Bioethics Discussion Blog: Patient Modesty: Volume 89

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Sunday, July 01, 2018

Patient Modesty: Volume 89





I took the above photograph of a "dirty" pond this morning (Descanso Gardens, Southern California) because it struck me as analogous with what is currently being written on this thread about the medical system which we are all experiencing.  Each fragment of  "dirt" was actually part of adjacent beautiful and organized plantings but each fragment going their own way ended up in this pond no one would want to enter..  Is this analogy consistent with the current medical care system? Worthy parts from the past and elsewhere but now just a "dirty pond" ..Maurice.

AS OF AUGUST 4 2018, NO FURTHER COMMENTS TO THIS VOLUME WILL BE ACCEPTED.  COMMENTS CAN CONTINUE ON :"PATIENT MODESTY: VOLUME 90".

178 Comments:

At Sunday, July 01, 2018 6:46:00 PM, Anonymous Anonymous said...

No, no, that pond looks a little too clean. In reality there should be dead bodies and lots of them. Along with a few dead alligators and maybe a snapper turtle or two. While driving do you notice what people are doing while driving their cars, they are texting texting and more texting. I even see them texting on the freeway, it never ends. Well, extend this to the workplace and you will find that nurses, medical staff text all day long. In the operating room, in the patient’s rooms, at their cabs. What else are they doing with their phones?

I’ve read where some hospitals as a condition of employment ask nurses for their Facebook account. These medical facilities want to see if they have talked about patients and/or posted information, ie photos etc about their patients. This was quite a rage over the last 10 years or so that a considerable amount of information about their patients ended up on Facebook as well as unprofessional photos. In fact if you gain employment these days at ANY medical facility you will be asked to sign an agreement that you will not share any patient information on social media.

Folks, as I recall Hipaa was passed in 1995, those laws were meant to protect patient information and patient privacy with hugh fines and imprisonment. Yet, nurses posting on Allnurses tell others that well don’t tell them you have a Facebook account and/or we’ll always make your settings to private that way you don’t get busted. You see the notion that there is no advocacy for the patient but rather to be able to get away with it.

PT

 
At Sunday, July 01, 2018 8:35:00 PM, Blogger Maurice Bernstein, M.D. said...

Following my analogy of the photograph, PT et al, don't you think the analogy holds that fragments in the pool represent now medical care providers who have become separated from the sturdy and beautiful ethical and humanistic structures of their prior professional education (whatever service it was) and now find themselves within the medical system pool,unstructured and now open to the moldy, fungal formations and behavior of others within the pool (your texting example) as each fragment collides with another and become attached, losing the behavioral sturdiness which was part of their original beginning educational structure?

Wow! I know you might think I over-read what went through my mind when I stood by that pool in what is a well known and beautiful civic garden in Southern California. But, anyway, that was my motivation for taking the picture today. ..Maurice.

 
At Monday, July 02, 2018 9:02:00 PM, Blogger Maurice Bernstein, M.D. said...

This is what I wrote on a medical education listserv on the current topic this afternoon. ..Maurice.


I would fully agree with Dr. suggestion " There may be some initial details that can be covered in the beginning of the HPI, but eventually, one would get to the kinds of questions that are a bit more personal, such as a coughing person's risk for immunocompromise. A skilled clinician will generally do well finding the moment in a conversation where more private details are necessary and can take a moment at that time, after beginning to establish a rapport, to give a version of the 'Miranda rights' that seems to fit the patient and the situation."
The patient is not one who "whatever you say now may be held against you" but the patient should be
told if demonstrating concern even after the physician explains the rationale for asking the question that the patient has the option not to answer. ..Maurice.

 
At Tuesday, July 03, 2018 10:47:00 AM, Anonymous JF said...

There is a lot of flaws in the medical world but when there are symptoms or injuries,turning to them for help seems like the only thing to do. Some of the deaths that occur isn't something that human power could have prevented anyhow. Some possibly could have if the patient hadn't delayed treatment. Some of which was caused by earlier modesty violations. Others because of the high cost of medical care. Also there are people in abusive relationships and are belittled and their problems and concerns are dismissed by their abuser. I for one think we would be in a world of hurt without doctors and hospitals. I also think 90 percent of the intimate care shouldn't be happening.

 
At Tuesday, July 03, 2018 3:32:00 PM, Blogger Maurice Bernstein, M.D. said...

A couple of days ago, I successfully finished a Continuing Medical Education Course for my California medical license renewal on cancer detection, diagnosis and clinical outcomes, the course provided by NetCE.com

What I was reminded about and learned regarding the current status of the various cancers and cancer screening, based on numerous studies and based on the current conclusions of various cancer organizations, there is necessary screening but also much unnecessary or inappropriate screening and it is critical that both physicians and patients should be aware and up to date on current evidence based conclusions regarding such screenings. What I read supports much of JF's conclusions, if not "90 percent of intimate care" certainly at least a suspected high percentage, if "intimate care" is meant to represent breast and genital examinations and that"care" representing examinations which are unnecessary in terms of the way screening is currently practiced by some physicians in conflict with current evidence.

Just as an example from my course document: " In 2011, the USPSTF reaffirmed its earlier recommendation against screening for testicular cancer for asymptomatic male adolescents or adults because of the unlikelihood of benefits from such screening . Self-examination is also not recommended. The Task Force notes that its recommendation is based on the low incidence of testicular cancer and the high survival rate, even when testicular cancer is detected at an advanced stage. More than 90% of newly diagnosed testicular cancers are cured; in 2016, there were 380 deaths caused by testicular cancer, with 8,720 newly diagnosed cases."

There is a lot of current more appropriate behavior for us physicians, nurses and others who interact with patients need to be taught and follow. ..Maurice.

 
At Tuesday, July 03, 2018 9:39:00 PM, Blogger Maurice Bernstein, M.D. said...

At 4:32pm California time today, I find I got a visitor to Volume 89 here from Hinet Taiwan. It would be so interesting to have folks from "distant lands" from UsA to write to our blog thread about their experiences in how they are treated by their local medical system. Is all the issues described here Volume after Volume a world universal issue or something generated by the medical system in the USA? ..Maurice.

 
At Wednesday, July 04, 2018 4:41:00 PM, Blogger A. Banterings said...

My friend up north emailed me wishing me a happy 4th. Along with his wishes he relayed an interesting story that happened within the last 6 weeks. He sees his primary for ADD/ADHD, the occasional cold/flu, and Tdap for stepping on a nail, but he does not do, and has NEVER the annual wellness visit.

On his last visit, his primary brought up CA screenings. As per his (lifetime) preference he declined. He thanked his primary for his concern and doing his job, but declined. When his primary started the questioning of why (of course he was ready to counter any argument with studies and statistics), my friend simply stated "that it is his right to do so".

His primary pressed the WHY issue. He was not sure if it was because his PCP felt that he could counter any argument against it or was just attempting to document "informed refusal." Finally he told his PCP that there is NO LOGICAL, ETHICAL, or LEGAL argument that his PCP could make against this reason. Case closed.

His PCP brought up the "informed refusal" issue and NEEDED (there is that word again) to be sure he understood all aspects of refusal before his PCP would accept his answer. He countered by asking, "Would you hold off accepting my answer if I simply acquiesced or just simply change my mind and (blindly) accept your screening recommendations? Would you not hold informed consent to the same standard, or just accept that you won the argument?"

His PCP gave him the canned answer that he goes over guidelines, his expert opinion, risks, benefits, etc. He asked, "Would you request me to give you my reasons I am choosing to do this to show my understanding of the choice beyond your recommendation? I think not..."

His PCP left it with "think about it, we will revisit this at your next appointment." Clearly there is a double standard with informed consent and informed refusal. ALL providers accept accepting their recommendations as an "informed decision," yet there is an interrogation when the patient refuses their recommendations or suggests an alternative (whether it is an accepted alternative or not).

The only exception that I have seen is (sometimes) when there is a major procedure that has a high probability of complications (chemo, open heart surgery, etc.) or if the procedure is a "Hail Mary pass." For the most part, the same standard of informed refusal is not held with informed (or even implied) consent with the same physician for the same procedure. EMRs actually reveal this fact when medical records are reviewed. Informed refusal notes occur at a higher rate, are much more detailed, and document the physician's thoroughness in explaining risks, benefits, and alternatives than with informed consent.


Question: Why such a disparity?

Answer: Paternalism.




-- Banterings




 
At Wednesday, July 04, 2018 6:45:00 PM, Blogger Maurice Bernstein, M.D. said...

Thinking about the United States Preamble to the Constitution on this July 4th day of United States independence, I think that it is particularly the words "Justice" and "Promote the General Welfare" that our medical system has to be structured and maintained. ..Maurice.

 
At Wednesday, July 04, 2018 8:34:00 PM, Blogger Maurice Bernstein, M.D. said...

Continuing with Banterings last post here is a 2016 article abstract from Science, Technology and Human Values.
http://journals.sagepub.com/doi/10.1177/0162243916656059#crossmark-widget
Unfortunately, I have no access to the full article but only the Abstract. ..Maurice.


Informed Refusal
Toward a Justice-based Bioethics
Ruha Benjamin First Published June 23, 2016
Abstract
“Informed consent” implicitly links the transmission of information to the granting of permission on the part of patients, tissue donors, and research subjects. But what of the corollary, informed refusal? Drawing together insights from three moments of refusal, this article explores the rights and obligations of biological citizenship from the vantage point of biodefectors—those who attempt to resist technoscientific conscription. Taken together, the cases expose the limits of individual autonomy as one of the bedrocks of bioethics and suggest the need for a justice-oriented approach to science, medicine, and technology that reclaims the epistemological and political value of refusal.

 
At Wednesday, July 04, 2018 10:17:00 PM, Blogger Maurice Bernstein, M.D. said...

Professional behavior hopefully will be changing at the USC Keck School of Medicine where I teach with the finally dumping of two medical school deans, university gynecologist and the President of the University itself. Our new dean of the medical school is a woman and that could be a significant change.

http://blog.medjobnetwork.com/people-category/first-female-dean-a-sea-of-change-at-uscs-scandal-plagued-medical-school/?\

..Maurice.

 
At Thursday, July 05, 2018 5:26:00 AM, Blogger Biker in Vermont said...

My guess is that physicians are in a tough situation when it comes to informed consent with patients refusing certain care. Somehow they need to get the risks of refusing care into the conversation so as to not be on the hook with the patient later saying that they didn't understand the risks of refusal. The trick is in how to go about it. I'd suggest something like "I understand and will honor your refusal but it is my duty to make sure you understand the risks of not proceeding". Maybe the patient would have been OK not having anything explained, but their heirs might be looking to blame the physician and be seeking a big payout for not having properly informed the patient.

 
At Thursday, July 05, 2018 5:48:00 AM, Blogger Biker in Vermont said...

Concerning the new USC Dean, between the actual scandals the school is reeling from and the hiring of a female dean there likely will be little tolerance for the kinds of sexual abuse that cost the other two their jobs. That is a good thing. Society generally accepts that that kind of abuse is wrong and a female Dean is likely not going to look the other way in the current environment.

I think the larger question is what will the effect of women advancing to the upper ranks of medical hierarchy be on the far more common types of disrespect and undignified care that patients (especially men) receive. The reality is that the male hierarchy hasn't done anything to address the gender imbalance and so perhaps there isn't much risk of it getting worse, but could it get worse?

 
At Thursday, July 05, 2018 9:34:00 AM, Blogger A. Banterings said...

A belated Happy 4th of July to everyone!

Maurice,

In regards to your comment:

Thinking about the United States Preamble to the Constitution on this July 4th day of United States independence, I think that it is particularly the words "Justice" and "Promote the General Welfare" that our medical system has to be structured and maintained.

The problem with your argument is that the current system is NOT maintained by the Constitution or (ALL) the people. In fact, it is maintained by by the profession that has exempted itself from the rukle of law in most instances and replaces this with self governance.

For example when the profession did not police bad docs, society (government) did not step in and "maintain" the healthcare system. Either the repeated civil lawsuits OR the states required physicians carry malpractice insurance. The discipline of underwriting made the malpractice insurance too expensive that the bad docs could not practice OR practice as an employee under the scrutiny of their employer.

The Flexner Report was the beginning of medicine's self exemption from the Constitution. Society is waking up, the Affordable Care Act was one of the first major act by the Constitution (government) to maintain the healthcare system. I welcome the Constitution (government) maintaining the medical system. Then it will be accountable to society.



- Banterings



 
At Thursday, July 05, 2018 11:22:00 AM, Blogger Maurice Bernstein, M.D. said...

The title of this thread "Patient Modesty" has set over the years being published with that title has, perhaps, overlooked another "modesty" issue and that is the issue of the "modest doctor". I found that I published a thread February 2008 "Is Being A Modest Doctor a Virtue and a Benefit for Their Patients" which was followed with a few interesting comments.

Would an example of physician modesty be at the outset of the doctor-patient relationship the presentation of the "patient's Miranda Rights"? Is physician modesty in speech and behavior something which is a necessity to be a beneficial physician and should be emphasized in medical student education?

Do you see any modesty within the medical system itself beyond that of the patient which has been discussed here year after year? "Being modest, humble, non-ostentatious, unpretentious " as expressed by an ethicist on that physician modesty thread acceptable and practical for the entire medical system to follow?
Banterings, do you think that "government maintaining the medical system" would accept and practice "being modest, humble, non-ostentatious and unpretentious"? Really? ..Maurice.

 
At Thursday, July 05, 2018 1:19:00 PM, Blogger A. Banterings said...

Maurice,

Here is a link to the Informed Refusal: Toward a Justice based Bioethics paper you cited above.


-- Banterings


 
At Thursday, July 05, 2018 2:01:00 PM, Blogger A. Banterings said...

Maurice,

In critique of the Informed Refusal: Toward a Justice based Bioethics, I worry about one of the last paragraphs:

Rather than simply acknowledge that ‘‘refusers’’ are justified in their distrust of the medical and scientific establishment, a substantive approach to enacting justice requires a reorientation away from the purported traits and dispositions of ‘‘problem people,’’ to paraphrase Du Bois (1903), toward the relative trustworthiness of institutions. The notion of ‘‘informed consent’’—although developed to protect the rights and autonomy of individuals to accept or refuse participation in research—implicitly links the transmission of information to the granting of permission. As Corrigan (2003) argues with reference to a number of previous studies, ‘‘the request to consent can be interpreted as guidance to consent’’ (782; emphasis added).13 The juxtaposition of ‘‘informed’’ and ‘‘refusal,’’ by contrast, links the transmission of information with an expectation that individuals may very well decline participation.

I fear that although this paper seems to support informed refusal, it seems to argue "the needs of the many outweigh the needs of the few...."

I worry when it uses the term benefit-sharing. This seems to point the logic of the Communist Manifesto OR Niccolò Machiavelli's The Prince.

Refusal does NOT have to be informed. Just as with literacy tests being found unconstitutional by the Supreme Court, one does not need to enact any understanding to exercise their Constitutional Rights OR Human Rights. As my friend said, it is simply his right to refuse.

The KMD article, The difference between care and service is significant hints at refusal.


-- Banterings





 
At Thursday, July 05, 2018 3:35:00 PM, Blogger Maurice Bernstein, M.D. said...

Of course, there are limits to "refusal" and one includes professional behavior despite what is thought to be legal support.
Here is the current, ongoing, Arizona example:

https://www.azcentral.com/story/news/local/peoria/2018/06/23/z-arizona-walgreens-pharmacist-denied-mother-miscarriage-medicine-because-personal-beliefs/727805002/
..Maurice.

 
At Thursday, July 05, 2018 7:42:00 PM, Blogger A. Banterings said...

Maurice,

I think that you misunderstand my commentary. As EO stated about the CDC(Center of Deception and Corruption) "kidnapping" citizens for "the greater good", OR my example of the Communist Manifesto's "From each according to his ability, to each according to his needs.", we find these things abhorrent because it intrudes on our inherent (God given right) to personal freedom.

As found in the Preamble of Constitution:

We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.

...as a society we work for the general welfare, but (individual) LIBERTY is what this country is founded on. This is most evident in (protected) freedom of speech.

Medicine has always exempted itself from the rules of society: emergency exceptions to consent, exceptions to examine, touch, and invade one's body, standing orders, the overuse of catheters, PEs on anesthetized women, etc.

In critique of the Informed Refusal: Toward a Justice based Bioethics seems to support informed refusal, but tries to demonstrate how is counter to science and technology. The paper seems to be more about making people feel they are benefiting from having their position of refusal ignored.

As my friend's discussion with his PCP, patient autonomy, our God given human right to self determination, and the right to refusal (whether informed or not) is ABSOLUTE. Medicine tries to obscure this by saying patients have the right to "informed refusal."

This is the same semantics as providers saying "I need to..." or "you must do..."


As I stated, the ONLY thing one MUST do is die (at least) once in their lives. Anything else is either one's own wishes OR at the wanting of some else.

The same thing is seen in the list of patient rights, which is always paired with patient responsibilities. Patient rights are enacted by law, patient responsibilities are medicine's attempt to validate ignoring the patient rights. It is as if medicine is saying to get your rights, you must agree to these responsibilities (which takes some rights away).

The same goes for implied consent. The rights and dignity of the patient are absolute, the medical exception to these rights are a work of fiction, a lie perpetrated upon society so many times that the uneducated began to believe it as truth.

Simply saying "it is my right to..." then requires the physician to respect the decision along with "I no longer wish to discuss the matter." Failure to do so, bullying, threats of retaliation (such as dismissal) is UNETHICAL, IMMORAL, and ILLEGAL.

That is not to say, the physician can ask if the patient wants to revisit the topic at a later date, but again the physician myst respect the patient's original decision including not further discussing (that is a form of bullying).

Informed refusal provides a false facade that allows the physician to discount the patient's reasons thus making the patient BELIEVE that they do NOT have the right to refuse.




-- Banterings





 
At Thursday, July 05, 2018 9:03:00 PM, Anonymous Anonymous said...

Visit small hospitals in rural America and what do you find, empty emergency rooms. In farming communities people don’t run to the emergency room when they have a runny nose. I’ve worked in those small rural hospitals and once knew an old timer physician that was so old that the state took his drivers license away due to his poor vision. It didn’t stop him from working, he walked to the hospital and did house calls, on foot.

Come to large cities like Phoenix or Houston and you will find 4 urgent care centers in one square mile. I call urgent care centers Quack in a Shack. What a joke! With my insurance my emergency co-pay is $100, yet if I visit a Quack in a Shack it costs me $150. Does that make any sense, of course not. Quack in the Shacks are run by nurse quacktitioners or physician actors with no in house resources like a lab or radiology. It makes no fiscal sense but then nothing does when 4 Trillion dollars is spent in this industry annually. Attribute a lot of it to the inner city lower socioeconomic neiborhoods with the knife and gun clubs and the socialite meth heads.

That used to be the case but not any more as even upscale hospitals like Mayo and others have their own problems with patients watching ER and other medical reality shows and then showing up mimicking symptoms. My point is large cities have a medically abusive population and that population is further met with a business that further enables the abusive need. Take for instance, many emergency rooms now have an app that you can download on your phone. Make that ER appointment when you want, Now you can cleanup, apply your warpaint and show up at the ER looking better than ever and be seen faster.

I’m actually shocked that insurance companies will even pay your bill. Is it really an emergency, thanks to the abusers on both ends of the opioid crisis and the knee jerk reactions of the government and the medical community don’t expect to get any more stronger than aspirin or toradol for that necrotic bowel pain you have. Now Maurice, are we expected to believe that your medical students are better trained or recieve a curriculum that is above standards of other medical schools. I rear the questionnaire and frankly it dosen’t happen like that in the real world. Furthermore, if one of your medical students walked by a patient’s room where a nurse is doing an intimate procedure with the curtain not drawn or the door closed would your medical student take it upon themselves to close the curtain or the door. Would he/she mention to the nurse to maintain the patient’s privacy.

PT

 
At Thursday, July 05, 2018 9:40:00 PM, Anonymous Anonymous said...

Typically to recieve the congressional Medal of Honor you have to show bravery above all expectations against an opposing armed force. It used to be that in addition to the medal, you would recieve $100 a month. The theory or the thought was that you could buy enough bread to feed yourself each month for no one should starve who risks it all for their country. Current Medal of Honor recipients today recieve anywhere up to $3000 a month along with free airfare.

