tech has no formal training
and only last week she was working as a housekeeper for the hospital. She says she loves it when it's prison day, that is when
the prison sends their patients to the hospital for the prisoners colonoscopies. All 16 male patients. One gastroenterologist. You
do the math.
Several years ago it was announced that 12,000 patients had contracted Hep C, Hep A, Hiv and just about anything else that that
was in the endoscope due to inadequate cleaning process. If I recall correctly, this occurred at the VA center in Alanta. Why anyone
would want a colonoscopy is beyond me when the latest iteration of CT scanners can perform virtual colonoscopy. A 10 minute
scan performed safely. You drink 1 liter of water and get a scan.
PT
NT
You should convey your thoughts to the hospital or endo clinic that you have preferred to get a virtual colonoscopy at another hospital
because their are no side effects , yet more importantly. There will be no female endo techs or female endo nurses during your exam.
Since you would never know what the endo schedule entails for that day you could do yourself a favor by saving your life and excluding
you from an unsafe schedule and inexperienced staff. Now, if you enjoy that kind of thing simply make some fake tattoo's on your arm,
be sure to tell the all female endo staff that you just got out of prison and I'm sure you will get a whole lot more attention.
PT
NT,
These are basically the reasons that men (such as myself) have just elected to drop out of the healthcare system. I do not go unless it is for something straight forward like sutures (even then I tough it out and “super glue” the wound myself).
I do NOT do preventative care at all.
I also take responsibility for my own healthcare.
I also see nothing wrong with this either.
—Banterings
I too agree with Banterings on his latest post, patient heal thyself.
PT
To answer Bantering's post, and also the innfuriating one of a person that goes
by the name of JB, it's not at all true that medical Modesty is a "quintessential
Americn phenomenon". It's world-wide. If someone's foreign in this blog, it's me.
And I can confirm that Americans are not the only ones interested in improvement on
that front.
If France banned exams under anesthesia "it's for a reason". Looks like someone with
skin in the game. I was also offended by the assertion that modest people want to ma-
ke it harder or the providers to do their jobs. One thing this person doesn't get: OF
COURSE we want to make it more difficult for a true deviant to get their kicks, sexual
or otherwise!!!
Majo,
I reread all my posts in this volume since I never stated that AND I do NOT believe that medical Modesty is a only an American phenomenon.
If anything, foreign physical exams are more traumatic.
It is commonly known that many European and Scandinavian countries have a more liberal view of nudity. Just look at television programming or the French Riviera.
Last that I knew, a European physical exam went something on the line of meeting with the physician in his/her office to go over the oral portion of the exam (history, complaint, etc.).
The next step was stepping into the (usually attached) exam room and the exam beginning. It may be an "undress as you go" OR a "go ahead and get undressed now" (with the patient naked for the remainder of the exam). Perhaps the Muslim influx has changed this.
Can you (Majo) confirm either way?
As a matter of fact, I have mentioned my acquaintance with Lars Peterson, author of Medical Rape; Authorized German Perversion. (More about Lars and his works here:)
I even introduced Lars on my blog here:
Finally a welcome to Majo, Alden, and the others returning or first time posting here!
—Banterings.
To Bantering and PT. I agree 100% with you both. I believe you should be free to choose your healthcare from whoever you choose . After all , your still the one responsible for paying the bill. You should get the care that you are comfortable with.
On a different note. Several years ago comments were made by some on idea's they had on how to get the care your comfortable with. A modesty movement so to speak. The only person that appears to be doing anything is Misty. Thank you Misty for what you do but doesn't anyone else have any idea's on how to bring about change . Everyone should be able to choose the gender of their healthcare provider. AL
Al,
Some of the ideas (with terminology) that is uniquely mine, I have seen making its way into guidelines. These are most likely the result of some short papers I did or my comments on the guidelines before they were released.
I am in the process of writing a book that will show patients how to receive the care they want and should push the system to changes.