The first woman to be awarded the Medal of Honor was a female physician who during the civil war provided care to both sides of the conflict and for that she became a POW but was later awarded the Medal of Honor. What has become of medicine today and those who are supposed to be role models or aspire to be good servants of medicine. No one wants to move and practice in rural America, it’s not good business. I once had a patient complain about their bill and since I was in administration that day i did a follow up. This patient came to the emergency room and was seen by a physician assistant ( physician actor). The bill was high and there were a few duplicate charges as well but a number of pricey exams. I mentioned to the PA about the complaint because she has been known to “ over-utilize” which is not good in the eyes of Medicare for those who are in the business and who are aware of this phrase.

The response from the PA ( physician actor) was “ well we have to get something out of them”. Yes, that’s right, it’s a business, meet your quota for the month like traffic cops and you will be sure to have a job with the group. My advice to everyone reading this blog, avoid Quack in the Shacks, rather visit your GP and try to stay out of the emergency rooms, it’s bad for your health and your purse or wallet.

PT

 
At Thursday, July 05, 2018 9:43:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, many interesting points both you and Banterings presented. With regard to our teaching right from the beginning first student visit with a patient is to pull the curtains around the patient and yourself.
If the beginning student was walking by a room exposing a nurse performing an intimate procedure with door open and no drapes closed, that, from my experience has not occurred with my students, so I don't know whether the student has at this point of their experience the willingness to enter the room they were not assigned and admonish the nurse along with drawing the curtains. They are not at a stage in ward staff comfort to challenge the staff's routine actions, though they might ask "should I close the d oor?"With their assigned patients, the drapes are closed as well as the door and also the students are advised to ask the patient to turn off the TV to enhance communication.

I doubt our medical school training is better than others though I know that our students' interactions in the first year is more with real hospital ward patients than "standardized patient" actors in some other schools. ..Maurice.

 
At Thursday, July 05, 2018 9:55:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, I agree, the "emergency room" should be for medical/surgical emergencies and not for lesser symptoms which can be evaluated and handled by a family office physician. The problem is that many patients lacking any of the various forms of "medical insurance" use the "emergency room" for all their care and this leads to emergency room malbehavior on both sides. ..Maurice.

 
At Thursday, July 05, 2018 10:24:00 PM, Blogger Maurice Bernstein, M.D. said...

Now I want to get back to the point from which I started Volume 89: the transition from "adjacent beautiful and organized plantings (medical students in their first two years of education) to "dirt" in the "pool" of the medical system because of the "hidden curriculum" well defined an explored in this article "Medical Education: Beware the Hidden Curriculum" though written by a medical school teacher in Canada, certainly applies to what is going on in the United States.

I believe the "hidden curriculum" is not only an issue regarding physician behavior but I suspect it occurs just as regularly in the nursing and the other associated "professionals" within our medical system.

You may think I am simply trying to defend our first 2 years of medical education.
Although, I admit we have to keep up with societal changes and medical science advancements in knowledge, nevertheless the "hidden curriculum" in the later years of education and experience is a major factor in what the current medical system looks and "feels" like and may represent a primary etiology of why "patient modesty" is not simply a patient idiosyncrasy. ..Maurice..

 
At Friday, July 06, 2018 6:52:00 AM, Blogger Biker in Vermont said...

This is a question for those closer to the action than I am. The scenario is a physician tells a patient "I recommend you have this cancer screening" and the patient responds saying no. If the physician just accepts that answer and notes the refusal in the chart, what happens a year later when the patient is terminal because their cancer was not caught in time? Do they get to claim there wasn't informed consent in their refusal because the doctor didn't push back on that refusal? Is the doctor going to be hung out to dry in a lawsuit?

 
At Friday, July 06, 2018 6:59:00 AM, Blogger Biker in Vermont said...

Adding to PT's comments about rural healthcare, increasingly there just aren't doctors that people could see. NP's and PA's are filling the void, but even then it might be hard to find one taking new patients. For some people the ER or Urgent Care type place may be their only choice. When I needed to find a new PCP, I could not find a physician within 1.5 hours of where I lived that was taking new patients. Few NP's and PA's within that circle were taking new patients. I ended up with a PA about 1.75 hours from where I live, there not being any physicians there taking new patients either.

 
At Friday, July 06, 2018 7:12:00 AM, Blogger Biker in Vermont said...

Dr. Bernstein, in the hidden curriculum article you linked to it says near the end "We need to add “Above all be not silent" to “First do no harm”. That would be a great addition but I think what keeps most of the players silent is the societal norm of "go along to get along". They may never again see that patient being needlessly exposed but every day they've got to work with that co-worker that needlessly exposes patients. Their loyalty is more to their co-workers than to the patient no matter what they may say to the contrary. Us vs them.

The problem with "First do no harm" is that when it comes to treating patients with respect and dignity, each person in the healthcare arena gets to decide for themselves what constitutes harm. Whether the patient feels they've had their dignity respected is not a consideration. It's a one way street.

 
At Friday, July 06, 2018 8:12:00 AM, Blogger Maurice Bernstein, M.D. said...

On review of my prior various threads, I found one aspect of "patient modesty" which we didn't discuss on this ongoing thread volumes "Patient Modesty" and yet there is some interesting comments on that 2009 thread "Patient's Medical History: Should the Description of Race and Ethnicity be Forbidden?" and particularly within the first line of the writeup as an introduction to the patient's medical history. You may want to consider this ??modesty?? issue here. ..Maurice.

 
At Friday, July 06, 2018 11:45:00 AM, Anonymous Anonymous said...

It’s common knowledge that blacks are more susceptable to diabetes and asthma than whites. You will make a mental note of that when you first see the patient, does the race really need to be written down? Does it matter if the patient is married why does that need to be noted in the chart. Most patients will write down an emergency contact number anyway. Now getting to the patient’s occupation, I’m at a mystery as to why that always seem to matter. Would it matter if 12 year old little Johnny got in a fight at school and was punched in the nose?

Charlie is seeking care while in the prison infirmary and now has severe pain in his knee, some swelling noted. There are occupational hazards in every form of employment. An orthopaedic surgeon once told me that his most wealthiest patient was a circus clown, does it matter really in the end or does it put together a picture that tends to categorize everyone in a class. What about men from India, do we ask about their caste if applicable. If you are an attorney you certainly don’t want to let that be known when you are a patient. Once known would you think that your occupation might somehow affect the way medical care might be dispensed to you? Would staff pass judgement on you.

Suppose it is known that you are in the military and just left Afghanistan arriving in the states. You injured your foot while mowing the lawn and there are several Muslim nurses in the emergency room. Would you be seen any different? Many returning servicemen from Vietnam in the late 60’s and 70’s in californica were spat on and called baby killers. How might you be treated in an emergency room with a make America great again hat? Would it matter to your care if you let it be known upon questioning at the doctors office that you are an abortionist? In medical charts that line where it says occupation should be deleted. From a fiscal standpoint financial responsibility is what’s looked at anyway so why does it matter what you do to get that financial responsibility.

PT

 
At Friday, July 06, 2018 12:13:00 PM, Anonymous Anonymous said...

I want to engage everyone in a small experiment, by simply calling 2 hospitals at random. Once you have the main number to the hospital you choose ask for Administration. When Administration picks up simply say, hello I’m am a potential patient and I would like to know what your core values are?

Now, you are going to get either one of two initial responses. The first one might be “ why would you want to know that? You could reply by saying well I’m going to need hospitalization and I want to know beforehand what emphasis your hospital places on values that form your hospitals foundation.

The second response will be “ oh wow, let me see if I can find somebody who knows what those are” You are now going to be put on hold and/or transferred to a number of people while the 🎶 music is playing.

PT

 
At Friday, July 06, 2018 12:15:00 PM, Blogger A. Banterings said...

Biker,

Anyone can file suit against anyone for any reason. What happens is if one's position is defensible. The more info the doctor has the better position he is to defend that the physician did what was necessary. It is never cut and dry. It is a moving target not of discreet values but on a continuum. Legally it is called the standard of care; basically what the average physician in the area would have done.

If the physician documented a reason for denial (including it is my right to), attempted to educate the patient (gave him ACS pamphlet on recommended screening), periodically revisited the topic (and noted refusal again), and did not ignore the patient's request for alternative testing (FOBT vs colonoscopy), then the physician did everything possible and has a defensible position.

That does NOT mean the physician will be dismissed from the case. It depends how he attorneys present the case, their maneuvers, and settlement offers ($20K to go away, $100K to prove I am right).

Any lawsuit inflicts some degree of pain, and people who have had their dignity trampled upon will file lawsuit for other mundane, frivolous reasons just to extract some justice.




-- Banterings



 
At Friday, July 06, 2018 4:02:00 PM, Blogger A. Banterings said...

PT,

...or you might get "the I don't know and I don't care" answer of that can be found on our web site at www.IdontCare.com.


-- Banterings


 
At Friday, July 06, 2018 4:07:00 PM, Anonymous JF said...

A worker who ignores modesty violations isn't protecting her coworkers. She's protecting HERSELF! Her status at work. I once saw a movie where a young girl was pregnant by her own father. Her best friend eventually figured it out but didn't want to turn it in. Before she wanted to save her friend, she wanted to save the friendship.

 
At Friday, July 06, 2018 4:41:00 PM, Blogger Biker in Vermont said...

Whatever info deemed pertinent to a patient's situation is what should be recorded. Most of the time occupation may not matter, but sometimes it does. My Dad worked in a chemical factory for 40 years, much of it before there was any meaningful regulation from OSHA and the EPA. Had he ever seen a PCP other than the "company doctor" and they knew where he worked, perhaps he'd of been carefully monitored for the kinds of cancers he was at risk for. Instead it was found after it had metastasized.

 
At Friday, July 06, 2018 8:38:00 PM, Blogger Maurice Bernstein, M.D. said...

I may I noted this previously, but it is standard practice to instruct our first year students that the first line of a history and physical writeup should follow this content pattern:

"The patient is a 64 year old white married former building construction supervisor..."
which is then followed by the reason the patient was hospitalized.
In this case it could be "the presence of an unexplained left pleural effusion on a chest x-ray taken because of unexplained week-long shortness of breath."
Here the first line sets the stage for the reader to suspect among other possibilities a mesothelioma from the full first line description which included the patient's former occupation and possible asbestos exposure. ..Maurice.


 
At Friday, July 06, 2018 9:05:00 PM, Anonymous Anonymous said...

Maurice

Pleural effusion can also be attributable to CHF, renal disease or a fall. I shudder to think people coming to a diagnosis with occupation first in mind. That the diagnosis could be arrived at after some investigation clinically or after a series of diagnostic tests. I might mention that prior to Hipaa laws in 1995 much of patient information from medical offices was placed in dumpsters. With names and occupations found the medical information about the patient was used against the employee in regards to health insurance etc.

PT

 
At Saturday, July 07, 2018 9:04:00 AM, Blogger Maurice Bernstein, M.D. said...

PT, of course even unilateral pleural effusion has a number of possible causes, to be aware at the outset the patient's current or prior occupation(s) can set in the mind of the medical professional a specific diagnosis of employment origin which may have been overlooked when considering all the other etiologies of pleural effusion and no mention of the patient's employment at the outset of the document or even absent in the essential "Personal History" section of the Past History.

If a goal of diagnosis is what has brought the patient to the physician's office, the patient's personal history may provide a diagnosis no routine drawing of blood for testing can ever provide. ..Maurice.

 
At Saturday, July 07, 2018 2:51:00 PM, Blogger Maurice Bernstein, M.D. said...

I have something to add which might upset some of my visitors here. Whereas, I will strongly agree that the patient knows a lot more about him/herself than the physician on the first or all the subsequent visits whether in the office or hospital. This self-knowledge is based on the patient's own physical and mental experiences and distresses but also their medical education based on past experience, books, TV or the internet. Nevertheless, no patient excluding an active physician-patient has had the intense and complex education of all the essential details of medical diagnosis and treatment which medical students experience in the first two years of schooling. And the schooling is not derived from random exposure to TV or the internet but carefully designed education programs correlating facts of the past with facts of the present and speculating about facts for the future. All these facts provide the armaments for diagnosis and treatment of their patients.

Yes, obviously, the physician's use of these tools of their years of learning must be integrated with the self-knowledge of their patient but what I am getting at with this posting is that patient autonomy should not be expressed as a patient's denial of the knowledge of their physician who is attempting to make a diagnosis and provide appropriate and successful treatment.

If I appear to be attempting to defend the medical school teachers and the education of their students, I am. If am attempting to defend the "worthy" aspects of the medical system, I am.

Nevertheless, there is much to be improved even by major revisions within the medical system and therefore I am also comfortable with the extensions of the present discourse within "Patient Modesty" beyond the issues of physical body exposure. ..Maurice.

 
At Saturday, July 07, 2018 4:50:00 PM, Blogger Biker in Vermont said...

You'll not get any arguments from me on that matter Dr. Bernstein. I know physicians know far more than I ever will and I want to know their recommended course of action. I do not pretend to know any of it as well as they do. In return I want them to hear me out if for example I say I will do the procedure but I don't want to be sedated. I have no problem whatsoever if they pose questions back to me making sure I understand what I am asking for. I'm all for informed consent.

The missing piece for me that I would like to more see become the norm is to be told how a procedure will be done and who will be present. At a minimum I want them to accept my asking such questions as valid questions that deserve a respectful answer.

 
At Saturday, July 07, 2018 7:11:00 PM, Blogger A. Banterings said...

Maurice,

I have something to add which might upset you...

Patients might NOT know what is wrong (exactly), but they know something is wrong. Furthermore, patients are willing to consult with crowdsourcing.

The internet is also creating access to computers that are better at diagnosing than physicians:

IBM's Watson - Best Doctor In The World?

Watson Proving Better Than Doctors at Diagnosing Cancer

ANNALS OF MEDICINE
APRIL 3, 2017 ISSUE A.I. VERSUS M.D. What happens when diagnosis is automated?


Computers are already better than doctors at diagnosing some diseases

Study: Computer Better Than Doctors in Diagnosing Skin Cancer

Research shows computers make better medical decisions than doctors




-- Banterings



 
At Saturday, July 07, 2018 10:08:00 PM, Blogger Maurice Bernstein, M.D. said...

I agree with the last article noted in Techspot:
"Even with the development of new AI techniques that can approximate or even surpass human decision-making performance, we believe that the most effective long-term path could be combining artificial intelligence with human clinicians," a member of the project added. "Let humans do what they do well, and let machines do what they do well. In the end, we may maximize the potential of both."

I also bet there will be more "heuristic errors" created by both the artificial intelligence and physicians as they work together and the physicians become more dependent on the artificial intelligence.
Has anyone proven that artificial intelligence programs can avoid what has been the defect in physician clinical decision making, heuristic errors? ..Maurice.

 
At Saturday, July 07, 2018 10:32:00 PM, Anonymous JF said...

DrB I have to admit, I didn't think of asking about occupation having to do with patient symptoms. I'm a little more suspicious by nature. My thoughts about why they wanted to know if patients were married or not was investigating whether the patient could fight back if they decided to string her/him along to financially exploit them. I feel pretty sure that that happens. My family doctor where I used to live wasn't above stringing me along for YEARS. I told him right off the bat, I thought it was my gall bladder. Some doctors are fond of dismissing women patients. Possibly because a woman isn't going to become violent. I have thought that when a kid comes in with an injury and they want that kid to undress, it having to do with investigating for child abuse. Checking for bruised butts, or rectal or vaginal bleeding. I guess it isn't completely possible to completely eliminate undressing at the doctors after all.

 
At Sunday, July 08, 2018 3:29:00 AM, Blogger Biker in Vermont said...

To the extent that AI can help diagnose and/or direct treatment would be yet another step forward. As I read the articles I thought about rural & small town areas that are increasingly being served by NP's and PA's as PCP's for lack of family physicians and internists. Having AI at their disposal might make up for some of the lack of training NP's and PA's have. That's better than relying solely on NP's and PA's, but it is far from an ideal solution to the doctor shortage.

My concern is that AI will be used to replace physicians rather than assist them. There is already a growing problem of NP's being churned out of fast track online programs, people who have never even worked as an RN. I have a young relative pursuing that track whose ego is already saying she'll be the equal of any internist and who says she will be an independent practitioner. She doesn't know what she doesn't know and I am left wondering will people like her know how to properly use AI as a tool.

 
At Sunday, July 08, 2018 6:25:00 PM, Blogger Maurice Bernstein, M.D. said...

As I look back over the subject matter covered in blog threads other than our 89 Volumes of "Patient Modesty", I find I have covered topics which have been discussed on "Patient Modesty" but in a different format and with those who comment who are apparently not a "Patient Modesty" contributor now or in the past.

One such example, worth going back to 2009 to read is such a topic with the title

"Violation of the Patient's Autonomy?: Is that Ethical"


Click and read and return and express your opinion to our current "Patient Modesty" visitors. ..Maurice.

 
At Sunday, July 08, 2018 7:41:00 PM, Blogger Biker in Vermont said...

The last person, Lee, who posted spoke very clearly to the aspect of informed consent that is critical to what is generally discussed here. How a procedure will be done and who will be present is almost always left out of the informed consent discussions. The result is patients feeling that they have been ambushed. An "informed" patient would never feel ambushed because they'd know what to expect.

Informed consent is thus similar to patient dignity. It is what the medical staff say it is. Whether the patient feels they were informed or were afforded dignity is not a consideration. It is a one way street.

 
At Monday, July 09, 2018 7:51:00 AM, Anonymous Anonymous said...

The nursing feminists have already proposed concepts of their own regarding informed consent and patient autonomy, Meyers philosophical
feminist perspective. It dosen’t end there. Now there is a feminists approach to the opioid epidemic. Then there is the comprehensive feminist approach to health care. As well as the feminist approach in the decision making process of health care choices. Long story short when it’s time for male patients to have a say as far as informed consent and autonomy all paperwork you sign will be null and void.

PT

 
At Monday, July 09, 2018 10:15:00 AM, Blogger Maurice Bernstein, M.D. said...

I fully agree that the "Me Too" movement should also apply to males within the medical system either as employees or as patients. ..Maurice.

 
At Monday, July 09, 2018 10:36:00 AM, Blogger A. Banterings said...

Maurice,

Honestly I would prefer the human touch of a physician, BUT unless the profession changes, patients are going to flock to AI owned by big hospital corps. In the end, there will still be errors, but different kinds. What there will not be is dignity violations of the patient.

Here is what the future of "medical pods will look like as imagined by the movies Prometheus (Alien) and Elysium (which focuses on healthcare rationing).

A society's technological advancement is proportional to its (science) fiction. (Reference)

The question of AI historically has been, will the medical Tricorder from Star Trek (Dr. McCoy)become real? That is becoming a reality. Look at the latest advances using cell phone technology:

Healcerion Receives FDA Clearance for New SONON 300L Wireless, App-based Ultrasound System
Alivecor cell phone EKG

As PT stated, feminism is a war on men. Just look what feminism has done to men in the last 30 years:

The War Against Boys
Women are dominating men at college. Blame sexism.
We must stop indoctrinating boys in feminist ideology

I am not against equal opportunity, but modern feminism is a war against men.

As to heuristic errors, too often physicians dismiss a patient's complaints as "psychological" or want to focus on missed cancer screenings. Often these are following instinct and not symptoms or history. Medical error are the third leading cause of death in the US and missed diagnoses is the number one reason for suing doctors.




-- Banterings





 
At Monday, July 09, 2018 12:34:00 PM, Blogger NTT said...

Good Afternoon:

A truly useful informed consent form will be written in such a way that it doesn’t make the patient feel like they are signing a legal document.

At the top of the form you have the institution’s name then the next line says Informed Consent Form.

The following lines should read something like this.

There is NO rush to fill out this form. Please take your time and read it through completely so that you have understanding as to what is about to take place. The surgeon and staff will wait until you are completely satisfied that you understand what, when, how, and why we are doing this before you sign the form. If you feel any pressure to just skim and sign, please ask for a supervisor so the situation can be corrected immediately. We’re not here to rush you. We’re here to help you get healthy again.

The next section of the form should be filled out by the surgeon. It should state the procedure being done, why it’s being done, and finally give the patient an idea as to how it’s being done. You don’t want your patient going on the table on is back then wondering afterwards how that scar got on their back because when they went in they were laying on their back.

The next section will list ALL the participants and their titles. This includes the pre-op staff that will be prepping the patient, the surgical team itself, the surgical team assistants, the anesthesiologist and his assistant(s), and finally any other individual regardless of title that will be in the operating room observing the surgery while you are unconscious.

The goal is to be transparent with your patient and give them as much information as possible so they can truly make an informed decision.

Best possible scenario would be to get the form(s) filled out to the patient as far ahead of schedule as possible so they can look them over in a setting where they feel totally comfortable and at ease.

Now to switch gears over to the "Me Too" movement.

In my humble opinion you will never see a male "Me Too" movement simple because of the way society has stereotyped the male gender.

I would say that less than 2% of the male population that has any dealings with the medical community speak up & stand up for themselves. It’s not in a man’s makeup to speak up in a medical situation because many men are/were taught from infancy to be strong & don’t show weakness. So, they shut up, put up, are humiliated, and come out of the encounter psychologically changed.

To find out what’s going on out there, I’ve gone to some PCa support group meetings. I’ve talked with the guys that are on the front lines going through their ordeal. Many don’t like and don’t want females involved but are afraid to speak up for fear of retaliation from their current caregivers.

I went to one meeting where they had a female group leader. Nobody talked for two hours accept on the break when she went for coffee. How dumb can the medical community be to put a woman lead on a men’s PCa support group.

The train is leaving the station on this issue. The female movement is moving faster each and every day.

Men everywhere in this great country of ours must put their fears aside now and start speaking up before the last car on the train leaves the station and it’s too late to be heard.

I know I don’t want to get stuck with medical that I’ve had no say in.

Regards,
NTT

 
At Monday, July 09, 2018 1:25:00 PM, Blogger Maurice Bernstein, M.D. said...

NTT, you have written great "support" to my very, very original conclusion written from my very first Volumes on this subject.. that those complaining about their patient modesty issues here were and represented "statistical outliers". "Statistical outliers" in the sense you wrote that most men "are afraid to speak up"

Experiencing discomfort or worse without "speaking up" is never going to be productive of resolution. So, men, take a hint from what the women are doing in the "Me too" movement and vocalize your complaints and perhaps those that do so now will no longer be termed "statistical outliers". ..Maurice.

 
At Monday, July 09, 2018 4:05:00 PM, Anonymous JF said...

When there were more male orderlys, did more men seek medical care? In my opinion, male staff should attend to male patients automatically, when patients are gonna be exposed. Female staff, female patients? Same thing. The only exceptions would be emergencies or patient request. Just getting a male nurse/orderly could backfire. If it would bw inconvenient for that nurse or orderly to come and attend to that male patient, the staff person, if he is spiteful might leave the door open or provide intimate care in front of family or female staff deliberately.

 
At Monday, July 09, 2018 4:29:00 PM, Blogger mitripopulos said...

Ah, Dr. B, Such a good suggestion about speaking up. However you don't appreciate the consequence of doing that in that you are marked as a"demanding patient" by the doctor. Even if you speak up that your medical history is being ignored in favor of statistics as being the deciding factor pushed by the doctor. Sorry, but the medical industry is strongly showing a "Trumpism" its approach, namely ill informed and buck passing.

 
At Monday, July 09, 2018 5:43:00 PM, Blogger Biker in Vermont said...

Here is a current article on KevinMD about the questions medical students are being taught to ask.
https://www.kevinmd.com/blog/2018/07/dont-worry-medical-students-dont-judge.html

 
At Monday, July 09, 2018 6:33:00 PM, Anonymous Anonymous said...

The very professional female staff at this nursing facility decided to do a Snapchat video of a dying patient, they were arrested.

Foxnews.com. 3 charged over alleged Snapchat video of dying stroke patient titled, The End. These women were 19-21 years of
age who were arrested. The patient was a 76 year old female awaiting a hospice nurse to arrive. The 3 women were charged with
exploiting an elderly and disabled person at this senior assisted living facility in Georgia. Would you consider this patient a statistical
outlier if she complained or is the category reserved only for male patients. Appreciate that there are perhaps hundreds of incidents a
week like this yet rarely do they get caught.

PT

 
At Monday, July 09, 2018 8:47:00 PM, Blogger Maurice Bernstein, M.D. said...

I am not sure what the Kevin MD student statement is trying to support. Our first year medical student are taught and expected to understand that all questions when asked must have some clinical significance in one way or another. Yes, there are established categories of questions such as within the Past History allergies, as an example. Also within the Past History is what is called Review of Systems, where bodily systems such as pulmonary, cardio-vascular, gastro-intestinal etc, the patients are asked whether they ever had symptoms or diagnoses in those example categories. There could be a huge number of possible symptoms and diagnoses which could be asked in each category but the students are taught to ask only those which are more common or more clinically significant.

All questions asked a patient should be questions of clinical value and clinical significance for that patient.

Oh, you all may have no idea how much non-clinical information flows from a patient during an interview such as sports interest, non-clinically pertinent family activities, politics and much more. Students are instructed to respond with personal views to these topics, to express interest and support but mindful that it is important to what we call "re-direct" in a kind way, the patient's spontaneous dissertation back to issues pertinent to the patient's current symptoms and general health. What I am getting at is that it is not unusual for patients getting off the subject of their immediate health and that re-direction is necessary for time conservation in order to obtain more valuable clinical information from the patient. ..Maurice.

 
At Tuesday, July 10, 2018 11:55:00 AM, Blogger Maurice Bernstein, M.D. said...

If visitors here think that the way the medical system is handling the patient physical modesty issue is disgusting or worse ,just read the many visitor comments to the blog thread started in 2012 with 50 Comments up to the present:
"Does End-of-Life, Hospice, Comfort Care Represent "Murder, Euthanasia, Killing"?"

Is the problem that the medical system doesn't understand the concerns of the patients and their families or is the problem in the opposite direction or more likely both ways? ..Maurice.

 
At Tuesday, July 10, 2018 12:41:00 PM, Anonymous JF said...

My mother had all those tubes coming out of her and she bounced back and lived for 11 more years. The saddest part was the damage caused by her trach but she needed it badly at the time it was given to her.
My uncle died at age 86 and I believe the hospital was at fault. He was in excellent health and looked 20 years younger than he actually was but got some bowel obstruction and then he was dead.

 
At Tuesday, July 10, 2018 3:32:00 PM, Blogger NTT said...

Good Evening:

Mitripopulos, mNY OF US appreciate the consequences of being "marked by the medical community. Many of us have been.

But if men don't find the courage to stand up for what they believe is right, the medical community will ignore us.

If however more and more men start telling the medical community this is wrong, CHANGE IT. They will have to listen.

We need to start a fire under every man in this country. No more going quietly into the night.

If you don't want to do it for yourself, do for your sons, grandsons, & their male offspring.

We have the ability and more than that, we owe to them to put a stop to this here and now, once and for all so that any man can get the medical help he needs without fear of retaliation or being disrespected the entire time.

JF had the right idea.

If enough men get past their fear and speak up, they will have to hire more men in tech & nursing fields which in turn could very well lead to when a man goes for treatment & its gender specific they automatically assign a male caregiver to him.

This isn't a pipe dream. It's time for men everywhere to put down that beer, get off that comfy couch and start talking and keep talking until people start listening.

Elections are coming. Tell Washington time is up. We want help if they want the votes.

Take care everybody.

Regards,
NTT

 
At Tuesday, July 10, 2018 4:31:00 PM, Blogger A. Banterings said...

I must do this post in 3 parts, due to length.

Part I

Maurice,

You ask, "Is the problem that the medical system doesn't understand the concerns of the patients and their families or is the problem in the opposite direction or more likely both ways?

Medicine does what it wants without concern for societal values and expectations OR patient Human Rights simply because medicine possesses a (self granted) power over society, and (simply), because I can.

The problem is that medicine is a monopoly that (poorly) self regulates, thatexpects trust (blindly) of the patient (without being earned), with the modern system being started by a philanthropist of questionable character and intentions who had already exploited the public as a robber baron to amass his wealth.

It was born of another monopoly (at the time); the pharmaceutical industry. This 1906 Flexner Report created the current medical monopoly in an attempt to create a standardized monopoly of pharmaceutical prescribing. The resulting power granted to an existing organization, the AMA was also just as corrupt and based on poor science, one example of this is the sale of the The AMA’s Seal of Approval.

End Part I



-- Banterings


 
At Tuesday, July 10, 2018 4:31:00 PM, Blogger A. Banterings said...



Part II


Long before the Flexner Report, the AMA already had a policy that served its members' self interest and consolidated their power to ensure complete domination over patients (and society), medicine wrote rules favorable to itself and its self appointed power. Consider the language of the 1847 Code of Medical Ethics of the American Medical Association, titled "Obligations of Patients to Their Physicians", endorsed this paradigm.:

The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness, to influence his attention to them. A failure in one particular may render an otherwise judicious treatment dangerous, and even fatal.

This became known as Paternalism. It is based on the axiom, "All power tends to corrupt; absolute power corrupts absolutely". Medicine justified it as "For Your Own Good".

For at least 2,500 years, the doctor-patient relationship has resembled the parent-child relationship. The norms of medical ethics, codified in historic documents or perpetuated as informal traditions, encouraged doctors to shield patients from bad news and from general medical knowledge. While Western medical tradition has always included some patient protections, such as informed consent (and its antecedents), doctors have possessed broad powers to withhold treatments that patients desired and, at times, to mislead patients for what they perceived to be the patients’ own good.

A turning point in the shift from physician paternalism to respect for patient autonomy was the requirement for the patient's informed consent to treatment. The concept of informed consent did not exist in writings on Egyptian, Greek, or Roman medicine. Indeed, the phrase "informed consent" was not used until the 1950s. The notion of "consent to treatment" was a consequence of the Nuremberg Trials that later became enshrined in the research and treatment codes of democratic nations.


End Part II



-- Banterings


 
At Tuesday, July 10, 2018 4:32:00 PM, Blogger A. Banterings said...

Part III



The Internet has forever changed the patient-physician relationship. "Because I am a doctor" is no longer an acceptable answer. The Internet has also shown that physicians are not always right.

Physicians' loss of public trust is by their own doing, and not some conspiracy. One of the main issues is the lack of understanding patient values and patient autonomy that our Human Rights, bestowed by our creator grants us.

One example is teaching pelvic exams on anesthetized women. Despite society finding the behavior abhorrent, physicians defend this practice and medical students find this practice completely acceptable (as they (medical students) are taught to dehumanize and objectify the patients).

Medical providers, as official “authorities of the body” often take that authority over the body, often bypassing a patient’s individual right to consent to what happens to us in the name of medicine, or to make choices that might be in conflict with what the medical provider wants us to do.

In spite of the public outcry, Medicine still tries to deceive patients and allow the practice.
It continues to occur, and medicine continues to continue to deceive patients with guidelines that state; "should be discussed", NOT "MUST BE..."

Even in Canada All members of the gynaecologic surgical team (including medical students, residents, and fellows) are expected to introduce themselves to the patient before her gynaecologic surgery. Medical students must identify themselves as




-- Banterings



 
At Tuesday, July 10, 2018 6:10:00 PM, Blogger Biker in Vermont said...

Certainly there are patients who either have unrealistic expectations or that are just unpleasant people. Every industry deals with them. We all can name a few we've known or experienced ourselves. Conversely there are people in every industry who should never be dealing with customers or the general public for the same reason. I'm sure we've all got those stories too.

What is somewhat unique with healthcare is the significant power imbalance and the vulnerable state that patients are often in when seeking healthcare. Requiring patients to undress only serves to amplify the power imbalance and disorientation patients might feel. This is amplified yet again when patients are expected to be undressed for opposite gender staff and for non-professional level staff (which is the majority of who patients are undressed for).

Just as respectful and dignified care is defined as what the healthcare staff say it is, what is an appropriate level of exposure is what healthcare staff say it is. Similarly everyone down to the teenage MA is a professional because they say so. What the patient thinks is never a consideration. Even those Press Ganey surveys we sometimes get never ask important questions that might make a difference. They don't ask us if we feel we were treated in a respectful and dignified manner. They don't ask about what we thought of the staff gender assigned to us for intimate care. They don't ask if we feel we were needlessly exposed or exposed for longer than was necessary, or exposed to people we didn't need to be exposed to. Why don't they ask much of anything important about the patient experience? Do they really think the temperature of the room and the quality of the food are a higher priority to be asking about?

These are the ways how healthcare stands out vs other industries.

To specifically comment about hospice and palliative care, I have dealt with hospice twice for less than a day each time at the very end, and they made a huge difference in those short windows at a time when we just didn't know what it was we were supposed to be doing.

I also dealt with palliative care in a hospital settings and that I was not real impressed with. To me it was just another way to churn the bill. My brothers and I told them to knock off the needless tests and scans when our mother was past any possible recovery. The hospital then assigned two palliative care doctors who started the morphine routine, and ramped up the dosage when the insurance company said she had to be discharged to a nursing home. She was not going to make it no matter what and was beyond being able to communicate or do anything(massive stroke), but it felt like the hospital was doing whatever they could to maximize what was being billed, including having her die there vs a day or two later in a nursing home. The "informed consent" on the part of my brothers and I wasn't truly informed as to what they were doing.

 
At Tuesday, July 10, 2018 9:20:00 PM, Anonymous Anonymous said...

Biker in Vermont

Well if that’s not enough I’ve seen tests ordered on dead people and their insurance billed for it! It’s called Fraud. These were not patients that were being harvested for organs either, they were patients that wore a wristband that says DNR( do not resuscitate). I’ve even heard of emergency room providers wanting to play the role of coroner and that overly enthusiastic er tech wanting to play the role of some CSI investigator. The patient’s deceased, move on to live patient’s who are on their call button and need help. I feel a revamping of medical ethics to to happen in healthcare with strict consequences, this is not Target or Starbucks people pay a considerable amount of money for healthcare to be insured. Co-pays are expensive, medicines are expensive along with the time patients invest to recieve care. Finally, I just don’t know about the new healthcare workers of today, lazy, lack of respect. They can’t put their stupid cellphone away for 30 minutes and do their job.

PT

 
At Wednesday, July 11, 2018 1:24:00 AM, Blogger mitripopulos said...

NTT, Thank you for reading all comments. I am not afraid to speak up or to take anyone on who is not willing to move in the direction I am going in. I have successfully gone after a hospital, female RN and a Female doctor, in which they had to surrender their liscn's and the hospital settled without complaint for what today would be one and a quarter million. At the time I was 22. Without my lawyers knowledge I constructed the terms of settlement without a nondisclosure clause or the other choice was a court case for assault of a minor. In my business of 31 years I retained a lawyer to review contracts I wrote and she always questioned why I paid her a few when my contracts were harder than Roman concrete. I am easy to deal with but if anyone becomes an obstacle, I take no hostages.

 
At Wednesday, July 11, 2018 4:20:00 AM, Blogger Dany said...

Doctor Bernstein,

I want to comment on a post you made on the 7th of July, regarding the knowledge, skill, and experience of doctors. This is not specifically about modesty but still relevant to your post.

I regularly find myself at odds with my providers because they dismiss my past experience (and the knowledge I have of my own body). Here is a very real example of this.

Since I was a kid, I've been having recurrent otitis (middle ear infection). To date, I'v had them more often than I have fingers and toes to count them (in fact, I might need to use someone else;s toes to count them all). The first line treatment for earaches is ear drops (typically corticosteroids) but, the thing is, it doesn't work for me. Oh, it will reduce the swelling, opening up the ear canal so they can see the ear drums, but it's not addressing the root cause (the infection).

This is not a boastful claim; every single time I presented for earaches, it was otitis. Every single time, it required antibiotics to resolve. Every. Single. Time.

(The only variable here is how long it takes for whoever examine me to recognize this, which translate to how much pain I have to be before I am taken seriously.)

For those not familiar with otitis, the main danger is infection (pus) building up behind the eardrum. Too much of it may cause the eardrum to rupture (burst), causing permanent hearing loss. This may happen if the infection is allowed to build up untreated for a while (typically 10-14 days).

You have no idea how many times I have butted heads with my providers over this. I keep saying the ear drops aren't going to work (and they never do), that I will have to come back (which I usually do, unless I decide to go to the ER), that they would save time (and spare me unnecessary suffering) by prescribing antibiotics right way but nope, they just don't listen. I might as well talk to a wall, for all the good it does me. They are deliberately delaying treatment, putting me at risk of serious (and permanent) hearing losses.

In the past, I would get so fed up that I would go to the ER (after my first visit to my PCP), because he/she wouldn't prescribe antibiotics, insisting I finish the treatment (ear drops) despite the fact that it wasn't working (and yes, I can tell).

In fact, there's an hospital who known me as "Mister Otitis" (went there 6 or 7 times for the same issue). When I went, I would explained that I've been having earaches for X days, was seen by my PCP on day Y and giving ear drops, which I have been using for Z days, but it didn't work. And could they please check, I have otitis. I was never turned away, or refused antibiotics. Typically by then, I'm in serious pain and begin to experience hearing losses (because of the building up fluid behind my eardrums).

Now, if I go to my doctor for earaches, I don't argue as much (or at least I try to be a bit more tactful). I just challenge the treatment (state that it won't work), and ask for a follow up appointment (the next week). On that follow up, when the person who examine me finally, reluctantly, admit that I do have otitis, I make a point of bringing the fact that I told them so on the last visit (of course, making them admit they were wrong is like pulling teeth).

Anyway, the point of this long diatribe is to highlight the fact that, no, doctors aren't always right. Sometimes, patients do know what's best for them (this comes with experience).

Dany

 
At Wednesday, July 11, 2018 10:46:00 AM, Blogger A. Banterings said...

Warning! This post is a stinging rebuke of the whole practice of medicine. It is not directed a any particular person (such as Maurice). What little trust I had in the system is ALL GONE! Recent events have proved my hypothesis correct.

Medicine is (mostly) infected with power-corrupted sociopaths who have self-exempted themselves from the norms, expectations, and laws of society to protect their deviant subculture. Medicine does what is best and easiest for medicine. Medicine inveigles society with fluff and window dressing such as the Hippocratic Oath, ETHICS, mimicked emotions such as empathy and compassion, illogical ideologies (such as gender neutral healthcare), and ritualistic, cult-like, pseudo religious ideologies (such as cancer screening).

Patients are NOT safe in the healthcare system. Patients should be accompanied by an armed chaperone (truly a chaperone, to chaperone the provider). Every infraction not atoned for by a provider should be met with civil litigation followed by a criminal investigation.

The whole medical education system should be dismantled and rebuilt from the ground up with civilian (societal) oversight.

Providers who have not made a complete moral inventory, allocuted to past wrongdoings ( such as violations of patient dignity as a subset of Human Rights), worked to remove all these defects of character, sought to make amends to persons harmed, sought to make atonement with society as a whole, should be sought out and made to answer for crimes against humanity.

That is what these systematic abuses of patients are, crimes against humanity.

Now you ask, what has brought me to this point of view that so many would decry as unjust, unreasonable, and vindictive?

My answer is...



(Medscape 2018) Pelvic exams done on anesthetized women without consent: WHY is this still happening?




...And some commentary:

...In a recent excellent article by Phoebe Friesen in the journal Bioethics, she notes that “that the practice is alive and well” in many US and UK medical schools. (Source: Wiley Online
Library Journal of Bioethics)


Pelvic Exams On Anesthetized Women Without Consent: A Troubling And Outdated Practice




So why is this happening in 2018 when since 1999, 2004, 2009, and 2012 ALL BIOETHICISTS agreed that this practice was immoral, unethical, an affront to Human Dignity and Human Rights?

No longer can any members of the profession pass the buck. The profession wants to self regulate, so the ENTIRE profession is guilty and ALL members are accountable.





-- Banterings






 
At Wednesday, July 11, 2018 5:36:00 PM, Anonymous Anonymous said...

A. Banterings

I don’t think anyone in healthcare needs to pass the buck. There are soo many bucks flowing in to the tune of $4 Trillion dollars annually, a stack of thousand dollar bills stretching 273 miles. Next year it will be more than that perhaps reaching 300 miles high but they don’t care, we are the ones paying for it.

The declaration of human rights means nothing. Article 1, states all human beings are born free and equal in dignity and rights. Hospitals say this same nonscense in their core values, along with the patient bill of rights. How many times does all this have to be repeated. How many bills of rights does there need to be for patients. How many times are they going to beat this dead horse over and over. Is the concept just as fake as the cyberspace it supposedly exists on.