I am not the best writer, so this is a struggle for me.
—Banterings
I am teaching 4 groups of 7-8 second year medical students tomorrow the male genital examination (as are the other instructors) and you can be sure that, as part of the course's protocol, we are teaching the students to examine the patient's genitalia while the patient is standing in a gown, then elevated by the patient during the exam. ..Maurice.
Maurice,
I sent out a statement several days ago, but don't see it posted.
Regarding your last post, what prompted it?
Are the patients being remunerated for their service to you and the students?
Ray
Ray, I have not seen what you wished to be posted.
My last posting was based on concern written to this thread about the nudity of patients subjected to rectal or genital exams. Though first and second year students at our school do not do rectal or pelvic exams on real patients, they are still taught the process in preparation when they will do these exams later in their education and career.
No, patients are not "remunerated" for their participation with first and second year medical student education except they are informed, made-aware that their participation is much appreciated and needed. Patients are understanding of the value of their participation and I would consider their acceptance of the student really altruistic. ..Maurice.
Part One
I would like to share a personal anecdote with the reader. My mother was always a self-effacing woman; when I was young, she was successful at convincing me that she was not very intelligent. That impression of my mother was short lived; I learned to consider her to be a wise emissary for her generation. When I wronged another and she found out about it (which happened a time or two), she would sit me down and speak with me, employing various strategies and cogent arguments to persuade me of the error of my ways. Her intent was not to humiliate me into admitting culpability but to instill in me a sense of shame for what I did, not for what I was. She was invariably successful.
Once, with bowed head and tears of shame welling up in my eyes, I admitted responsibility for the wrong I had committed, she would let me know with no equivocation, that culpability must be followed by a punishment commensurate to the seriousness of my “crime” – the dreaded apology. Too ashamed to offer the apology for my transgressions myself, I would plead, “Please, won’t you do it for me.” Of course, being a woman of integrity and high moral character, she would turn down my request and I would shuffle as slowly as I could to my victim’s place of residence with hat in hand, and offer my apology with a stutter and shaking voice as tears of shame dropped from my bowed head. “I’m sorry Mrs. Morausch for throwing a rock through your window and breaking your antique vase.”
This was the way I, my siblings, and my young neighbors were raised and we figured that most other children of our working- and middle-class origins were raised in the same manner. I wonder if I’m alone among my early peers to realize that the world of bureaucrats works in reverse of the ways that we were taught as children. But more than likely these age peers of mine tossed away their childish beliefs and, along with me, became the cynics we are today. Nowadays, bureaucracies have a job for just about every little thing that occurs in them from members of the Board of Directors, each with a different specialty, to the clerical workers of lower management with their specialized roles – and different departments, each with its own set of specialized functions. Among these departments one will invariably find an “I’m Sorry Department” better known as the Public Relations Department. The people who man (or woman) these departments are well trained experts in apologizing for the errors made by other people. For example, I underwent a colonoscopy awhile back. I told the nurse I’d like to go to the bathroom before I left. She followed me in and when I asked her to give me my privacy, she refused saying “it’s against policy.” I countered with, “You mean policy requires that if I need to urinate I must do it while you watch?” Without hesitation, she responded, “yes.” “I’ve more self-respect and dignity than to do something like that,” I proclaimed as I walked away.
Ray
Continued
Continuation: Part Two
I filed a complaint with the clinical director who apologized with great earnestness for the behavior of the nurse; she wrote that she and the facility director had created a code of conduct to prevent a repeat of what I experienced. It was clear that she thought her letter of apology would put an end to the issue, but I wasn’t satisfied. I followed her letter with what I believed to be a reasonable request: “Will you please favor me with a copy of the code of conduct?” I never heard from her again.