Every hospital in the United States has core values as do many corporations, but, wouldn’t you think core values as it relates to patient care would supersede the concept of profit and in that I mean many hospitals are non-profit but it’s actually not true because there are bills to pay. The core values are based on ethics, trust, commitment to community and a promise to deliver high quality patient care. The real world is, however, completely devoid of any promise made to patients. This word “promise” is actually found in the stated core values of many medical facilities, meaningless words, hollow, void and shallow.

PT

 
At Wednesday, July 11, 2018 6:17:00 PM, Blogger Biker in Vermont said...

Banterings, I read the comments on that article and they seem typical of what we see anytime consent is discussed. Basically they are hiding behind vague references such as "students may participate in your care" as constituting informed consent to multiple vaginal exams while anesthetized. Some of the responders seemed to think its OK if they limit it to just a couple students who met the patient beforehand.

Real informed consent would be signing off on something to the effect of "the surgeon, Resident, and 2 medical students will all perform vaginal exams after the patient is anesthetized".

Something I find particularly arrogant are statements that patients going to a teaching hospital should know students will be practicing on them after they are anesthetized. How are patients supposed to know this if nobody tells them? What is common knowledge to the staff is not common knowledge to the general public, nor do vague "students may participate in your care" statements make that clear.

I personally will do my best to allow students to participate or observe surgeries and procedures because I know that it is important to their learning, but I expect to be asked and I reserve the right to say no if what is being asked of me is beyond my comfort zone.

 
At Thursday, July 12, 2018 9:27:00 AM, Blogger A. Banterings said...

PT,

What would change the system, AND what I would like to see is a trial of providers for crimes against humanity.



-- Banterings



 
At Thursday, July 12, 2018 6:48:00 PM, Anonymous Anonymous said...

A. Banterings

To be honest with you, I don’t know. Appreciate the fact that I have worked in health care for over 40 years and truly healthcare is the most screwed up industry out there. If I had my way the whole system should be burnt down and started anew. I’ll tell you something else, the system is so inept that they are very inefficient even in collecting revenue from supplies and procedures. Most hospitals lose millions and millions of dollars from a very antiquated charging system. If you check out Becks review website for healthcare, there are many hospital closures throughout the country. For profit hospitals should never exist, investing in The probability that a certain number of people will fall ill and rolling the dice and expecting an 8-10 % return on investment has always been disturbing to me. Medicare/ Medicaid fraud will never end despite the government placing $500 million dollar fines on hugh hospital corporations in this country. The very fabric of healthcare is infected and has been for decades and the cost of healthcare is spiraling out of control.

PT

 
At Thursday, July 12, 2018 7:15:00 PM, Anonymous Anonymous said...

A. Banterings

Another angle that I’ve investigated hospitals is reviewing ratings on Yelp. At one particular hospital there were ratings on Yelp that were bacically all ones. With comments such as “ if I could give the hospital a zero I would”. I once spoke with a CEO at one of our sister hospitals about poor Yelp ratings and he said “ well when I first came here one of the things I tried to do was get staff to smile more.”

Now, the next time you visit a hospital pay attention to the looks on faces of staff. I know this is subjective because healthcare staff are busy but are they frowning, do they just look like they hate their jobs, well they do. I won’t begin nor explain what I’ve done to improve the experience of patients for that might reveal who I am but what I’ve done was quite revolutionary. Not many facilities are willing to accept novel approaches to really bump up the patient experience.

What they ask on those reviews from Press Ganey is exactly what the hospital wants to satisfy Medicare/Medicaid for reimbursements, it’s not about the patient. One of the questions is “ how was the taste of the food? “ Really! Hospital food is not supposed to taste good. It’s designed by a dietitian, not OUTBACK RESTURANT. I seriously doubt Press Ganey will ever ask about privacy, why would the hospital want to set theirselves up for failure? There will never be the question, “ were you able to change into a hospital gown in privacy?

PT

 
At Thursday, July 12, 2018 8:22:00 PM, Blogger A. Banterings said...

Maurice,

I would like to ask you a question because of your inside knowledge as a medical school teacher and an ethicist:

How could (other medical schools justify this in 2018?

It had been debated ad nausium AND concluded that this is unethical and borderline illegal:


Educational pelvic exams on anesthetized women: Why consent matters.

AMA Journal of Ethics: Pelvic Exams Performed on Anesthetized Women

Ethics versus education: pelvic exams on anesthetized women.

Time to end pelvic exams done without consent

Practice vs. Privacy on Pelvic Exams

Pelvic Exams Done on Anesthetized Women Without Consent: Still Happening


Pelvic Exams On Anesthetized Women Without Consent: A Troubling And Outdated Practice

Unauthorized practice: teaching pelvic examination on women under anesthesia.

Using tort law to secure patient dignity


You even agreed that the practice is unethical (on this blog). So how could this still occur?

Do you still think that the medical education system is not broken?

This would be a good question for list serve.

Honestly, the answer is medicine does not care, and it sees no problem with this practice.




-- Banterings













 
At Saturday, July 14, 2018 6:17:00 PM, Blogger Maurice Bernstein, M.D. said...

Banterings, since 2003, this ethical misbehavior is now legally a crime in California. I haven't checked the three other states (Hawaii, Illinois and Virginia) who are said to prohibit un-consented pelvic examinations upon a patient either while awake or under anesthesia. Here is the California law:
http://www.leginfo.ca.gov/pub/03-04/statute/ch_0601-0650/ch_644_st_2003_ab_663

SECTION 1. The Legislature finds that, according to an article in
the Wall Street Journal on March 12, 2003, medical students often are
allowed by their training physicians to practice pelvic examinations
in operating rooms on a patient who is unconscious and has not given
explicit consent to the examination. Pursuant to the practice, the
training physician performs the examination first, and the medical
student repeats the examination.
SEC. 2. Section 2281 is added to the Business and Professions
Code, to read:
2281. A physician and surgeon or a student undertaking a course
of professional instruction or a clinical training program, may not
perform a pelvic examination on an anesthetized or unconscious female
patient unless the patient gave informed consent to the pelvic
examination, or the performance of a pelvic examination is within the
scope of care for the surgical procedure or diagnostic examination
to be performed on the patient or, in the case of an unconscious
patient, the pelvic examination is required for diagnostic purposes.


Notice that the exceptions dealing with "scope of care" have nothing to do with "medical education".

I will tell you Banterings et al, I suspect a major reason why some medical education of pelvic exam is still performed on patients is because those institutions who carry out this practice refuse to pay for skilled teacher-subjects upon whom the students can practice and learn. I can think of no other reason unless they consider what they do is ethical and legal since their state legislatures have not stated otherwise. ..Maurice.

 
At Saturday, July 14, 2018 10:01:00 PM, Blogger A. Banterings said...

Maurice,

I know about the CA law. What I was looking for was some insider insight that you might have as a instructor at a teaching institution (at least an answer than my thesis that medicine creates sociopaths).



-- Banterings



 
At Saturday, July 14, 2018 11:51:00 PM, Blogger Maurice Bernstein, M.D. said...

Banterings, specifically with your thesis "medicine creates sociopaths", I would not be surprised since there comes a time beyond the first and second years of medical school when the demands made by the patients and the medical system have changed "concern" and "empathy" for the patient to "disregard" attempts at "closeness" or "understanding" and thus looked upon as sociopaths. Could the same dynamic be also occurring in the nursing profession? So I will agree that any sociopathic behavior by physicians and nurses may be developed by the demands within the medical system in which they are working. ..Maurice.

 
At Sunday, July 15, 2018 7:32:00 PM, Blogger Maurice Bernstein, M.D. said...

I think, early on, that we may be inadequately teaching students how they should behave for the betterment and protection of their patient when they soon will enter a system where multiple others will have a "hands-on" interactions with their patient both in decision-making but also in other behavioral issues, either for the patient's best interest and concerns or to support the provider's self-interest whatever that might be.
I was reading a published presentation
https://repository.library.georgetown.edu/bitstream/handle/10822/711962/Pellegrino_M80.pdf?sequence=1
about what was happening to the Hippocratic ethic in the latter 20th century as the medical system was changing and, of course, continuing on to where we are now. The author, Edward D. Pellegrino MD, was one of the first physician ethicists and wrote the following, leading me to my concern about current inadequate medical student education. (Continued on next Comment) ..Maurice.

 
At Sunday, July 15, 2018 7:34:00 PM, Blogger Maurice Bernstein, M.D. said...


THE ETHICS OF INSTITUTIONALIZED MEDICINE:
The institutionalization of all aspects of medical care is an established fact. With increasing frequency, the personal contract inherent in patient care is made with institutions, groups of physicians, or teams of health professionals. The patient now often expects the institution or group to select his physician or consultant and to assume responsibility for the quality and quantity of care provided. Within the institution itself, the health care team is essential to the practice of comprehensive medicine. Physicians and non-physicians now cooperate in providing the spectrum of special services made possible by modern technology. The responsibility for even the most intimate care of the patient is shared. Some of the most important clinical decisions are made by team members who may have no personal contact at all with the patient. The team itself is not a stable entity of unchanging composition. Its membership changes in response to the patient's needs, and so may its leadership. Personal concern are far more difficult to assure with a group of diverse professionals enjoying variable degrees of personal contact with the patient. No current code of ethics fully defines how the traditional rights of the medical transaction are to be protected when responsibility is diffused within a team and an institution. Clearly, no health profession can elaborate such a code of team-ethics by itself. We need a new medical ethic which permits the cooperative definition of normative guides to protect the person of the patient served by a group, none of whose members may have sole responsibility for care. Laymen, too, must participate, since boards of trustees set the overall policies which affect patient care. Few trustees truly recognize that they are the ethical and legal surrogates of society for the patients who come to their institutions seeking help. Thus, the most delicate of the physician’s responsibilities, protecting the patient’s welfare, must now be fulfilled in a new and complicated context. Instead of the familiar one-to-one unique relationship, the physician finds himself coordinator of a team, sharing with others some of the most sensitive areas of patient care. The physician is still bound to see that group assessment and management are rational, safe, and personalized. He must especially guard against the dehumanization so easily and inadvertently perpetrated by a group in the name of efficiency.
The doctor must acquire new attitudes. Since ancient times, he has been the sole dominant and authoritarian figure in the care of his patient. He has been supported in this position by traditional ethics. In the clinical emergency, his dominant role is still unchallenged, since he is well trained to make quick decisions in ambiguous situations. What he is not prepared for are the negotiations, analysis, and ultimate compromise fundamental to group efforts and essential in nonemergency situations. A whole new set of clinical perspectives must be introduced, perspectives difficult for the classically trained physician to accept, but necessary if the patient is to benefit from contemporary technology and organization of health care.

 
At Monday, July 16, 2018 4:33:00 AM, Blogger Biker in Vermont said...

Good insights by Dr. Pellegrino that can explain some of what patients encounter. I am old enough to have come of age prior to hospital systems buying up all of the private practices creating the system we have now, but in terms of treating patients with respect and dignity the good old days were worse than today. Back then there was no modesty consideration afforded men and boys at all. Been there.

Dr. Pellegrino says of modern day physicians "He must especially guard against the dehumanization so easily and inadvertently perpetrated by a group in the name of efficiency." Do they even try to do this?

Using my dermatology example from last year, the scheduler was hostile to my even asking for male staff and shut down the conversation. On the day of my exam the nurse wouldn't talk about it, and then the doctor was hostile to my request, though the women were kept out of the room. The Head of Dermatology then chose not to respond to my follow-up letter, and I only got anywhere by going direct to Patient Relations. Those 2 doctors were apparently OK with their dehumanized system made slightly more efficient by forcing male patients to have their genital exams observed by 2 female staff members (scribe & LPN). What I felt as the patient didn't matter to them.

Going in the other direction, urology in that same hospital treats me with great respect when I ask for a male nurse for my cystoscopy prep, but I have no idea whether that is due to the doctors there having established the culture or a practice manager setting the tone, including the fact that there are male nurses in urology.

 
At Monday, July 16, 2018 9:37:00 AM, Blogger A. Banterings said...

Maurice,

As to group ethics, if everyone practiced the simple act of "First do no harm...", then the welfare of the patient, which NOT includes one's physical wellbeing, but also their spiritual and mental well being as well as protecting their human rights and dignity, then everyone would be on the same page.

Interesting that your last 2 posts tie to the Hippocratic Oath.

I am well aware of changes that the Hippocratic Oath has undergone. Just recently, the Swiss version (the Swiss Oath), pledge to resist economic pressures. There has always been controversy with atheist physicians and the Hippocratic Oath. The World Medical Association has attempted updates Hippocratic Oath to attempt to bring it in line with the trend ofv globalization.

You had also question the modern identity of the profession joined. Here is how the issue of PEs without explicit consent is affecting the entire profession:

We know that the Flexner Report lead to a monopolization of the profession of medicine by the AMA by standardizing medical education. The AMA has even stated:

As the Council on Ethical and Judicial Affairs of the American Medical Association concluded, such guidelines "make clear that it is inappropriate to assume that a patient is implicitly willing to participate in the training of medical students or other health professionals merely by being admitted to an academic medical center."

Yet, under the AMA, the practice continues to occur.


What of all the physicians who are members of the AMA? Why have they not called for an end to the practice?



-- Banterings

 
At Monday, July 16, 2018 4:31:00 PM, Blogger Maurice Bernstein, M.D. said...

A reader of our thread wrote me e-mail but wanted what was written to me to be published anonymously. Here is what the individual wrote. ..Maurice.


"The first key strategy for patients is visit providers with open minds and high yet reasonable expectations. Don't go in expecting to be treated poorly. Be civil, be polite, be accommodating when reasonable -- but be prepared. The second key strategy for all patients is knowing a hospital or clinic or private practice's core values, mission statement and rights and responsibilities policy and then hold them to those. Also, Medicare patients need to have a copy of the Medicare patient rights sheet. The first item involves being treated with respect and dignity. If a patient has reasonable expectations and makes them clear, in most cases there will be a serious attempt to meet them. Let them know up front that you want transparency, esp. if they can't meet your expectations. Don't tolerate intimidation or bullying, but look behind the words caregivers use and into their eyes. Try to read what's behind the message behind the words themselves. If you have a bad experience, write to the hospital or clinic, but if you don't get a response or get an inadequate response -- you must follow up. Hospitals fear unexpected visits from the Joint Commission or other agencies when those agencies follow up on a complaint they receive -- especially if the complaint says that the complainer wrote to the hospital and didn't get a response or got a "nothing" response. The attitude within hospital systems is often that -- if there are few or no complaints regarding a certain issue -- everything can just go on as usual -- even if they know there is an issue. If enough complaints come in, polices do change. There is a tipping point. You've got to push the complaints to that point. If you continue to run into obstacles, write letters to some members of the boards of directors of institutions and make it clear that you have complained but got no response or an inadequate response. But be careful with these letters. If you sound like a crank you'll be treated as a crank. And make sure you have tried to go through the channels with no success before reaching out to the board members. Don't get emotional. Just describe what happened as objectively as possible."

 
At Monday, July 16, 2018 5:49:00 PM, Blogger Biker in Vermont said...

Seems like good advice from the anonymous reader.

 
At Tuesday, July 17, 2018 8:06:00 AM, Blogger Maurice Bernstein, M.D. said...

And here is a question presented to a clinical ethics listserv which I know will stimulate a few comments in response on this blog thread. ..Maurice.

During a Patient Care Policy Committee today, the question was posed r/t patient refusal of video monitoring. The example given is a patient who is receiving dialysis whose family is sneaking in food that is affecting her dialysis outcomes. The physician ordered for the patient to be on video monitoring for this reason, but the patient has refused to be monitored. We understand the patient has the right to refusal, however it is interfering with her treatment and outcome. Does this qualify as a safety issue? Can the patient refuse monitoring?

 
At Tuesday, July 17, 2018 8:21:00 AM, Blogger Maurice Bernstein, M.D. said...

I don't intend to place a comment on that listserv but if I did I would write:
"The patient's refusal for video monitoring should be accepted and obeyed after the patient has been fully informed about what has already been observed and what the clinical consequences of the "sneaked food" would affect the patient's dialysis and future health. The family also should be so informed." Anyone have a argument opposing the right of the patient to reject video monitoring? (from what is the usual view here, I would suspect the answer is "No")..Maurice.

 
At Tuesday, July 17, 2018 9:51:00 AM, Anonymous Anonymous said...

Maurice

Patients are on dialysis for many reasons but are often end-stage renal failure, so who cares. Maybe they are awaiting a transplant, however, for those patients who are severe diabetic the hospital sets them up for failure. With questions from Press Ganey to the likes of “ how was the taste of the food “. Hospital food is put together specifically by a dietitian for a very specific reason, it’s not supposed to taste good. Families will sneak food in to the patient, order pizza etc.

I’ve even seen family and friends in intensive care units inject crack cocaine into an existing iv line of the patient who asked for his fix. The patient coded. About all you can do is explain to the patient and document, document and document. Video monitoring of patients is some bad knee jerk reaction to a problem that really cant be corrected. Many patients and their families are going to be non-compliant and you can’t prevent that. I can assure you that every entrance and every Hall way of every hospital is video monitored.

Video monitoring of patients should never occur although some facitilities are using it as a tool to prevent falls or bad patient outcomes it will be abused in some cases. There are many tools already in existence to prevent patient falls, respiratory events etc. Cameras, video monitoring has no place in patient rooms period for any reason.

PT

 
At Tuesday, July 17, 2018 10:29:00 AM, Anonymous Anonymous said...

Oh, but I can just see it coming next. Nurses and physicians will have to start wearing body cams to record every interaction they have with patients. It’s not just family sneaking food into the hospital for the patient to eat, it’s patients ordering pizza and having it delivered to the patient’s room. “Patient to nurse, hey would you like a slice of pizza, you look hungry. “ Nurse to patient” where did you get that? Patient, “ I ordered it from Pizza Hut. Nurse, sure why not.

Many surgeries, blood tests, diagnostic imaging studies are often delayed because the nurse either forgot the patient needed to be npo( nothing by mouth). That npo sign was never put on the door to the patient’s room. So when the food trays were delivered to the rooms by food service they never saw a sign so the patient eats breakfast. Thirty minutes later the surgery team is at the patient’s room to escort them to the or and guess what, they see the food tray. Surgery is cancelled till tomorrow, no anesthiologist is going to intubate you for surgery after you just ate. Want to know how often this happens every day at hospitals?

There are failures on both sides, medical staff not performing up to the standards of care, patients and their families not being compliant and I could list hundreds of examples just like above and yet some in healthcare think the solution is just to add another stupidity layer like video recording in the patient’s room. Tack that one on to the ever increasing $4 Trillion dollars we already spend to try to get good care.

PT

 
At Tuesday, July 17, 2018 11:55:00 AM, Blogger A. Banterings said...

PT,

In keeping with your theme of spending and integrity in healthcare, here is Pro Publica's series, Health Insurance Hustle. ProPublica and NPR are investigating the various tactics the health insurance industry uses to maximize its profits.

Perhaps the most worrisome is the article Health Insurers Are Vacuuming Up Details About You.

To an outsider, the fancy booths at last month’s health insurance industry gathering in San Diego aren’t very compelling. A handful of companies pitching “lifestyle” data and salespeople touting jargony phrases like “social determinants of health.”

But dig deeper and the implications of what they’re selling might give many patients pause: A future in which everything you do — the things you buy, the food you eat, the time you spend watching TV — may help determine how much you pay for health insurance.

With little public scrutiny, the health insurance industry has joined forces with data brokers to vacuum up personal details about hundreds of millions of Americans, including, odds are, many readers of this story. The companies are tracking your race, education level, TV habits, marital status, net worth. They’re collecting what you post on social media, whether you’re behind on your bills, what you order online. Then they feed this information into complicated computer algorithms that spit out predictions about how much your health care could cost them.


In other news...

Hospital execs say inpatient volume growth isn't rebounding.

The article looks at the data with mild speculations on the reasons why. Perhaps I can suggest a reason; patients would rather be abused for a single day in an out patient surgery center than be abused 24 hours a day for 3 to 5 days inpatient.



-- Banterings




 
At Tuesday, July 17, 2018 2:06:00 PM, Blogger Maurice Bernstein, M.D. said...

What I am about to write is not to reflect any unhappiness or negativity about our small group of regular contributors to this "Patient Modesty" thread. It is just that based on my visitor monitor system, there are a number of first, second and third time visitors who could potentially contribute to the discussions here but obviously don't. So, with this posting I want to invite them to voice their opinions, whether in agreement or disagreement with what they read what was already written here.

This is one of my responsibilities as Moderator to encourage all discussion relative to the general subject whether it is on one side, the other side or some middle ground. So, please, you first, second, third or more Readers, become Commenters and "speak up" identifying what you wrote with you own pseudonym. "Speak up" is our general advice motto for this Patient Modesty thread. ..Maurice.

 
At Tuesday, July 17, 2018 7:30:00 PM, Blogger Biker in Vermont said...

As one of the regulars here I will second Dr. Bernstein's invite. I like hearing and learning from the experiences and perspectives of others. If you work in healthcare, all the better given how the modesty and related issues we discuss here are such a seemingly taboo topic within healthcare.

 
At Thursday, July 19, 2018 8:52:00 PM, Anonymous Anonymous said...

I’m responding to the anonymous e-mail Maurice received.


The Joint Commission will never ever make an unannounced visit. The mission statement has nothing to do with patient care. Here is an example of a mission statement from one hospital. “ our goal, to be financially strong and make our shareholders happy”. Insisting that a medical facility adhere to their core values while you are a patient will only get you a psych exam. No one will know what you are talking about. Only upper administration will know what their core values are for their institution once they look them up. Bringing up the word transparency to your nurse or provider will raise a bunch of red flags and they will try hard to get you discharged as soon as possible.

Medicare/Medicaid patient rights sheet. More and more hospitals are refusing to accept patients on Medicare, they don’t have to participate at all, do your homework before you choose the facility. You have to be expecting that you will be treated poorly cause you will be treated poorly. My advice is this, try to stop it before it happens. Ask for the charge nurse and if you are not satisfied with the response ask for the House supervisor. The house supervisors rotate and they are on duty 24/7. The house supervisor is always a nurse, if you are again not satisfied with the response and your concerns are valid within the Standards of Care then say this.to the house supervisor, “ ok, I’ll bring it up to the BON that I brought this to your attention and you did nothing about it. “ I guarantee you they will then pay attention to your concerns. Any patient can bring a formal complaint to the BON ( board of nursing).

Another strategy patient’s are doing is rating the hospital on Yelp, although I recommend you tell the truth when you rate the facility. More than ever a patient care advocate nowadays are reviewing comments on yelp and will get back to you, your complaint is now public domain. Another strategy is after complaining to administration follow up with a complaint to the state. That is the agency that regulates hospitals. The state has the authority to shut a hospital down and will make unannounced visits. Expect a response from the hospital’s administration regarding a complaint to be worded like this, “ it’s unfortunate you had a bad experience at our facility. Because they really don’t care!

PT

 
At Friday, July 20, 2018 11:35:00 AM, Blogger A. Banterings said...

I must do this in 2 parts.

Part I


PT,

Those are great suggestions. Let me follow up on some more:

PT has brought up in the past unnecessary catheterization justified by "standing orders" and as Dany mentioned, C Diff swabbing as part of an infection control plan (which by the way is technically and legally a standing order). So if one is being treated with a procedure as a standing order, one is to request a copy of the standing order with the signature of the authorizing physician or the ordering physician's name (chances are that they will have no clue where to find this).

Most likely with for profit hospitals, these standing orders are issued out of the corporate office by the medical director in the C suite. Most likely he is a physician licensed in the main office's state or his home state (if he works of of another office). That means that the facility is following prescriptions from a physician NOT licensed to practice in your state.

Another form is by tests being automatically ordered by computer systems (as seen in the case of HCA (this is a great explanation of how for profit hospitals work). At this point, because no one person ordered this, the organization created it, then the executives of the corporation (the C suite) is held responsible.

Another thing that providers do not realize is that mistakes in medical records now constitute wire fraud.

The official name of the Affordable Care Act is actually the "Patient Protection and Affordable Care Act", there are legal remedies there.

As we discussed previously, there is Medical Battery

Patient can now sue clinicians for privacy violations such as the practice responding to a subpoena.

There are also POLST violations:
Maryland and most other states, MOLST or POLST — Physician Orders for Life-Sustaining Treatment — forms become part of physicians’ orders; they apply in every health care setting and provide a clearer guide to patients’ wishes than standard advance directives.

One can have "no Foley catheterization in their POLST.

End Part I



-- Banterings

 
At Friday, July 20, 2018 11:35:00 AM, Blogger A. Banterings said...

Part II

Then there is my favorite: Americans with Disabilities Act (ADA).

Under Title III of the Americans with Disabilities Act ("ADA"), private health care providers, including clinics, hospitals and doctor’s offices, as places of public accommodation, are required to provide their services to individuals with disabilities in an accessible manner. Specifically, the ADA requires that providers provide individuals with disabilities full and equal access to their health care services and facilities and provide reasonable modifications to policies, practices and procedures when necessary to make health care services fully available to individuals with disabilities, unless the modifications would alter the essential nature of the services.


The U.S. Department of Justice, Civil Rights Division is charged with enforcing the ADA.

The DOJ has taken enforcement actions against providers for failing to accommodate patients (HIV being the best example). There are many other conditions that can require accommodation; PTSD from previous ill (abusive) treatment by healthcare providers...

Major depression is also a side effect of receiving medical care.

Involuntary treatment causes PTSD.

PTSD Common in ICU Survivors.

Here is a very good paper on the subject: When Treatment Becomes Trauma: Defining, Preventing,
and Transforming Medical Trauma


It is very common for a health crisis lead to PTSD

1 in 3 Patients develop PTSD from a stay in the ICU.

Children are particularly susceptible to PTSD from medical treatments.

There are many organizations that will advocate for "disabled" patients.

Here are 11 Tips for Surviving a Hospitalization when you have PTSD.



-- Banterings



 
At Saturday, July 21, 2018 10:32:00 AM, Anonymous Medical Patient Modesty said...

Hi everyone,

I wanted to let you all know that we have developed a brochure about men and modesty in medical settings. I would love to see if some of you would be willing to volunteer your time to distribute those brochures in your community.

You can find more information at this link: Men and Modesty in Medical Settings.

Misty

 
At Saturday, July 21, 2018 5:45:00 PM, Blogger Maurice Bernstein, M.D. said...

Again, as Moderator, I and I am sure that many of our USA readers and contributors would appreciate those of my visitors to Volume 89 who are living in other countries to tell us your experience or understanding of medical practice of the systems where you live. Remain anonymous but designate the country where you reside. ..Maurice.

 
At Saturday, July 21, 2018 9:13:00 PM, Anonymous Anonymous said...

Misty


With all due respect if I were to buy 100 of your brochures for $36.70 that might be barely just enough to distribute maybe all the medical facilities within a 6 square mile area, at least where I live. The brochures would most likely be thrown in the trash within the first 5 minutes after being handed out. The big pharma people have decided that one Ambien pill for $5 gives me a good nights sleep and my blood pressure pill for that day is $2.50, the statin I take daily is another $2 and for lastly the Viagra well that’s $8-10 a pill. We are at about $20 and that’s just for one day. Not sure I’m willing to sacrifice 2 days of my medicines to try to get a point across to a few facilities of what they should already be doing.

There were 140 women at the ESPYS awards who were given an award for being victims of Dr. Nassar. In what society do you get paid serious money for swinging from monkey bars but yet awarded millions because he said/ she said. Then you are given an award on television, makes no sence to me. There have been over 100 female teachers over the last 10 months who have been arrested for having sex with their young male students, some of these boys were 13 years old. I doubt they will ever be on television for any kind of award let alone be compensated a dime. But that’s just part of the double standard and we haven’t ever begin to factor in the medical component of this. I’m sorry to say this but your brochures for male patient modesty will be laughed at.

At first those looking at the brochures at the medical facilities may at first wonder if it’s some kind of a joke. They will ask where did these come from? I dunno, some guy was out today when it’s 117 degrees outside dropping them off, must have been some wacko. One can only guess what the comments would be if they were left at a Urology or a mammography clinic. I appreciate your efforts but our society is just to backwards, too double standard, too repressed to even consider the concept.

PT

 
At Sunday, July 22, 2018 11:15:00 AM, Anonymous Medical Patient Modesty said...

PT,

I actually do not recommend that you distribute those brochures at medical facilities at all. I know they will be thrown away by medical professionals.

I recommend that those brochures be distributed to men in the community (church, community events, parks, grocery stores, etc.). I do not believe those brochures should be lay around.

I also would love to see those brochures distributed to college guys on college campuses.

It's wise to distribute brochures about patient modesty issues in non-medical settings because you know some medical professionals will do whatever to get rid of them.

Misty

 
At Sunday, July 22, 2018 2:12:00 PM, Blogger Maurice Bernstein, M.D. said...

There has been frequent publications on this thread of rather lengthy Comments. Some of them mine. There is nothing wrong with that since virtually all present worthy detailing. However, I want to present a challenge to this blog thread writers. That is make your point and tell your story in just 55 words (not more though it could be a few words less if you can express your whole point in a few words less).. This story-telling in 55 words is a literary challenge presented yearly by the weekly San Luis Obispo, California "New Times" and the best are published. The current year's best has just been published. I have tried several times in the past but have not been selected. The rules are simple: The should be a title (a few words in length but these words DO NOT COUNT in the 55.) Of the 55 word story, there should be a beginning, a middle, and a conclusion, the conclusion should be dramatic and make the point of the story. All words count in the 55 though the numeric expression of a number is one word as well as established acronyms (AMA, as an example of the American Medical Association). For a bit more details go to https://www.newtimesslo.com/sanluisobispo/55FictionHowtoEnter/Page


So try to make your Patient Modesty point as a "fictional" story in 55 words. As an example, here is my story of the unethical behavior of professionals in hospital practice. . ..Maurice.


Title: "Hospital Unethics"

Hospital ethicist scratched his head in disbelief. What was the physician thinking about writing a "no resuscitation" order without communicating with the competent patient? Two feet away from Dr. Jones, the ethicist looked directly into his eyes. "You have done something unethical!" With that exclamation, the ethicist rose up from his hospital bed and arrested.

 
At Sunday, July 22, 2018 10:09:00 PM, Anonymous JF said...

I'm a better doctor than you are, he shouted into her face. I work 24 hour shifts but you think it's killing you to work a 12 hour shift.
You delay one meal for one hour and act like you're gonna die!
Walk in MY shoes, You cow. and tell me I abuse and bully staff and patients.
So I stripped that loser in front of a few people! He's ALIVE isn't he! Speak to me about such things again and you're OUTA here. The end.

 
At Monday, July 23, 2018 6:40:00 AM, Blogger Maurice Bernstein, M.D. said...

JF, GREAT! You made your point in 86 words (not the established 55) but the story had a meaning! Thanks. Anyone else wants to try? ..Maurice.

 
At Monday, July 23, 2018 6:47:00 PM, Anonymous Anonymous said...

"Sir,Things didn't go too well with patient John Doe!" nurse Susan stammered.
I tried to assist Dr Derek by holding the patients penis and Shannon was the chaperone.
First the patient told me he could hold his own penis and hes squeezed my hand and broke it. Then he ripped Shannon's dress off and threw her in the waiting room and said it was for her protection and comfort. Then he assaulted Dr Derek and lastly he jumped out the window on the 14th story.

 
At Monday, July 23, 2018 6:55:00 PM, Blogger A. Banterings said...

I just caught a news story about the "stand your ground" law in Florida. The implications for patients to protect themselves is another protection that society enacts that can be used as a response to the profession of medicine's dismal failure to self-police AND to recognize acceptable social behavior (can you say PEs still occurring on anesthetized women).

I have no problem with one defending their human right to ensure bodily integrity and protect their dignity by "standing their ground."



-- Banterings



 
At Monday, July 23, 2018 9:03:00 PM, Blogger Maurice Bernstein, M.D. said...

At Monday, July 23, 2018 8:56:00 PM, Blogger Maurice Bernstein, M.D. said...
You may be interested in how genital exams are taught to second year medical students at
Alpert Medial School of Brown University as reported in 2013. Actually, the program is similar to how our school teaches 2nd year medical students. I am not aware of our student's experience feedback but I suspect it would be similar to those described in the article.
Here is the link:
http://www.ijocs.org/clinical-journal/teaching-intimate-physical-examinations-an-innovative-program-of-instruction-and-reflection-for-medical-students.pdf

As you can read, the school is well-aware about NOT practicing on patients without full consent. ..Maurice.

 
At Tuesday, July 24, 2018 2:17:00 AM, Anonymous JF said...

That sheriff's response to that shooting is a disgrace. The people of the United States are being pitted against each other.
It's exactly like they want us to take the law into our own hands. I wish this rough spot would end!

 
At Tuesday, July 24, 2018 4:57:00 AM, Blogger Biker in Vermont said...

Dr. Bernstein, the manner in which medical students are being taught is good, except for one significant omission that can make for all the difference for patients in real life situations. This is who else will be in the room, whether they are same or opposite gender, and whether consent is being obtained. Nurses, MA's, scribes, chaperones, techs.

 
At Tuesday, July 24, 2018 7:41:00 AM, Blogger Maurice Bernstein, M.D. said...

Biker, scribes are unneeded for a pelvic exam since it would take only seconds for a physician to write on electronic media "pelvic exam was performed and was normal". Although the students learn where the anatomic structure is externally and what is inspected and palpated internally in detail, each of these anatomic observed or palpated tissues do not have to be detailed in documentation of a pelvic exam unless for some reason a routine proper exam could not be carried out or significant abnormality was found. So that gets rid of the scribe! The same applies to a male patient genital exam. With regard to the chaperone of the same gender as the patient, that should be of no problem unless providing concern to one of the parties.

What students have to learn is how to manage their own personal sexual concerns or embarrassments and their education of how to understand and how to be supportive of the concerns of the patient during the examination. So this is beyond just where and how to inspect or palpate but how to behave toward the patient's feelings and even their own. And, believe me, much of this teaching is performed by the "teacher-patient" both male and female whom the student is examining. ..Maurice.

 
At Tuesday, July 24, 2018 11:03:00 AM, Blogger Biker in Vermont said...

Dr. Bernstein, during the training using paid volunteer patients there are only the students, their instructors, and the patient. There are not any of the other staff members that might be present in real life. My question is whether the teaching of medical students includes discussion of the potential impact on patients of other staff members being present for intimate exams. For example I might be OK with a genital exam by a female physician but her bringing a 2nd woman into the room (chaperone/scribe/nurse/MA) is a deal breaker.

 
At Tuesday, July 24, 2018 11:46:00 AM, Blogger A. Banterings said...

I must do this in 2 parts.

Part I

Biker et al,

What is really missing here is the necessity of the exam and the wishes of the patient to do the exam. Who does the exam and who is in the room is secondary once the patient decides to proceed with the exam.

I know that Maurice will defend medical education by saying that students are taught to perform exams only when indicated. This is the primary flaw with medical education and the practice of medicine: These exams and procedures MUST (only be) OFFERED! (NOT Must be PERFORMED.)

There is enough research that shows that many physicians omit such exams, that it justifies NOT performing such exams, thus creating a new standard of care.


How Much is Too Much During the Physical Exam?

Is Physical Examination Required Before Prescribing Hormones
to Patients with Gender Dysphoria?


Deferred pelvic examinations: a purposeful omission in the care of mentally ill women.

Inadequacies of Physical Examination as a Cause
of Medical Errors and Adverse Events


Don't Neglect to Physically Examine Adolescents

Why Does the Physical Exam Stop at the Navel?

Don’t overlook anus, genitalia during total body skin exam

Genitourinary Assessment: An Integral Part of a Complete PE

Are male patients comfortable with women doctors?

Is deleting the digital rectal examination a good idea?

All for Want of a Rectal Exam


Genital examination: when and how? (What I Learned from Jodie)



End Part I



-- Banterings


 
At Tuesday, July 24, 2018 11:59:00 AM, Blogger Maurice Bernstein, M.D. said...

In my school, the second year med students have a session (in which I and other instructors teach a session 3 groups of 6) regarding these issues Biker along with practicing on "plastic" models simulating the genitalia during which time the student is observed explaining to the "patient" what is to be expected or is being carried out. Yes, the issue of chaperone and privacy is brought out in the lecture to the class prior to their practice session.

Some weeks later is when these students are faced with a live human being who is a teacher and a genitalia exam subject. These teachers who are witnessing and experiencing both the psychological and physical aspects of the exam provide each student with immediate constructive feedback. That completes the education of these exams prior to the third and fourth years which hopefully involves patients who are awake and fully permissive of the student continuing their genitalia examination learning on them. But this is the extent of the medical student's education on the subject. ..Maurice.

 
At Tuesday, July 24, 2018 12:02:00 PM, Blogger A. Banterings said...




Part II

So what does "to offer" mean?

First off, it should start with asking explicit consent in a nonthreatening way that allows the patient to refuse without retaliation.
It would be more valuable for a student to face one refusal from a patient then performing 1000 intimate exams on anesthetized patients.

The other issue is that medicine has to wake up to the fact that it is only doing what is best and convenient for it's members. For a profession that (supposedly) trains its members to think critically and logically, it has made some very piss poor decisions historically and REPEATEDLY.

I have not even gotten to the part that when the evidence is examined in all these intimate exams that are found to be a matter of RITUAL rather than science. Even in trauma, rituals proliferate: Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. Even the AMA acknowledges that many physicians treat cancer screening as a religion.
(See: Is Our Attitude Toward Cancer Screening Based On Faith Or Science?)


All we are doing is overscreening k and overdiagnosing which has lead to doing more harm than good.

Even things that are NOT diseases are treated as a disease, like pregnancy. (That is why a growing number of U.S. mothers are turning to midwives, rather than physicians, for prenatal care, labor, and delivery.)


-- Banterings



 
At Tuesday, July 24, 2018 1:57:00 PM, Blogger Maurice Bernstein, M.D. said...

Banterings, I agree that what has been "routine" in the past is "excessive, unnecessary and potentially harmful" in the present. An example is "screening" for testicular cancer which I wrote about on July 3
http://bioethicsdiscussion.blogspot.com/2018/07/patient-modesty-volume-89.html#c2528565399701591637

..Maurice.

 
At Tuesday, July 24, 2018 2:20:00 PM, Blogger A. Banterings said...

Maurice,

My point exactly. All these intimate screenings have their roots somewhere else:

-- Because we can...
-- Let the patient know that I am the one in charge.
-- Ritual.
-- Flawed science.
-- Something else.
--A combination?

Is it also no surprise that these are the things that patients hate the most and most often refuse?



-- Banterings





 
At Tuesday, July 24, 2018 4:32:00 PM, Anonymous JF said...

I fully agree that male patients shouldn't be put on display for female chaperones or scribes.
I know I keep saying the samw thing over and over but MANY of us female patients are NOT ok with having our genitals and anus's put on display for female chaperones or scribes either.

 
At Tuesday, July 24, 2018 6:08:00 PM, Blogger Dany said...

Banterings et al,

It could be that this is only my experience and doesn't apply to others but I have yet to have a physical examination where the clinician "offered" me to do a Genitourinary examination. An offer should sound like "would you like to...?" or even "I would like to..." but no, that is not how things have been presented to me. I'm not even sure "proposed" or "suggested" would qualify here.

What a clinician will typically say is "I need to..." or sometimes "I will..." This doesn't leave the impression of a choice but then again, that's exactly why it is presented that way (a not so subtle nudge). To let the patient believe that it is unavoidable, that they don't have a choice. And only the ones who already have strong objections will speak up and voice their refusal. And even then there is no guarantee things will stop.

Intimate exams are, in my opinion, rarely necessary, unless the patients themselves have a concern and wish to seek help. There's enough information available to the general public, coupled with sexual education programs (assuming they are half-decent) to provide anyone with, if not a full diagnostic, at least some idea of what might be wrong. From that point on, it's up to the patients to decide if they want to consult or not.

I forget who said it but a quote comes to mind: "In a well patient, someone who does not present any sign or symptom of a pathology, there is little to no benefit in performing a GU examination." This could also be said of rectal examinations. An if any patient cannot tell that something might be wrong, they have bigger problems than worrying about who will look at their genitals.

That being said, I fully understand that the level of education and knowledge about sexual health will vary from individual to individual. But speaking for myself, I have put a stop to GU examinations at the age of 15 yo, and I'm none the worse for it. And no, my genitals are not about to fall off either. I don't think I was particularly lucky, or that I dodged a bullet.