What the clinic director tried to do is called “cooling off the mark.” The expression originated with “professional” pickpockets who work in pairs. The first picks the pocket of a “mark” while his partner watches. Once the “mark” realizes his wallet has been lifted, he gets heated, screams, yells, spits, and threatens to go to the police. The latter is, of course, the last thing pickpockets want the “mark” to do because the presence of police cramps their style. So, the pickpocket’s partner approaches the “mark” and, with a look of sincerity in his eyes, feigns empathy with the poor fellow’s misfortune: “I feel for you, guy. The same thing happened to me, but there’s nothing to be done about it. Sure, I called the police, they took my name, asked me how much I lost, and told me ‘tough luck.’ They could care less. I left feeling like a sucker.” The mark is thereby “cooled off,” he walks away feeling like a chump and blaming the police rather than the thief for his loss.
People who work in an organization’s “I’m Sorry Department” have been trained to be just as expert and just as disingenuous as those pickpockets. And, like the pickpocket, the offender is free to offend again without shame, guilt, or remorse.
Ray
Ray,
I understand very well what you describe. At one point in college, I was an assistant manager for a repair service. The organization was dysfunctional. Despite dictates of customer satisfaction, each location and each department in each location was a fiefdom of the manager that ran it. Their ultimate goal was not that of the corporate office (customer satisfaction, maximizing profits, growing the brand, etc.), their goal was to maximize their bonus, doing the least possible (growth brings change), without coming on corporate’s radar.
Many times the customers did not receive the service they should. The reasons tended to rest with management, such as having a tech do a job he was not skilled at. Needless to say that we dealt with many an angry customer who just wanted their repairs done correctly. At the same time, I was in the throws of my counseling (psychology-related) degree. After the first few months, I perfected my script for dealing with irate customers.
I also sincerely wanted to help these wronged people and saw to it personally that their repairs were done correctly. What my techs saw was a visibly irate person apologizing to me after 10 minutes. (Usually the apology was for directing their anger at me when I did NOT cause their problem and I wanted to help them.)
I became the PR. Unlike most PR departments, I made changes that prevented repeat occurrences. What struck me was that I was the only one driving the changes, the rest were content with the status quo.
In business today, one must promise customer satisfaction and if their organization has no awards to show, they must create a trade organization that will award the business. Key words are key: digital, upgrade, social, networking, big data, meaningful use…
Most of the people who use these words do NOT understand what they really mean.
Just look at cell phone carriers or cable TV; these are the same as voting for President. It is not “who is the best,” it is “who sucks the least.” Do companies really think customer service is an automated phone system?
Healthcare is no different. They will tell you that what they are giving you is what you need and the best product/service to meet that need.
—Banterings
Mike sent the following to Volume 72, which has long been closed for additional postings.
Here is his posting. I hope he returns but to the current Volume 74. ..Maurice.
I am a long time follower and occasional contributor on this forum and wanted to share a story. I had my physical with my long time doc this week. They just converted the office to the full electronic setup with everything dictated on a laptop or tablet in the office. It makes refills and appointments very easy, but has its drawbacks as well. He never had anyone else in the room for exams before, but now there had to be an electronic scribe. Naturally, he had a female assistant manning the laptop taking notes on all of his questions and my answers about meds and such. Nobody at any point ever asked if I was OK with it. I was fine with her being there up to that point but was in my head wondering what I was going to say when the exam came because I did not want her there then. When it came time for my exposed part of the exam, she promptly turned her laptop 90 degrees and faced the wall away from me. I appreciated her doing that completely on her own and felt at least a little bit like my privacy was respected but at the same time I feel like her presence was still kind of forced on me. Since this was my long time Dr which I value very much, I was not quite sure what to say about the extra person in the room. Unfortunately, I am afraid this electronic dictation and record keeping is the wave of the future and that we can all look forward to yet another person in the room manning that equipment.
Mike
To Mike,
You simply say, "Doctor, I have given no consent either informed or implied for your assistant to be in this room during my exam. Please have her leave at this time. Thank you."
That should take care of the situation without offense.
Ed T.
Hello:
Banterings I agree with your 02/07/16 post and I too now have stopped all preventative care after being mocked again for having a modesty issue.
Called a place to setup a male related test & was told no we don't have male techs. Our female techs are capable of doing the test. Then I was told I shouldn't be so modest as I'm a man and men aren't modest.
It still just amazes me on how this country continues to ignore it's men's modesty issues.
What more do we have to do to be heard? When are they going to start treating us like human beings.
What do you do when people won't listen?
What do we have to do to get a sit down with the powers that be & the laws either changed or strengthened to give men their equal healthcare rights.
If change doesn't come, men will continue to die needlessly.
Respects to all.
Regards,
NTT
NTT
Isn't it amazing that young female techs with several weeks training and several months experience have so much wisdom about life [rhetorical].
BJTNT
www.jcert.org/sites/jcert/uploads/document/2011-standards/standard-radiology.pdf
No male techs in mammography, which is what the above website will take you to.
Written by Debra Poelhuis, she is the program director at Montgomery county community
college. She proposes that all radiology students be rotated through the mammograpgy
department when x-Ray students including males do clinical rotations at the hospital.
Now, for a moment don't get thinking that this woman simply wants equality for both sexes
which is simply not the case. She had made this proposal because there were some lawsuits
citing inequality when a group of students doing clinical rotations, specifically excluding male
students from mammograpgy. Yet, female students were allowed to rotate through all areas
particularly where exams, procedures of male patients were involved.
How have hospitals managed to circumvent this discrimination. By two ways, a) they simply
refuse to have students at their facility. If they welcome students, they ask for female students
only. Many hospitals no longer have mammography nor Labor and Delivery. Why, profits, as
well as relieving them of liability of a sexual discrimination suit. Mammography has essentially
moved to outpatient facilities. Labor and Delivery suites are now usually centrally located at one main
hospital. More and more midwifery centers are now opening.
In conclusion, many females in healthcare will appear to advocate more men in clinical areas such as
mammography with a spin on it. They have no intentions ever of allowing men in these clinical areas
to work. They actively pull strings behind the scenes to guarantee and ensure "The double standard continues.
The female healthcare industry continues to say " we are all professionals" , " you don't have anything we haven't
seen before." ," men are not modest, quit being a baby" . " he must have a small penis". " men are all perverts".
" if he requests a male to insert his foley" I take that as a refusal for a foley". " never mind all the negativity and
unprofessional comment we post on all nurses". " we see more penis than a prostitute" " his penis was so small,
I could not find it. " , " go take a look at the size of that guys package in 207". " go take a look at the penis ring
on the guy in 524." I took a cell phone pic, it's on my Facebook page, says the CNA ". We are all professionals
and to show you that we are, just look at our staff bathroom on our MICU ( Medical intensive care unit) . Covered
from the floor to the ceiling with full nude foldouts from play girl magazine. It only took us 3 weeks to do it. Looks
like a professional came in and had it done!
PT
Maurice
You spend as you say a considerable amount of time with your students, and that you mention that your female students perform
genital exams on males and so forth. As you know Mayo hospital recommends that women have their first mammogram by
age 40. Since there is so much discussion regarding your students lately, have you thought about being proactive and suggesting
to your female students that it's hypocritical to examine male patients but excluding oneself from being examined by a male. Your
female students could even be more proactive and suggest that there should be a male nurse there when she delivers her first
child.
Speaking of Mayo hospital I'm certain all of you have recalled the 5 th year resident at Mayo hospital who took a cell phone pic
of a patient's penis and shared it with all of or I should say most of his colleagues. That he was fired and the patient collected a settlement of $ 250,0000. Not exactly a smart thing to do but he did the next best thing and that was to move as far away from Phoenix
Arizona as possible.
PT
PT, actually since my students are first and second year medical students, they do not perform genital exams on any gendered patient, period! As for the female students experience with pelvic exams performed by their own physicians, I don't know their experiences with regard to the gender of their doctors. Hopefully, they will have the opportunity to select their own preference with regard to gender as will their patients later in their training and career. ..Maurice.