As a good friend of mine used to say "It's not rocket surgery..."

Dany

 
At Wednesday, July 25, 2018 4:32:00 AM, Blogger Biker in Vermont said...

I am only here alive today because at age 51 my PCP did a urine test as part of my annual physical. He told me afterwards that in the absence of risk factors, of which I had none, many doctors no longer do that test as a matter of routine. It surfaced an aggressive high grade cancer that had it not been found at an early stage, I'd of been terminal by time I had any symptoms.

Thus far I have not refused any test my doctors suggest or say they want done, nor have I refused any part of an exam. Perhaps there will be something in the future, but thus far I haven't encountered it.

For me tests and exams are not the issue. Gender and dignity are.

 
At Wednesday, July 25, 2018 8:01:00 AM, Blogger Maurice Bernstein, M.D. said...

Performing any test whether it turns out "positive" or "negative" requires some historical or physical examination basis for it being performed in the first place. In addition, performing a test which turns out "abnormal" or "normal" requires the physician and patient understanding the specificity and sensitivity of the test and whether the result is consistent with the already known facts of the case, regardless of whether the facts represent normality or abnormality. If inconsistent, the results cannot be ignored but must be explained by repetitive or other tests to provide explanation. ..Maurice.

 
At Wednesday, July 25, 2018 11:11:00 AM, Blogger A. Banterings said...

Dany,

If you read Joan Emerson's paper, Behavior in Private Places: Sustaining Definitions of Reality in Gynecological Examinations, she validates this as a tactic used on patients. On pages 78-79 (the 5th & 6th pages) she states:

...Furthermore, the staff claim to be merely agents of the medical system, which is intent on providing good health care to patients. This medical system imposes procedures and standards which the staff are merely following in this particular instance. That is, what the staff do derives from external coercion—"We have to do it this way"— rather than from personal choices which they would be free to revise in order to accommodate the patient.

If you read my previous post, you see that all the papers urging that these exams be done are only proving that the standard of care is to "OFFER" such an exam.

I have made this point about must/need to vs. TO OFFER. In 42 CFR § 441.56 [Required activities] (b)[Screening](1) it states:

The agency must provide to eligible EPSDT beneficiaries who request it, screening (periodic comprehensive child health assessments); that is, regularly scheduled examinations and evaluations of the general physical and mental health, growth, development, and nutritional status of infants, children, and youth... ...As a minimum, these screenings must include, but are not limited to:

(i) Comprehensive health and developmental history.

(ii) Comprehensive unclothed physical examination.



If you read EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents, it talks about Medicaid services being OFFERED.



Again, teaching providers to OFFER services is a consumer driven concept, REQUIRING them is a PATERNALISTIC one.



-- Banterings


 
At Wednesday, July 25, 2018 2:43:00 PM, Blogger Dany said...

Biker,

I understand your point of view. And my last comment was not intended to diminish or disrespect what you think is right for you. However, I will argue that a genital examination is not the same as a urinalysis. The former demands exposure, the latter doesn't. I have no issue with UAs or providing a urine sample, so long as I don't have to do it while someone's watching me... Or requires a clean catch (that would definitely not go over well).

In fact, since my hematuria was discovered, doing UAs - Dip stick and urine cytology - is now a permanent fixture in my life. It's annoying - since I am not entirely convinced it is useful anyway - but, it's no hardship to do so I stoically endure it.)

What I object to - and will always do - is having my genitals routinely examined when there's nothing wrong with them. Obviously, if I begin to suspect there's a problem, I'll do my homework and then I'll consult. But I will carefully pick the provider I will go to (and it's not going to be a woman, unless I absolutely have no other option).

It's not that I think I know everything there is to know about sexual health (because I certainly don't); but I believe I know enough to decide if something is worth consulting for or not. The bar, as far as what one needs to know (say your average pumpkin), isn't as high since coming to a diagnostic isn't the aim, but only to figure out something is wrong (or might be wrong). That's usually when you need a doctor for.

Bantering, you don't need to sell me on this crap. I've been attuned to this sort of manipulation since I stumbled upon this blog and now I'm amazed at how often healthcare providers uses it. I even challenged one of my past provider on this specific issue (nudging and manipulation of their patients). The conversation rapidly turned awkward (for him mostly). In the end, I got my point across (which was for him to stop pushing me, I didn't like it)

Dany

 
At Wednesday, July 25, 2018 5:53:00 PM, Anonymous JF said...

Some tests can be done by a urine test and swabbing could be done by the patient. I predict that a health care worker could be as likely as the patient to accidentally contaminate a swab and they'd be LESS likely to speak up and admit that they did it.

 
At Saturday, July 28, 2018 8:02:00 AM, Anonymous Anonymous said...

Recently, I was involved in a situation that I think demonstrates how difficult the battle to end the double standard in medical care will be. I drove my wife to an appointment in a medical building we had never visited previously. When we entered, she needed to use the restroom before we got on the elevator.
As I waited for her, I couldn’t help but notice a large glass fronted office labeled “Women’s Health Center” which seemed to occupy most of the first floor. I also saw an information desk to my left staffed by a young women who was talking with another woman who was dressed in scrubs. I interrupted their conversation by commenting that the women’s center was quite impressive looking and they both readily agreed. At that point I couldn’t help but comment that “I suppose the men’s health center must be on the second floor.” Both women simultaneously burst into laughter. The fact is that both women obviously see a woman’s health center as being a perfectly acceptable part of the medical system while the thought of a male health center simply seemed ridiculous to them.
I have no ready solution to changing this mind set, but I thought sharing this incident might serve to remind readers what a difficult challenge we face and how important it is for each of to individually stand up for our privacy and modesty rights in medical settings .

MG

 
At Sunday, July 29, 2018 6:02:00 AM, Blogger Biker in Vermont said...

MG, if it was just the women in healthcare more progress would have been made by now. The reality is male physicians, nurses and others see it the same way as women.

The best and perhaps only course of action most of us have is to advocate for ourselves. Eventually some practices may find it easier to accommodate male patient modesty than to deal with the disruption. Somehow my urology practice saw it’s way to hiring a couple male nurses. Was it past patient complaints? Last year when I made my 1st dermatology appt. the scheduler was outright hostile to my asking for male staff and it went downhill from there. You may recall I went through a couple rounds of elevating my complaint. I recently made my annual appt. there and when I indicated I wanted male staff I got a polite OK for a response. Was that a result of my complaints?

 
At Sunday, July 29, 2018 9:20:00 AM, Blogger Maurice Bernstein, M.D. said...

You know, I have a feeling based on my history as a physician that a patient's concern and eagerness for a diagnosis and treatment, if they come to the physician with symptoms, trumps any concern about the gender of those who will be involved in their diagnosis and care. This feeling is based on the many years of my medical practice.

What I say about the absolute absence by any patient regarding any mention of provider gender is true and led me to my very early Volumes and a bit beyond to consider what has been written here as representing "statistical outliers". I now have the feeling that "not speaking up" was a cultural "norm" in years past and even now and that what is written here by my visitors does represent a more common concern. So, we still have Constitutional "free speech" in the United States and it is my advice to all potential patients to weigh their symptoms, concerns and need for urgent diagnosis and care and, if safe and acceptable, to "speak up" their gender and procedural concerns to wherever they are in the medical system and expect some satisfactory response by the system. And, if the system fails their promises then "speak up" more forcefully to the superiors in the system. ..Maurice.

 
At Sunday, July 29, 2018 12:00:00 PM, Blogger Biker in Vermont said...

Dr. Bernstein, unless you brought female observers into the room for male patient genital exams your male patients wouldn't have had anything to voice a concern over. The one possible exception to that is if you were sending them elsewhere for an intimate exam or procedures and your male patients knew it would be female staff doing those exams and procedures.

Years ago when my doctor (male), who always did his exams in private, sent me for an ultrasound of my bladder, I had no inkling I would be fully exposed nor that it would be a woman doing it. I had never had an ultrasound before and posed no questions or concerns to him. At the time I trusted he'd of told me anything I needed to know. He didn't.

If we are statistical outliers it is in the fact that we are amongst the few who will speak up. In the old days I hid my embarrassment with bravado convincingly done, so the fact that many men don't seem to mind doesn't mean they aren't embarrassed.

A key point here is that most medical care is not urgent in nature. Appointments are often made months in advance. Most patients are not in the midst of an emergency and do not have that as a reason to set aside their modesty.

Not speaking up is still the cultural norm for men, those that norm is ever so slowly eroding.

 
At Sunday, July 29, 2018 1:48:00 PM, Blogger Maurice Bernstein, M.D. said...

And now a doctor's view as written November 17 2013 in my blog thread "I Hate Doctors: Chapter 3"
"I Hate Doctors": Chapter 3 http://bioethicsdiscussion.blogspot.com/2010/08/i-hate-doctors-chapter-3.html

At Sunday, November 17, 2013 9:03:00 AM, Anonymous said...
Had a look, dont have a problem with anything they say. Patients have a right to see a doctor of any gender they choose. I prefer male doctors personally if I am ever forced to see my own GP by my wife. I hate doing intimate examinations on women. I avoid it at all costs. Its embarassing, time-consuming (you have to often find a chaperone which is harder than it sounds) and often unnecessary. 99% of medicine is history and observation - with diagnosis is often clear within 1-2 minutes if you shut up and listen, which I admit not many doctors know how to do. Examination is often for show. I always offer female patients the opportunity to have intimate examinations done by female doctors. That's actually not true - I usually quite sneakily TELL them to see a female doctor (or nurse) for intimate examinations as it saves me loads of time (a properly conducted one will take 5-10 minutes) while I organise pelvic scans and hormone profiles (which takes 1-2 minutes). As you can see, every second counts. Besides, I probably already know the diagnosis. This is what some patients seem to find hard to understand - that tests and examinations are to confirm what the doctor already knows. Its no surprise that Sherlock Holmes was written by a doctor - those same skills of history taking/interviewing, observation and deduction are invaluable to detectives as well as doctors. And I agree with what another commentator has indicated above - that a sign of a doctor is a deep concern with getting the diagnosis and treatment right (rather than with merely keeping the patient happy). I prefer a live unhappy patient to a happy dead one. GP
>


You know, the pressures of current doctor-patient interaction and responsibilities, it may really come down to GP's last sentence: "I prefer a live unhappy patient to a happy dead one." Maybe that is going through the mind of those in the medical system who don't seem to listen to what you tell them. ..Maurice.

 
At Sunday, July 29, 2018 3:02:00 PM, Anonymous JF said...

The scheduler was hostile? Maybe it would be useful to secretly record those conversations.

 
At Sunday, July 29, 2018 3:08:00 PM, Anonymous JF said...

Absence-- key word. If I ( and many other people ) would have been treated like Biker was, chances are GREAT that I would have just left and not come back.
Problem with that is too many patients and too few doctors.
Not only would the doctor not care , he/she probably wouldn't even notice.

 
At Sunday, July 29, 2018 3:20:00 PM, Anonymous JF said...

I once went to a gynecologist who had his chaperone in the room already. He shared an office with her.
She was working at her desk and once got up to get a book off of her bookshelf. She wasn't looking up my #$@ but if I would have said Stop or otherwise showed distress she would have been aware.
Whether or not she would have sided with me or any patient is questionable. It is always questionable because most people are cowards when their own livelihood is at stake.

 
At Sunday, July 29, 2018 4:51:00 PM, Blogger Biker in Vermont said...

JF, just as family members & friends cannot be assumed to be impartial chaperones, it would have to be a pretty egregious scenario for a staff member to ever speak against their employer. At the same time, I presume that the ones who would never do anything wrong are the ones who are most diligent in having (or offering) a chaperone.

Walking away from the kinds of things we talk about here lets them win. Busy practices have as many patients as they can handle so if any of us walk away, somebody else will just take our place. Better to stay and fight for change, and in that case I did get some change.

I will add that my deciding to have all of my care at that one hospital gives me some degree of clout. Being I already had an established relationship with primary care, cardiology, urology, and gastroenterology, and not having had a problem anywhere else, I suspect my complaint against dermatology was taken more seriously.

 
At Sunday, July 29, 2018 6:03:00 PM, Anonymous JF said...

He prefers a live unhappy patient over a happy.dead one?
I guess that depends on the intensity of the unhappiness. If the patient is actually traumatized, he/she may never come back and could die sooner because of that. More likely they would live , but put up with symptoms.

 
At Sunday, July 29, 2018 7:34:00 PM, Anonymous Anonymous said...

Healthcare in the United States is the most expensive in the world, yet we rank at the bottom. Why do we pay more for less? We are not getting the best care for our money. America’s healthcare ranks low among developed countries, Why. Is it greed in the system or is it due to overutilization? When it comes to many of the measures of healthcare system functions the United States healthcare system is an outlier.

I did say the word outlier to describe our healthcare system and those are not my words but rather it came from researchers who have found that although we spend more for healthcare and in return we get very little. That makes the United States healthcare system an outlier compared to other countries, not us on this blog. Furthermore, one might recognize that considering for every 5 bucks we spend, one of those dollars goes to healthcare and in that regard our healthcare hasn’t translated into better outcomes on a variety of fronts.

Dollars first, ethics second or last, however you want to describe it. Respectful care, how much does that cost or how much more should it cost? You might believe you should be given respectful care when you appreciate the vast amount of monies poured into the industrial complex called American healthcare to the tune of 4 Trillion dollars annually. It’s enough to make you sick just thinking about it. It’s rate of climb continually outpaces inflation.

PT

 
At Monday, July 30, 2018 5:28:00 AM, Blogger Biker in Vermont said...

PT, my understanding is that other western countries that spend far less on healthcare than we do in the US do not do also a better job when it comes to gender issues. In fact I think in some countries the patient has little say in who their doctor is let alone the gender of doctor or staff.

The vast overspending in the US is (in my anecdotal opinion) from end of life heroics and with over utilization by the elderly. When my father was dying of cancer and I was conveying to the doctor what I now understand to be what happens when the body is starting to shut down (but I didn't understand back then), rather than just tell me he had days or maybe a week left they hospitalized him and started in with the tests and treatments at great expense knowing he was approaching the end anyway. In addition to the wasted resources he lost a precious few final days at home with my mother.

When my mother had a massive ongoing stroke which the hospital knew she couldn't survive, they continued scan after scan and other tests and specialist visits anyway until my brothers and I told them to knock it off, and then they pumped the billing efforts hard in the palliative care direction. All she needed after the initial diagnosis was a nurse to keep her comfortable through the dying process but that hospital focused on billing a couple hundred thousand dollars for those last few days instead.

With my in-laws who had the more typical long slow decline with advanced age and eventually dementia, the doctors appts and tests were endless. My wife took them to their appts in their later years and they were never more than "you're doing great Mrs. L, see you in 3 months, but let's do this test before then." This was with their primary care and with assorted specialists. When my father-in-law was in the nursing home as an alzheimer's patient his primary care would poke his head in the door periodically, say "How are you doing Mr. L". Of course Mr. L didn't know who the doctor was, nor how he was doing. The doctor would then move on to the next room, probably billing at least 10-15 office visits an hour. My wife finally had to tell him to knock off ordering bone density tests on a man in his mid-90's, mostly bedridden, and who couldn't tell you what year it was. The tests were just detracting from keeping him comfortable.

Repeat these examples with millions and millions of the elderly and you are vastly and wastefully overspending.

 
At Monday, July 30, 2018 6:22:00 AM, Blogger A. Banterings said...

Maurice,

As to your post at At Sunday, July 29, 2018 1:48:00 PM, the anonymous was absolutely correct:

...often unnecessary. 99% of medicine is history and observation - with diagnosis is often clear within 1-2 minutes if you shut up and listen, which I admit not many doctors know how to do. Examination is often for show...

He further states the obvious sans a reference to any study validating the fact, but then again, he is a physician:

...I hate doing intimate examinations on women. I avoid it at all costs. Its embarrassing...

Unfortunately the medical education teaches to ALWAYS examine the patient at ANY COST. This is OVERSCREENING, which has lead to the situation we are in now of overscreening, overdiagnosis, and overtreatment


If you look for disease, you will find it.


Much of it is for show. Many physicians push it to make it look like that they are doing something.

Furthermore, it is a result of poor doctoring skills (poor history taking skills and a lack of listening).

Again, if medical students were taught that this is taboo in society, even IF you are a PHYSICIAN, they would focus and develop other skills just as a person who loses one sense (blindness) compensates with other senses (hearing). I am NOT saying eliminate the physical (intimate) exam skills, just put them in the proper context of society, such as participation by a person is not justifiable as being acceptable simply by the fact that one is a medical provider.


JF,

As to the unhappy patient vs. the dead one, some patients prefer dead. Read: Tomophobia, the phobic fear caused by an invasive medical procedure - an emerging anxiety disorder: a case report.

I had once told a physician that "I would rather die with dignity than live without it."


PT,

The "Consulting Demotivator", it is all about the money being made by the banking industry (which it has become addicted to the revenue that fees produce). Healthcare preys on our most basic instinct, self preservation (or the fear of death). Whether it be with overscreening, overdiagnosis, and overtreatment (the promise of eternal life), OR justifying excessive procedures as medically necessary, there is money to be made and patients happily pay it.



-- Banterings












 
At Monday, July 30, 2018 8:15:00 AM, Blogger Maurice Bernstein, M.D. said...

What I am writing may appear repetitive, which it is..and in no way am I attempting to diminish the interest and value of Comments presented by our "regulars"..but I know that other humans at their computers or smartphones are reading this Patient Modesty thread and I truly would like to encourage them to contribute to the discussion here and present their views, even if in conflict with those of our "regulars". Again, I would like input from other countries beyond USA and even Canada.
How about visitors from France and England and Asia and elsewhere. I am ignorant regarding the patient-medical system dignity issues and would most appreciate education and I am sure our "regulars" will also find your views worthy of further questioning and response.

Of course, I appreciate the commentary and detailing of our "regulars" here but I think there would be more to "think about" if we heard the views of the "others" who I know are reading our thread. Again, I urge you to remain anonymous except for the country of origin but use a consistent pseudonym for your name. ..Maurice.

 
At Monday, July 30, 2018 1:27:00 PM, Anonymous JF said...

Dr B and everybody else.
Is there anyway of doing away with that kind of financial rape. Why is it legal and can it somehow become ILLEGAL! Your story and others like it makes me want to round up the offenders, put them in jail cells and allow them to starve to death.

 
At Tuesday, July 31, 2018 2:18:00 AM, Anonymous JF said...

For most of you, opposite gender care is your trigger. But for some of us it's being put on display for a person that doesn't contribute anything to our care.
To us, THAT is abuse. With that being said, I'm indifferent when I'm under.

 
At Tuesday, July 31, 2018 6:28:00 AM, Blogger Maurice Bernstein, M.D. said...

I get a feeling from reading the Comments here that some physical examinations and challenging the patient's modesty issues are really unnecessary and that diagnosis of the patient's condition can be made in a quicker and less potentially embarrassing manner. For example, would there be a host of diagnoses that your local pharmacist could make in a more modest and simpler fashion?

I created a new thread just on this subject with extracts from two articles covering the subject of pharmacists and diagnoses.
You may be interested in reading that thread and commenting there.

With the current long waits in emergency rooms for simple diagnoses and the more prolonged and complex visits at a physician's office for similar diagnoses, obviously there is currently consideration of any potential diagnostic and prescriptive potential of licensed pharmacists at your local drug store.

Here is the link to the new thread:
http://bioethicsdiscussion.blogspot.com/2018/07/pharmacist-just-filling-prescriptions.html

What do you think?

..Maurice.

 
At Tuesday, July 31, 2018 8:02:00 AM, Anonymous Anonymous said...

JF

I think you have it backwards, it’s being put on display in front of people who have no business being there in the first place. Healthcare seems to promote this kind of warrantless voyeurism.

Maurice

Recently in Arizona it came to the attention that a physician had collected $750,000 in the form of monies and gifts from the pharmaceutical companies. Some agencies have asked that law enforcement investigate and I’m sure this is just the tip of the iceberg. Recently in Arizona as well a pharmacist refused to fill a female patient’s prescription that would allow her to complete her abortion. I know many many people who drive to Mexico each month to buy their medicines from the pharmacies. You see in Mexico you don’t need a script, you go in and pick out your medicines. You want 100 Cipro tablets, that’s $10. I have people bring me back medicines all the time, that way I cut out the middleman. I cut out the pharmacist, I cut out the costs of big pharma, I cut out the physician and his staff and probably cut out some warrantless voyeurism too in the process. The old saying, if you want something done right, do it yourself.

PT

 
At Tuesday, July 31, 2018 10:48:00 AM, Blogger A. Banterings said...

Maurice,

You stated:

I get a feeling from reading the Comments here that some physical examinations and challenging the patient's modesty issues are really unnecessary and that diagnosis of the patient's condition can be made in a quicker and less potentially embarrassing manner.

In the thread you reposted a doctor's view as written November 17 2013 in my blog thread Chapter 3"
"I Hate Doctors":


At Sunday, November 17, 2013 9:03:00 AM, Anonymous said...
...I hate doing intimate examinations on women. I avoid it at all costs. Its embarassing, time-consuming (you have to often find a chaperone which is harder than it sounds) and often unnecessary. 99% of medicine is history and observation - with diagnosis is often clear within 1-2 minutes if you shut up and listen, which I admit not many doctors know how to do. Examination is often for show.


Additionally:


...over 80% of diagnoses are made on history alone...

a careful history will lead to the diagnosis 80% of the time

I can go on with an array of text books that teach/preach exactly the same. So as to answer your question, YES, most physical exams done are really unnecessary!


-- Banterings




 
At Tuesday, July 31, 2018 3:58:00 PM, Anonymous JF said...

PT. I don't have it backwards.I said the same thing you did. The junk being displayed in front of extra unnecessary staff!
The only difference I can see in how I feel vs how you feel is I'm not more upset by an opposite gender doctor/healthcare provider. It's the scribe or chaperone that's the trigger for me, and doors being opened with no curtain or screen giving some protection.

 
At Wednesday, August 01, 2018 8:01:00 AM, Blogger Maurice Bernstein, M.D. said...

have a question about a topic pertinent to the discussion here that I don't recall has been considered.
Back in 2010, I started a blog thread titled "Should Doctors Examine, Diagnose and Treat Their Family Members?>" I had so far 25 responses, physicians and family members with physicians in their family.

What has that topic related to our "Patient Modesty"? Would our visitors here feel more comfortable being examined by a professional family member and then treated by that member? How about a male physician's medical pelvic exam on his wife or a female physician's male genitalia or rectal exam? Would the patient find comfort since it is doubtful there would be a chaperone or scribe at the moment. Any comments? ..Maurice.

 
At Wednesday, August 01, 2018 9:14:00 AM, Anonymous Anonymous said...

You know Maurice that’s a very grey area that most should not go there. I know of a female physician whose three young adult children were hooked on all kinds of drug. She writes scrips for them for several years until a pharmacist reported her to the DEA. After two years of legal wrangling and not being able to produce any medical records as Requested by the board her license was revoked.

PT

 
At Wednesday, August 01, 2018 10:06:00 AM, Blogger Biker in Vermont said...

Dr. Bernstein, I read that other thread you pointed us to and generally speaking I think medical professionals need to tread very carefully treating family members. To help steer them in the right direction is good, but actual examination and treatment for anything other than minor stuff is fraught with peril.

I did note that the respondents all avoided the issue of intimate exams. Elephants in the room are generally not to be acknowledged or discussed. Are these doctors giving their parents, adult kids, siblings etc intimate exams?

This is not an issue for me personally. No medical doctors in the family. A cousin is a nurse but I wouldn't ask her for advice nor would I ever consider allowing her to examine me.

 
At Wednesday, August 01, 2018 10:22:00 AM, Blogger A. Banterings said...

Maurice,

I absolutely agree that physicians treat family, friends, etc. If they are not qualified to treat them, then they are not qualified to treat the public. Furthermore, they are only going to do what IS necessary; NOT this is what we always do OR this is how I was trained...

For many years my primary was a family member and I never had (even to this day) all but 2 intimate exams. One I remember when I was about 5, and one in the last years when I found a lump (which was an epididymal cyst), and my wife INSISTED I get it checked. The only reason that I allowed it was because I trusted him and he only examined the testicle with the lump (not everything just t be sure...).

I think that physicians treat family the correct way (by doing only what is necessary). I have NEVER done preventative cancer screening, and I have no intention of starting.

Although I never had an intimate exam by a family member, I would be more comfortable with a family member in general than some stranger I may only see once a year...



-- Banterings



 
At Wednesday, August 01, 2018 1:05:00 PM, Blogger A. Banterings said...

Let me clarify for the record, the intimate exam was NOT done by the family member. This was many years after he stopped treating me.

The first exam that I remember was not done by him either, but I suspect that the way this exam was done is why I refused to go to mim again and my family member began caring for me.


-- Banterings


 
At Wednesday, August 01, 2018 2:12:00 PM, Blogger Maurice Bernstein, M.D. said...

At 10:16am my time today we got a first time visitor from Nairobi, Kenya to this thread. I hope that visitor returns and contributes their experience in their country. You are welcome!

I know my calling out to our foreign visitors is a bit boring to our "regulars" but since this blog thread has the potential to be read throughout the world, we, in the U.S.A should value modesty and dignity issues in other countries.

Are we Americans the only complainers with the behavior of our medical system? ..Maurice.

 
At Wednesday, August 01, 2018 3:17:00 PM, Anonymous JF said...

I would be devastated to have a family member checking me out or seeing me checked out that way! A spouse? I don't know.
I have to have anonymity for that kind of thing.

 
At Wednesday, August 01, 2018 6:44:00 PM, Blogger A. Banterings said...

Here in Pennsylvania it is common for us to take care of our elderly parents and grand parents. That includes helping clean them when they soil themselves. Believe me, the trauma that both parties is the equivalent of 15 med students with cell phones in hand logged into Facebook live ready to practice an intimate exam.

Yet, the love of family overcomes this horrible situation. Many people suffer this for years because the thought of going into a home is more traumatic for the elderly and the guilt of having to do that is unbearable for the children.

Let me relay a story that I heard from my upstairs neighbor. This was in an apartment complex that I lived in after grad school. My upstairs neighbor, a young, big, beefy guy in his 20's, worked in a warehouse. One day he "pulled" something in his groin. He asked his grandmother, a nurse if she thought it a hernia or something else that he needed to see a doctor for. His description was a little vague, but basically he unzipped his pants, pulled them down, and his grandmother "examined" his testicles and that region. Not sure if there was a "cough" or not.

His longtime girlfriend, a woman in her early 30's confirmed this. She thought it strange as I did, which I followed with a joke about a "close family" for lack of knowing how to deal with the situation. There was nothing sexual about the situation, just the love of family creating the level of trust that physicians assume to have from their patients.




-- Banterings





 
At Wednesday, August 01, 2018 9:18:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous wrote the following erroneously to Volume 83 but that Volume is closed, so I am reproducing the Comment here. Anyone want to write about a nudist as a patient and nudism relative to the issues discussed here. ..Maurice.


I am going to the urologist for an appointment for a hernia. Will I have to undress for this? Also, in my humble opinion, patient modesty is rather important to make people feel at ease and KNOW they can trust their doctor. HOWEVER, it should NEVER get in the way of the doctor being able to treat the patient. I am a nudist though, so such things are not a problem for me.

 
At Thursday, August 02, 2018 4:34:00 AM, Blogger Biker in Vermont said...

Dr. Bernstein, I read and re-read the posting from the nudist and am not sure if I am understanding where he/she is coming from. I think they are saying patients should be treated respectfully but regardless the patient should freely expose themself to whichever medical staff are there. Not sure where the initial undress for a hernia exam question would be coming from given the rest of the post.

Alternatively it could be that the person is a modest person by nature and differentiates medical settings vs nudist settings. Being exposed in medical settings is generally involuntary and the undressed patient is surrounded by fully dressed people. In nudist settings everyone is undressed which is a huge difference.

I am modest by nature and not comfortable with opposite gender exposure in medical settings. Conversely in my younger years I did some mixed company skinny dipping and have been to a nude beach a couple times. The 1st time was in my early 20's with my fiance and her best friend at a swimming hole, just the three of us. I was very uncomfortable undressing but doing the male bravado thing acting like it wasn't a big deal to be undressing in front of my fiance's best friend. She broke the ice by saying "sexy body" and I figured we've both seen each other at this point so just go with the flow and enjoy the day.

Then a woman that was older than my mother comes by with her grandkids. She's fully clothed and she's sitting at the edge of the water watching me intently. Now I'm uncomfortable again because it's no longer a level playing field. The point here is that medical settings are never a level playing field and I am not going to be comfortable with fully clothed women looking at me exposed. Why female healthcare workers don't grasp this concept is beyond me.

Hopefully that person will come back and elaborate more.

 
At Thursday, August 02, 2018 4:47:00 AM, Blogger Biker in Vermont said...

Banterings, some families are more open with each other, but I think your example of the guy and his grandmother may also be rooted in the era it happened in. I take it that it happened long ago when guys were raised to not have any expectation of privacy, often times including with the women in the family. It likely wasn't the first time she saw him exposed.

In more recent times I was shocked when I learned two guys I knew were giving their mother-in-law a bath every weekend. They were married to sisters and were a very lose knit family. The mother-in-law was a large woman and her daughters couldn't get her in and out of a bathtub so their husbands did it. During the week they had someone stay with the mother on her farm while they worked and then on the weekend the two couples took care of her. I adored the mother for her feisty wit and personality that called it like she saw it, and she'd of not allowed her sons-in-law to do this for her if she wasn't OK with it. That would never happen in my family but it worked for them.

 
At Thursday, August 02, 2018 7:49:00 AM, Blogger Maurice Bernstein, M.D. said...

Here are some Comments regarding medical system and nudity or nudism back in 2007. ..Maurice.


Anonymous said...
CLF
Have you had friends who came from a non-nudist upbringing that have adopted the
nudist life style. I would be interested in what it was that allowed them to
overcome the the norms they were brought up with. Was it a peer pressure (in a
positive way), was it the fact that they were around other nude people that allowed
them to make the transition? I wonder if that has any relationsihp to how they feel
when they are nude and others are not, i.e. in medical situations. Not sure there is
a correlation between that and the medical setting or not. Seems being comfortable
with others would lessen the situation in other scenerios such as medical...but
wasn't sure.....dg
Tuesday, February 27, 2007 2:11:00 PM

Anonymous said...
dg,
Yes, most of my nudist friends were not brought up as nudists. I guess that their
families had a relaxed attitude about nudity, but didn't do it in a public
environment. It is a bit of a hassle, for example, to get to a clothing-optional beach
- you usually have to walk farther, beyond the more conventional areas. Regarding
peer pressure, I think so - before I was married I used to bring my girlfriends to my
favorite nude beach (Lighthouse on Fire Island in NY) and some of them would
gradually take off their top, then the bottom, etc. Others would be so delighted by
the freedom that they instantly pulled their clothes off and sprinted into the waves
and stayed nude the whole day. Again, I'm not sure how this relates to the medical
situations, although I don't know for sure if, like me, when they're in a hospital
worrying about who sees what is not high on the agenda. I notice that you are seem
to be interested in nudism -- let me know if I or my wife can help in any way. This
is also for anyone else reading this, since it was the doctor who brought this subject
up in the first place!
-- CLF
Thursday, March 01, 2007 8:48:00 PM

Anonymous said...
CLF I appreciate the response, I was just curious as some of the posters seem
compfortable with nudity in the medical environment and others struggle with it. I
was curious if the factors that allow some to be comfortable are similar to those
that allow nudist to be comfortable with their nudity
Friday, March 02, 2007 4:16:00 AM

Anonymous said...
For me it's not the "being seen" part of nudity that makes me uncomfortable in a
medical setting. Rather, it is the differential in power. To an extent a patient is
vulnerable to whatever the Dr. thinks is necessary. Being more exposed than is
absolutely necessary is a very visual and tangible reminder that you are at their
mercy.

Here's the best way I can describe it - if I was at a nude beach and my Dr. and I
were nude I wouldn't have a problem. (Mind you I've never been to a nude beach but
I am just saying that I wouldn't have a major issue). However, me being
unnecessarily exposed for a second longer than necessary as part of a medical exam
in front of that same Dr. - makes me extremely uncomfortable.

For me it's the power thing being sexualized by the nudity.

 
At Thursday, August 02, 2018 8:26:00 AM, Blogger Maurice Bernstein, M.D. said...

And more on nudity including a great documentation by MER in Volume 12 (2009) and even PT was around to give his "2 cents".

I have a frank question to ask the males here whether the male issue is not so much visible nudity but of concern that the patient's genitalia may appear to others not "manly" enough or even of the reasonable fear of penile erection or even ejaculation during the exam. Let's get down to a dissection of the psychophysiology of what is of concern here. Perhaps these fears can be overcome and more focus placed on the diagnostic needs and values of recto-genital examination. What do you think? ..Maurice.

 
At Thursday, August 02, 2018 9:36:00 AM, Blogger Maurice Bernstein, M.D. said...

My teaching med students doesn't start until August 14 so I have a little more time to read and write to my blog.

I found another topic title on my blog that may be of interest here which contains an interesting commentary by a male former CNA and at the time of the posting studying to be a physician's assistant.

The blog's title is: "Eye to Eye Communication and Laying on of Hands: Anachronistic Medicine?"

..Maurice.

 
At Thursday, August 02, 2018 11:06:00 AM, Blogger A. Banterings said...

Maurice,

With respect to nudists, I have a number of friends in that lifestyle. The differences are:

1.) They choose to be nude in front of other people, in medicine it is "mandatory."
2.) The people that they are nude in front of, are also nude too.


Number two is very important because so many patients say "you get undressed too." That has even been mentioned on this blog multiple times.First this calls them out on saying they are specially trained to treat the genitals just like an elbow. If this is true, then they will have no problem being undressed.

It also takes away the element of bullying. (Reference Joan Emerson)

This is completely acceptable within the realm of medicine. After all there is a rich history and tradition of physicians (and others) "going first" to gain the trust of society and patients. One in recent memory, is the a 2005 Nobel Prize winners:The Doctor Who Drank Infectious Broth, Gave Himself an Ulcer, and Solved a Medical Mystery.

There has also been attempted legislation in Europe that doctors be n the same state of undress as patients and at a hospital in Australia, ED physicians wear ONLY surgical gowns (nothing else) as to empathize patients being stripped in the ED.

We see all these celebrities getting colonoscopies on television (funny, no doctors or nurses do this) so as to "lead by example," the psychological term being modeling.

Personally, I would be more comfortable undressing for medical reasons if the others in the room were undressed. Funny how the ones dresses see nothing wrong with undressing until it is suggested that they undress...



-- Banterings








 
At Thursday, August 02, 2018 5:41:00 PM, Blogger Biker in Vermont said...

Dr. Bernstein, certainly a man's perception of his endowment could be the reason for modesty but I'd caution against generalizing such a conclusion. I've been in locker rooms most of my life and can attest that there are very shy men who are on the high end of the range. If shy in a locker room, they're certainly going to be shy in a medical setting given the added variables of the power imbalance and potentially inappropriate attention from some staff.

 
At Thursday, August 02, 2018 6:40:00 PM, Blogger Biker in Vermont said...

Dr. Bernstein, now I will answer your question at a personal level in hopes that it helps the discussion. This is not easy to do. It is quite hard actually. The answer is yes a piece of my modesty is my self perception.

I lost a testicle at age 11 as a result of a bicycle accident followed by an incorrect diagnosis at the local hospital's ER. I subsequently had a several day hospital stay after what turned into emergency surgery. When I was rushed to the hospital a couple days after the ER visit, all I knew was I was in horrible pain. Nobody told me what the surgery was going to be before they did it, nor did anyone tell me what it was afterwards. I was all bandaged up down there and I figured it out on my own. None of the hospital staff ever spoke to me about what happened, and my 11 year old mind took that to mean it was so shameful it could not be spoken of. My parents never spoke a word about it either other than the day before I was to return to school my mother gave me a made up story to say why I missed 3 weeks of school. Now I realize she wanted to protect me from bullying, but back then it just confirmed for me that this was something to be deeply ashamed of and kept hidden. For a while I thought maybe it'd grow back but I didn't ask because I knew this was too shameful to be spoken of.

I had extremely shy teenage years doing my best to never be seen naked. I didn't do sports out of fear of my shame being broadcast given the group manner boy's physicals were typically done back then. I thought I'd be the laughing stock of the school if word got out.

I survived my teenage years and came to learn that it wasn't such a big deal. Nobody noticed in locker rooms, or if they did nobody ever said anything. It was a non-issue to my girlfriend (and now wife) and I slowly became comfortable with it, though I never spoke of it to anyone.

Fast forward and the day comes that we're done having kids and I'm having a vasectomy. I was comfortable with myself and OK with how the procedure was going to be done. The urologist of course knew beforehand that there was only one but it was a surprise for the nurse assisting him, and before he came into the room I had been judged by her, and not in a good way. It wasn't what she said but rather she lost her game face and her body language betrayed what she really thought. I was humiliated. All the confidence I had built up and thinking this isn't a big deal was stripped away. I silently endured the procedure, with absolutely no draping whatsoever I might add, and said nothing to her or to the doctor about being humiliated.

So, a piece of my modesty comes from knowing that female medical staff judge patients in this regard. They may have mastered maintaining a proper game face but they don't stop being human when they put on scrubs. Men don't mock other men for things like this and I remain comfortable with male staff, but I don't want to ever be the topic of conversation for the women at the nurse's station. I will add that suffering through subsequent unprofessional (in other ways) female RN's only served to confirm for me that there is a sexual component to male patient interactions for a certain % of female staff.

 
At Thursday, August 02, 2018 9:24:00 PM, Blogger Maurice Bernstein, M.D. said...

Here is the story from the current University of Southern California Medical School News. ..Maurice.


Med students Uni Choe and Sona Shah worked with a fashion designer to create a two-piece garment for hospital patients.

Chic hospital clothes? USC medical students have a design ready
If you’ve had to stay in a hospital, you’ve probably struggled with the straps and tried to close the gaps on your hospital gown. The traditional gown can leave a patient shivering and feeling exposed.

Sona Shah and Uni Choe, medical students in their third year at the Keck School of Medicine of USC, have come up with something better — chic hospital clothes that are, in Choe’s words, “interesting, fun and couture-related.”

“We created something comfortable and practical,” Choe said, “but more than anything it’s about patient empowerment.”

The pair researched materials and worked with a fashion designer to create a two-piece garment that covers from head to toe and makes care easier for patients and physicians. A soft, flowing smock with access ports for exams is combined with pants that resemble pajama bottoms.

“In the hospital, you don’t have much control over your environment,” Shah said. “If you want to be wearing something that’s more aesthetically appealing and comfortable, that should be an option.”



Producing a better hospital gown

Working with engineering students and advisers at USC’s Health, Technology and Engineering (HTE) program, Shah and Choe created hospital wear under the label We&Co.

“We made a good team, and the HTE program helped us get this prototype made in the midst of our crazy med school schedule,” Choe said. “They also helped us apply for patents.”

The yearlong HTE program brings medical and engineering students together to solve problems. George Tolomiczenko, PhD, assistant professor of clinical neurology, serves as administrative director.

Tolomiczenko was surprised by the students’ idea at first. “Then I saw how, by changing the ‘interface’ between clinician and patient, the relationship can be changed for the better,” he said. “It’s more comfort and less embarrassment through smart design, and a nudge toward direct empathetic engagement with a patient who’s not marked by the standard hospital-supplied garb.”

Shah and Choe have been conducting what they call “clinical couture trials” to ensure the outfit doesn’t get in the way of routine exams. Their prototype includes ports that can be opened for back, stomach, cardiac and abdominal exams.

“We’ve taken patient comfort and married that into physician workflow,” Shah said.



The evolution of chic hospital clothes

The prototype is cotton, but a more advanced design with different fabric is on the way. The pair traveled to the Material ConneXion library in New York to research materials that can incorporate self-cleaning effects, sustainability, breathability and insulation. Eventually, their outfit could include washable wiring, so the outfit becomes “wearable tech” that monitors a patient’s vital signs.

For now, price is a consideration. If mass-produced, the Choe-Shah creation could cost as much as $80. That’s a budget-buster for hospitals, but there’s an alternative to hospital-supplied gowns.