Maurice
Hopefully? You don't sound too optimistic. Female patients don't normally select the gender of their caregivers. That gender is
almost always in place. Male patients don't normally select the caregiver of their choice. Someone has already made that choice
for us, thus we don't have a choice.
PT
Maurice,
I believe that you are missing a very teachable moment. A discussion with your students about their choices of gender in their healthcare may alleviate some hurt feelings when patients decline students of the opposite gender.
This is also how we human beings learn empathy. The golden rule is a prime example, “do unto others as you have done to you.” We learn empathy by putting ourselves in another’s moccasins and walking a mile.
On another note, the NY Times published a piece yesterday titled: "Visit The Costumes That Obscure Doctor and Patient.”
The article is good, but the comments are even better.
—Banterings
I recently came across this:
The Moral Era - Donald Berwick, MD - 2015 Keynote at the IHI (Institute for Healthcare Improvement) National Forum
Here it is (shortened and simplified) on JAMA: Era 3 for Medicine and Health Care
It talks about how healthcare has not fulfilled its promise to society during the first 2 eras of healthcare (era 1: the rise of professionalism, and era 2: managed care, ACA, where we are now).
What his new era suggests is that it takes the patient out of patient centered care and has the physician keep paternalism as an “ace up the sleeve.”
This era 3 that he suggests sounds more like singing Kumbaya (removing the ACA and managed care mandates, but also takes away any power that patients have gained). You may call the eighth step, "Hear the Voices of the People Served,” patient centered, it is NOT. Dr. Berwick advocates “HEARING” the people served.
He does mention “…they are encoding a new the authentic transfer of control over people’s lives, to the people themselves…”. I believe that this is just as important as “listening.” This should be a separate step. I believe that he is sugar-coating this under “hearing” because his entire premise would be rejected.
Here is the paper; "Coproduction of Healthcare Service,” by Paul Batalden that Dr. Berwick mentions.
You may point to his “Sean story” as justification for this paternalism, but I am sure that for every “Sean story” I am sure that there is a “Justina Pelletier” story he can tell.
—Banterings
I wanted to respond to NTT’s note earlier. Most urban medical centers have spent significant capital and Human Resources on creating outpatient women’s care centers and service lines staffed exclusively with female RNs, MAs, Techs, etc. That is, these medical centers have tacitly invoked the Bona Fide Occupational Qualification exception for same gender (for intimate care) to hire only females as ancillary staff for their women’s clinics (and unfortunately this spilled over into departments like Radiology, etc.). So these medical centers demonstrate daily their policy that same gender staff should provide or assist in intimate care activities of clinic patients. Joint Commission standards, CMS regulations, local State discrimination laws (if your State has one, not all do), etc. never afford one sex more rights than the other. Since nearly all medical centers follow CMS regulations (which are a baseline for Joint Commission standards) and they also promote “patient - centered” care in the Patient Rights brochure you receive as a patient, there is little defense if they cannot provide similar accommodations to male patients, certainly in the outpatient setting where all visits are scheduled and the patient mix is well known. So I would strongly encourage anyone who received an outpatient healthcare service at such a medical center and did not receive similar accommodations to their privacy/intimate care requests to file complaints alleging violation of Patient Rights with CMS, with the Joint Commission (if the clinic is included in their Hospital and/or Ambulatory Care certifications), with the local licensing agency (if they require the medical center to provide patient rights similar what CMS requires), with a local government entity that handles discrimination allegations (if your state has discrimination laws that cover individuals receiving services in places of public accommodation), and potentially with entities such as the State Attorney General or the Office for Civil Rights. The point being medical centers relatively quickly and uniformly established female - centered clinics because a fraction of women complained about male staff being involved in their intimate care. Complaints to CMS, the Joint Commission, etc. can be expensive and unpleasant for a medical center and I think in many instances much more effective than a complaint to the Medical Center CEO. There is no cost to you other than your time to factually explain your patient rights violation/discrimination in the complaint. Even if they somehow adequately defend all of the filed claims, it does give them pause to think that it might just be easier to configure their hospital clinic staff to avoid being alleged to only provide female-centered care. - AB
I took at look at the current statistics for the nursing school affiliated with the large medical center where I receive care from now and was surprised to see over 16% of the enrollees were male. In fact, for the past 20 years at least 10% of nursing students in the entire US have been male and that percentage has risen in recent years. (Curiously the percentage of practicing nurses that are male varies significantly from state to state.) Regardless, be aware that the turnover rate of nurses employed at hospitals/medical centers is between ~10% - 20% per year (lower turnover when economy is bad, higher turnover when economy is good and nursing jobs are more plentiful). You can find this data on the internet and I’m also drawing from my own experience working at a large urban medical center for decades. So there is little defense by a urban medical center that claims to be an equal opportunity employer if they are not hiring significant numbers of male nurses (as they have literally hundreds of hiring opportunities a year to do so). Although the percentage of males that are medical assistants and certified nursing assistants may differ from the percentage in nursing, the same premise remains - urban medical centers have ample opportunity to hire male nurses, medical assistants, CNAs, etc. to balance their staffing to meet their patient mix and patient preferences. -AB
Ed T.
Your response to Mike is apropos. However, as reasonable as your recommendation is, it does not always “take care of the situation without offense” – indeed, it not infrequently aggravates “the situation.” I have found that some patients who have politely requested privacy when it has been unnecessarily threatened have been subjected to retaliation; they have been ridiculed, browbeaten, patronized, assaulted (i.e., threatened with battery), and/or told not to return because unnecessary privacy intrusions are “standard operational procedures.” One or another or a combination of these responses occurred in more than one-half of the cases studied. Furthermore, research by some psychologists who specialize in understanding the workings of the subconscious would lead one to hypothesize that even when health care providers seem to graciously submit to a patients’ request, some may define that request as a challenge to their status as professionals and subconsciously subject those patients to some form of discriminatory action. There is a name for a patient who challenges unnecessary privacy intrusions; s/he’s called a NAT (“not a trooper). And what do you do to a [g]nat when it gets under your skin?
Ray
AB
Your article is well written, however, there is only one thing the Joint Commission cares about, Donuts. Lots of them! The
Joint Commission is an agency that medical facilities PAY to join. They have no regulatory power over hospitals, medical
facilities or clinics. You pay them to join and then you get their seal of approval after they inspect your facility. What do they
look for? Quality assurance procedures for nursing, pharmacy, MRI compatible fire extinguishers, etc. They couldn't care
less regarding the genders of the caregivers at any facility. Look at their website. Yes, you can file a complaint with them
provided if and only if a medical facility has paid them for their " seal of approval". The complaint goes to an empty black
hole where no humans are on the receiving end. The complaint generates a reference number that is only a randomly
generated number. A worthless entity in corporate America.
PT
In response to PT above, it isn’t quite like that. While it is true that for many years the Joint Commission (JC) had little oversight of their actions in 2009 the paradigm changed. Now the JC has to apply to CMS to get approval to provide certification for Hospitals that participate in Medicare. They applied again in 2014 and were quite stressed to receive CMS approval. So 1) the Joint Commission answers to CMS now, and 2) if a Hospital doesn’t use the Joint Commission for certification, they must undergo direct CMS certification surveys periodically or they can’t participate in Medicare/Medicaid. Either way, a Hospital (and its Hospital based clinics) that participate in Medicare must meet CMS regulations. But what happens when you file a complaint with the JC? All complaints are sent by the JC to the Hospital for them to respond back to the JC. The hospital is given a short time frame to respond. If the allegations are particularly serious, the JC can do an unannounced survey, at the Hospital’s expense. Or they may require particular data to be submitted or award a deficiency that must be addressed over a period of weeks or months. In addition, the JC regularly issues each Hospital they certify a Hospital specific report indicating the top areas of focus for that Hospital. Data from CMS, past surveys, bad publicity in the media, recent complaints, etc. drive the areas of focus. So when the Hospital next gets surveyed they know the JC will we examining these 4 or 5 areas of focus more heavily than the other standards. So if a Hospital has had allegations of patient rights violations, then Patient Rights, Leadership and Human Resources could be surveyed more intensely at the next triennial survey. So, complaints not only bring an issue to light in the short term, they can be a challenging issue for an institution at their next survey.
Here are some of the patient rights from the Hospital Conditions of Participation that CMS requires of its participating Hospitals:
§482.13 Condition of Participation: Patient Rights
“A hospital must protect and promote each patient’s rights”
§482.13(c)(1) - The patient has the right to personal privacy.
Interpretive Guidelines §482.13(c)(1)
“The underlying principle of this requirement is the patient’s basic right to respect, dignity, and comfort while in the hospital.
Physical Privacy
‘The right to personal privacy’ includes at a minimum, that patients have physical privacy to the extent consistent with their care needs during personal hygiene activities (e.g., toileting, bathing, dressing), during medical/nursing treatments, and when requested as appropriate.”
I think participants of this blog are truly looking for respect, dignity and comfort during their medical encounters. In 2016, when plenty of human resources are available in medicine, it would be difficult for a Hospital/Medical Center leadership to defend intentionally providing different levels of care, dignity, respect, and comfort to one segment of scheduled outpatients compared to others, especially when they have been notified of the discriminatory practices via patient complaints. - AB
AB
Many hospitals and medical facilities don't participate in Medicare/ Medicaid. The Joint Commission has been around
for 65 years and yet I've only started seeing their faces about 2008 and I've been in healthcare since the 70's. The last
field inspector from the JC I met was a physician and at no time ever were patient complaints ever mentioned. In fact,
with the quickly evolving certifications that facilities may carry such as ( certified stroke center, certified chest pain center)
as governed by the American heart Association, the JC is basically left out of the loop. Quite frankly, they are somewhat a
joke which is why I mentioned donuts.
To be honest, most of them seem out of their league as to what valid processes are with regard to quality assurance. Now
I challenge you or any of our readers that if the need presents by all means make a complaint with the JC on their website. You
will be given a reference number at the end and that reference number will be all you ever receive. You will not receive a follow
up as to what was said or done, simply because there will be nothing said and there will be no follow-up.
Who heads these groups? CMS is headed by a nurse! The JC is headed by nurses and physicians. Who heads Press Gainey?,
a nurse. These agencies represent hospitals, the dollars flow from hospitals to these agencies. Hospitals pay Press Gainey and
Hospitals pay the Joint Commission and ultimately CMS is paid for by hospitals and the medical insurance companies.
I've never seen a JC inspector ever ask what the hospitals core values are. The core values of many hospitals say nothing at all
about privacy and dignity. I assure you there is not one nurse, physician or staff member who could recite the core values of their
institution let alone be able to say wether the words dignity or privacy exist within the core values.
PT
And finally
The Joint Commission is based out of Chicago and is a non-profit organization. Upon hearing a complaint that a hospital
that carries their seal of approval has within the nurses staff bathroom on an intensive care unit, pornography from play girl
magazine covering the walls and ceiling with full nude foldouts of males. That said staff bathroom has been this way for years
and years. That their male patients are frequently left uncovered while family and visitors frequent this intensive care unit.
That shop talk frequents the nurses station about the male patients packages and that the gender of this intensive care is
100 % female as is the adjacent two other intensive care units on the same floor. That the nurses and even female physicians
come to this unit to use the staff bathroom because it is their " favorite bathroom" in the entire hospital. True story!
Do you for one moment think that a non-profit agency such as the Joint Commission is going to have a level 1 field inspector
( physician) and another inspector level 2 ( nurse) pack, board a jet and fly to the city of this hospitals location from Chicago
to verify firsthand that the dignity and privacy of these patients are not being maintained. Despite the fact that this hospital has
a vast chain of command, a CEO, CFO, CNO , and a ton of female nursing directors who they themselves cannot maintain
the dignity and privacy of their own patients even though it says so on their core vales even if they don't know what said verbiage
exists!
PT
AB,
Excellent information! Your participation is appreciated.
Let me ask you this about the “Patient Rights and Responsibilities” that institutions post. I contend that (in most cases) the rights that they give are the rights afforded patients legally (as you have cited). The responsibilities however, contain many not required by law. There are things like paying your bill, noise (disturbing the peace), disorderly conduct, etc. that have other laws (not specifically for healthcare like the rights) that apply. For example, "provide complete and accurate information about your health and medical history, including present condition, past illnesses, hospital stays, medicines, vitamins, herbal products, and any other matters that pertain to your health” is not required by law.
Notice that in the Johns Hopkins Patient Rights and Responsibilities, the responsibilities (like many policies that apply to patients, like chaperone policies) use words such as “expected,” “should,” and "have the responsibility to.” They do not use words like “required to” or “must.” That is because these are not required by law,
The <a href="http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion1002.page?”>AMA Opinion 10.02 - Patient Responsibilities</a> is even more watered down with terms like "generally have a responsibility” and "are encouraged to .” These are attempts to make patients think that they must do these things by listing them with the patient rights that are granted by law.
Let me ask you (AB), what other ways can patients secure their dignity?
Finally, I would like to ask you some more questions about this topic. Feel free to contact me from <a href="https://www.blogger.com/profile/05026455474056909739”>my Blogger Profile page here:</a>
—Banterings
Banterings, I thought your post about Patient Rights and Responsibilities was excellent and I would like to add some information specifically about patient rights.
In Massachusetts, the Patient Bill of Rights contains, among a number of other rights, the following:
(h) to refuse to be examined, observed, or treated by students or any other facility staff without jeopardizing access to psychiatric, psychological, or other medical care and attention;
(j) to privacy during medical treatment or other rendering of care within the capacity of the facility; General Laws: CHAPTER 111, Section 70E
Yet when seeking treatment at a local hospital, my wife was asked to sign a consent form, the purpose of which the intake clerk said was to give the hospital permission to treat her. I took the time, much to the irritation of the clerk, to read the full document which not surprisingly included sections which in effect required patients to sign away the rights listed above.
I crossed out and initialed the sections about allowing students and just about anyone else to take part in her care as well as the section allowing videotaping and photography.
The clerk told me I couldn’t do that; so I responded by explaining the difference between informed consent and coerced consent and she declined to argue with me.
Then she handed me a copy of the form I signed giving the hospital permission to bill our insurance company but she did not give me a copy of the consent form. When I asked for one; she told me that they simply didn’t provide those to patients! (Gee, I wonder why?). I demanded a copy and threatened to take the issue to her superior before she reluctantly shuffled over to the copy machine and granted my request.
So please take the time to read these consent forms in full. (If you are too ill, hopefully you have an advocate who can do this for you) and cross out any sections with which you don’t agree.
Finally, even if you do sign a consent form without realizing exactly what it said, you may still withdraw your consent for any examination or procedure at any time.
MG
After MG’s comment I decided that I am going to compile a list of laws that deal with patient dignity (modesty). I am asking for any lists or copulations that others have so that I cam make a complete list. I will make them (publicly and freely) available.
I want both civil and criminal.
Examples of case law in decisions also are welcomed.
I can be contacted from <a href="https://www.blogger.com/profile/05026455474056909739”>my blogger profile page here:</a>
— Banterings
It is time now to CLOSE "Patient Modesty: Volume 74" and move on to "Volume 75". Keep the conversation going! ..Maurice.
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