“This is something patients’ families or friends could purchase for them, maybe in the hospital gift shop,” Choe said. “A lot of money is spent on flowers, and they don’t last long. This is something that could really change the hospital experience and then be taken home for comfort wear.”

Choe and Shah hope to have the next-generation We&Co hospital outfit ready to go to market in about a year.

— Ron Mackovich

 
At Thursday, August 02, 2018 9:50:00 PM, Blogger Maurice Bernstein, M.D. said...

Biker, unfortunately due to timing, I would have better had my current comment follow directly after your last posting.

I can fully understand your reaction to that nurse present during the vasectomy procedure. What was missing for the best participation in your procedure was at a minimum she should have read your medical history so be aware of one testicular absence and her observation would not be some surprise to her at the time of the procedure. To be a participant in a procedure and not to be aware of the patient's pertinent to surgery history is a professional wrong. Period! Not being aware of an important history of the patient while participating in surgery is what has led in the past to the opposite body part to be operated upon or removed. Sad behavior! ..Maurice.

 
At Friday, August 03, 2018 4:22:00 AM, Blogger Biker in Vermont said...

Dr. Bernstein, while her reaction was unprofessional and humiliated me, the larger issue is that it spoke to the fallacy female medical staff write again and again in various articles and blogs, that there is nothing sexual about healthcare and the proverbial "a penis is no different than an elbow" to them. I think I am pretty safe in saying that had I had been missing an arm or a leg, that if she betrayed any reaction it would have been that of empathy.

 
At Friday, August 03, 2018 6:40:00 AM, Anonymous JF said...

She shouldn't have been in the room at all. Patient death isn't gonna occur just because nobody of the opposite sex sees them nude!

 
At Friday, August 03, 2018 6:50:00 AM, Blogger Dany said...

Good day all,

Biker, I read your post and it is very compelling. Thank you, for sharing what is perhaps still a difficult aspect of your life. I don't know that I would have been able to react any better than you did. In fact, I probably wouldn't have. It's pretty sad when you realize these sort of incidents happen, when there is no reason why they should.

This only reinforce my beliefs that the reason(s) why so many men are reluctant to seek medical care is because of situations like Biker's. Men, generally speaking, are not granted the most basic of dignity by health workers; we are objectified, and humiliated.

As to wondering if a men's perception of his genitals might be related to modesty (specifically fearing being judged), or the fear of uncontrollable arousal (or worse), then yes; it is a valid concern. People tend to avoid embarrassing situations. The more embarrassing, the stronger the desire to avoid it. And it makes no difference being told that it's okay, that it's normal and "we" have nothing to be embarrassed about.

With regard to nudism, I suppose repeated exposure might contribute to alleviate the stigma surrounding nudity but, much like Biker and Banterings pointed out, the context is everything. Much like most of your contributors, I'm a shy guy and don't like the idea of being exposed. I avoid gyms because many still have communal showers (which are a problem for me).

My feelings about exposure don't change all of a sudden just because I happen to be at the doctor's office, a clinic or hospital. Objectively, I can rationalize the usefulness of it, in some circumstances, but I'm the one who will make that call; not the doctor or a nurse. And if I don't agree with you well... TFB. My body, my decision.

Dany

 
At Friday, August 03, 2018 7:52:00 AM, Blogger Maurice Bernstein, M.D. said...

We have a new source of Comments to our thread who has e-mailed me his personal experience stories and permitted me to present his comments here but also to disclose his full name. I will, therefore, follow his request. ..Maurice. p.s.-With regard to identification of names of individuals or institutions on these posts where derogatory comments are made which are not already in public media, those names will be deleted.


From yesterday:

Hi doctor
My name is Ron Giovagnoli
I had Many violations happen to me in the few encounters I had with the medical profession .
Here is one it Happened January 2015..

Took a viagra pill got an erection lasted more then 4 hours went to the local hospital. Was told to put on hospital gown and wait for urologist to come in. While waiting laying in bed a Nurse practitioner cane in not involved at all with my care. She approached my bed and said” May I see it” with a smirk on her face . “ May I see your erection”
I said why you are not part of my care team nor are you the doctor which I am waiting for. You have no business to be here . She then turned around and walked out. I should have called her supervisor or hospital administrator and complaint . This was for sure I nursing rule violation which should have getting her terminated or loss of her license .

I regret I did not follow up on that ethical violation .

Sad part is she is not the only perverted nurse out there . I have more encounters where they violated ethics for sure. No wonder I lost all respect and trust for the medical profession .
Ron Giovagnoli
Police officer
Retired


From today:


Maurice ,
You can post my email on your blog and you can use my full name . I have nothing to hide and speak the truth and facts.
In 2012 I became the victim of malpractice not just by 1 doctor but a slew of medical personal making mistakes and doing the wrong things. Basically I became the victim of what’s wrong with our medical system. The system is a rogue system where money and profits is the num dr one goal. As long money and profits are in the forefront more patients will die or get injured on the hands of the medical system. I was never a passive patient always involved with my care and took doctors advise at face value. After what happened to me I lost all trust but worse all respect for the medical profession . I responded to one surgeon who time me it wasn’t him who injured me like this. “ as long you look the other way and don’t change the way business is co ducted in your profession and as long you protect the bad apples by looking the other way you are as guilty as the one who do the deed. “
Ron


 
At Friday, August 03, 2018 8:24:00 AM, Blogger Maurice Bernstein, M.D. said...

I think that Ron has brought up a point which I don't think has been fully discussed here. And that is "“ as long you look the other way and don’t change the way business is conducted in your profession and as long you protect the bad apples by looking the other way you are as guilty as the one who do the deed. “

I tried to generalize this concern in a specific blog thread titled "Painting Groups with the Same Brush as Outliers: Is That Ethical?"

As you will see if you go to that thread, a back and forth between me and our PT.

Can an individual physician who has direct and personal responsibility for his or her patient with attention to be the patient's "best" doctor be considered ALSO responsible for the defects in the medical system and should be considered a "bad apple" because there are also "bad apples" in the medical system? ..Maurice.

 
At Friday, August 03, 2018 9:08:00 AM, Blogger A. Banterings said...

Maurice,

As demonstrated here on this blog, and with references that back those assertions, this is STATUS QUO for healthcare, NOT outliers. Up until 2003, ALL med students performed intimate exams on anesthetized patients without consent.

That is 100% of the profession thinking that violating a patient's integrity for their own benefit is acceptable!

SOCIOPATHS!

This is STILL occurring today in 2018...


Furthermore, the only ones who have ever owned up to this (and attempted to change the system) are Dr. Peter Ubel, Dr. Atul Gawande, Phoebe Friesen, and the original Harvard med students.

Either you are part of the solution, OR yo are part of the problem.




-- Banterings



 
At Friday, August 03, 2018 9:09:00 AM, Anonymous Anonymous said...

Hello Dr. Bernstein,

Re implicating negligent conduct by doctors, I suggest that the operant phrase is "looking the other way".


Reginald

 
At Friday, August 03, 2018 9:40:00 AM, Anonymous Anonymous said...

Hello,

The following comments are from a recent Nursing Times(UK) article. The URL of the complete article appears below. If lack of modesty for patients is a subset of poor patient care, maybe (by speaking up) changes will come to the way things have always been done. Article follows:
"Nursing claims to be an evidence-based profession, but sometimes it fails to live up to this claim. It is vital that we continually seek out the latest evidence and use it to question and challenge our own practice and that of our colleagues to ensure patients receive safe and effective care. Adherence to ritual and routine – we have always done it that way – is not an excuse for poor care."
https://www.nursingtimes.net/7025480.article?mkt_tok=eyJpIjoiWVRBM01EQXlOV1prTXpkayIsInQiOiJqN05SMnR3dkJIZXBpVkFuOEVlSUFiN0JKZ09vVWo3VVwvTHB2M3pORXpORG9kQjQ3c0pNQ1hVXC9rOFVwQStabWFJS2pTalBCVWpWNm1CRDI2Z0JxQmxBVldWM3gralJiYk9cL1RRSldOWStTUGc1K0NGTW9NTUhwWm9pYTg5dXY3SyJ9

Reginald

 
At Friday, August 03, 2018 2:23:00 PM, Anonymous Anonymous said...

Maurice

Well, I guess you didn’t get my last post but here goes again.

Healthcare has mandated female patients will always have a female mammographer, why. Is it because maybe their concern might be that their breasts might just not be “ woman enough” for male mammographers.

PT

 
At Friday, August 03, 2018 2:29:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, do you have a reference supporting and explaining that bizarre concern? ..Maurice.

 
At Friday, August 03, 2018 3:38:00 PM, Anonymous Anonymous said...

Maurice

If you are going to put on your psychiatrist/psychologist hat then you should broaden your view/perspective. I would never consider one might need some couch time out of a lack of complacency with a healthcare system that is so out of tune, dysfunctional and discriminatory behavior towards one gender. In the real world they say “ the squeaky wheel gets the grease “ so to speak, yet it’s not even considered from an ethical standpoint. You asked the question is this blog issue from a visible nudity or a “manly enough “ issue. Apparently, as a male patient I never expected that I’m required to star in a porn movie, let alone be judged for something based on evolution and genetics.

It’s peculiar to me that this issue is clamped down and locked tight for female patients regarding mammo, L&D etc and it dosen’t even raise an eyebrow that’s it’s a done deal for one gender, but, god forbid if men complain, “ outliers” not “manly enough” dont have anything we haven’t seen before. Never mind all the unprofessional behavior ie cell phone pics, Denver 5, Dr Sparks, Penn hospital, that’s just girls being girls. Why is there not a bioethics blog critiquing female patients for receiving soo much privacy and respectful care. You asked “ you asked for the reference. The best I can do is generalize, maybe it’s because they might not perceive themselves as womanly enough. Wait a minute, healthcare has a solution for that. It’s a billion dollar industry call breast enhancement, hundred of thousands of women seek this medical care each year. No one even bats an eye, yet for the few hundred men who seek penis enhancement due to birth defects or injury from the gulf war or to be “ manly enough” the jobs for these patients are endless.

PT

 
At Friday, August 03, 2018 3:56:00 PM, Blogger Biker in Vermont said...

Dr. Bernstein, concerning the "painting groups with the same brush as outliers", I know that most who work in healthcare aren't the proverbial bad apple. The problem is as a patient I have no way of knowing in advance which ones are. Avoidance becomes the path of least resistance.

Every hospital and practice says that their staff are total professionals who treat every patient in a respectful dignified manner. Every person who works in healthcare says the same of themselves. Yet that is not the way it always plays out for patients.

Part of the issue is each staff member, each hospital, and each practice gets to decide for themselves what constitutes respectful and dignified care, and it often boils down to whatever is convenient for them. The patient is never asked what they think.

Perhaps more importantly, hospitals and practices do not work very hard to weed out the bad apples. When is the last time a nurse was fired for commenting in the nurse's lounge in a non-medical manner about a patient's genitalia? In such instances they have the proof before them that the nurse is sexualizing her patients but they look the other way because it is out of earshot of the patient.

If treating patients in a respectful and dignified manner were truly a core value, the Denver 5 would have gotten fired. Dr. Sparks would have been fired. The people in that free for all photo fest in the OR in Pennsylvania last year would have been fired. But nobody gets fired because to do so wouldn't be convenient for the hospital.

Until the day comes that the medical world vigorously weeds out the bad apples, it is asking a lot of me to just automatically trust every female staff member. Years ago they had that automatic trust from me, but then reality set in.

 
At Friday, August 03, 2018 6:48:00 PM, Blogger Maurice Bernstein, M.D. said...

Biker et al, in a little over a week from now, I will be starting the teaching of a group of six "fresh" first year medical students on how to interact with patients of both genders in how to take a medical history and the beginning learning of how to interact with a patient as in year 1 they learn how to take vital signs, abdominal exam, neurologic exam, mental status exam and ophthalmic exam.
I will have 2 or 3 female students in my group of 6. Do I teach differently based on the gender of my student and reflecting on the gender of their patient? If you were teaching what would you say to those 3 male and 3 female students?

Here is the chance for those visitors to this blog thread to contribute something to my education and possibly to the education of 6 medical students. And, remember, they are only one group of 6 and not the entire medical system. ..Maurice.

 
At Friday, August 03, 2018 7:51:00 PM, Anonymous JF said...

Ron brought up that if and when staff looks away, those people are as guilty as the offenders.
I can agree that those people share in the blame but I can't agree that they are EQUALLY guilty.
People are afraid for themselves and their jobs and families. Their kids have needs. Sometimes I have kept quiet when elderly have been treated poorly. Last time something came up like that I stepped up to the plate but in an anonymous way.
Two of the med techs ( they were actually CNA's ) found an elderly woman covered in diarrhea. They took her outside and hosed her down with a garden hose. The area was fenced in and it was on 3ed shift and I didn't witness it. A coworker told me. I don't know if she caught them or if one of them told her or what. I tried to convince my coworker to turn it in.
She wouldn't and said she would lie if I turned it in without her.
The next night I shared what I heard with another coworker. She said if it came up she would deny hearing anything about it.
So I made an anonymous phone call and it was investigated. The CNA's were boyfriend/ girlfriend.
Neither admitted to anything but management wouldn't let the guy work on the alzheimers wing anymore. The girl couldn't work on the same wing as the patient. They bith quit shortly afterwards even though they'd been there for 2 years.

 
At Friday, August 03, 2018 9:07:00 PM, Anonymous Anonymous said...

Maurice

At this point in the game should your medical students have to be taught how to provide privacy and respectful care. Little late in the game I think, I know many never got it and don’t care about it and never will. For those that don’t ever get it well they just make out to be a crappy humanitarian. Moreover, it’s not like they are going to change the world or do much of anything to change the industry. They are the new self centered millennials that’s just about me,me,me and each new group out has less and less diagnostic skills, less listening skills. Just order a bunch of tests and hope imaging and lab results point to a diagnosis and/or a differential.

They just want to make it to the next round, move on to the next point etc etc, yes some dead bodies are left behind but whatever. It seems a lot of emphasis is placed on your medical students each year over and over. Unless the entire industry changes as a whole it’s just a mute point and where it stops nobody knows. Health care costs continue to spiral out of control as we will surpass that $4 trillion dollar mark and next year it will be more with less and less value. Copays, what a stupid concept, I remember when there never was such a thing. I remember a time when medicines were basically free when you had insurance. There was no $100 copay to be seen in the ER, and physician actors and nurse quacktitioners were not invented.

PT

 
At Friday, August 03, 2018 10:15:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, are you suggesting that on the first day, as I sit down with them, start off by telling them that I know that each student is starting out only interested in themselves even as they are exposed to interacting with sick patients and that this self-interest is a generalized medical system behavior, notwithstanding what ever the students are going to be told in their upcoming years? And how do I know this? Well, because of their ages, they belong to the well-documented Millennials and unless the medical system changes its operation to some other mechanism, the students' ongoing behavior will only be contributory and supportive.

Do you think they will accept, on day 1, such a diagnosis and prognosis of their future "professional" behavior and results?

Or should I wait until they describe to me their initial patient interactions and challenge them whether the object of the interaction was "we" or really "me"?

A challenge, PT, to start out the student's medical profession with such cynicism or would it better to carry on with observation of each student over several months of patient interaction, steering them in the direction of what the medical system should be all about: beneficence toward the patient themselves with no "if", "ands" or "buts". ..Maurice.

 
At Saturday, August 04, 2018 4:27:00 AM, Blogger Biker in Vermont said...

Dr. Bernstein, amongst the things I'd tell them if given the opportunity is that patient dignity cannot be defined solely by the medical staff, that the patients should have some say in the matter. That female staff finds it convenient to say men don't have any modesty doesn't make it so, and that when they have a male patient brave enough to speak up he should not be bullied or purposely embarrassed (nothing I haven't seen before etc).

They all need to understand that while hospitals and medical practices are businesses, the default when it comes to patient dignity should not always be whatever is most convenient for the hospital/practice. Patient dignity should not just be empty words devoid of practical meaning beyond the staff will be polite. I point to two past examples. I had two identical bladder ultrasounds. The 1st female sonographer fully exposed me. The 2nd did not involve any genital exposure. Both were polite and would surely tell you they did their job in a respectful and dignified manner. How could both of them be correct when one embarrassed me and the other didn't?

Your medical students will eventually have the ability to bring other staff and observers into patient exams and procedures. Perhaps they could be told to reverse the gender of everyone in the room and then ask themselves if the scenario still seems respectful and dignified.

 
At Saturday, August 04, 2018 5:01:00 AM, Blogger Biker in Vermont said...

Dany, yes it was very difficult for me to tell my story. I hope it helps Dr. Bernstein and other medical staff that may read this blog understand that healthcare is not always respectful and dignified no matter what the public relations and marketing depts say in their advertising.

As noted before I am totally comfortable with necessary intimate exposure with male medical staff and in locker room settings. After that surgery and the wall of silence I faced with the hospital staff and my parents, I was painfully shy and ashamed. However that did not get me out of mandatory gang showers after gym class grades 6 - 12 nor mandatory swimming in the buff my 1st year of college. Whether the other boys noticed my situation or not I don't know but never once did any of them say anything. My privacy was protected. I similarly never heard any comments on any of the guy's genitalia beyond that of complimentary comments on one guy who was at the top of the chart shall we say, and even that was only amongst the guys. As an adult I was in the locker room almost daily with other exercisers during the lunch hour at work for many many years. The full range of what mother nature bestows was present and nobody ever said a word to or about any other guy. Everyone's privacy was protected. I couldn't even say whether anyone ever noticed what I was missing. Now I go to a private fitness center with a gang shower and it is the same. Nobody ever says a word about anyone. Everyone is respectful of everyone else.

With the exception of my dermatology experience this past year every male I have dealt with in a medical situation has been respectful. Based on my cumulative experience I do go into medical procedures and exams with male staff trusting them vs being wary of how I will be treated by female staff. Different experiences male vs female, different mindset going into procedures and exams.

 
At Saturday, August 04, 2018 3:14:00 PM, Anonymous Anonymous said...

Maurice


Tell me just how your medical students differ from the rest of the nation’s medical students. Are they going to be more sensitive to patients of varying genders in regards to privacy and respectful care and if so then how? Are they going to be uniquely different from the general physician population, I seriously doubt it. The fact is discipline against physicians for sex-related offenses is increasing over time and is relatively severe.

Consider this, in1973 the first code of ethics of the American psychriatic association (APA) condemned sexual contact with patients. Then it took these CLOWNS another 16 years that in 1989 to say that “ sex with a former patient is ALMOST always unethical. “ Yes you read that right ALMOST, if you don’t believe me look it up. In fact after saying all that with their new codes of ethics, blah blah that physicians who were disciplined for sexual related offenses with their patients more than quadrupled from 1989 to 1996.

Oh boy, and I’ve still got another 22 years to go with statistics, yet we haven’t even got to nursing and all the other healthcare workers that sexuall abuse patients. I haven’t even talked about respecting patient’s privacy yet and I already want to throw up. Biker mentions about a female who was assisting the Urologist with his vasectomy, I spoke with a gentleman once who works in healthcare and when he had his vasectomy there were 3 female medical assistants in the room. I said to him, “ wow, you must have been very important that day that your vasectomy required 3 female medical assistants”

Why would a urologist need 3 medical assistants to perform a vasectomy? Folks, I have been involved in neurosurgery cases, open heart cases as well as difficult transplant cases, you name it I’ve been in the operating room for all of it. Never ever have I ever seen any one in even complex cases get more than 2 assistants in surgery. A vasectomy is anesthetic applied, snip snip, suture then done completed in the office. But this is our greatest healthcare at work, all $4 Trillion bucks of it at work. This is the layers upon layers of layers of codes of ethic upon ethics and more ethics on top of each other over the years. What good is any of it?

PT

 
At Saturday, August 04, 2018 5:56:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, my students will be no different than those who are being taught throughout the rest of America to respect the patient as a human being just as human as the students themselves and their goal is to be as attentive to maintain beneficence toward the patient as they would want for themselves.

To carry on with the analogy that started this Volume 89, after 4 years, the students will be leaving their fine tree of learning and be blown away as leaves and pollen to provide a source of more beauty but some may lose their way and end up in the "dirty pond" where no patient would want to enter and swim.

With that Comment, we have reached 175 Comments for this Volume and shortly, if our visitors think all this discourse is of value, we will begin Volume 90. ..Maurice.

 
At Saturday, August 04, 2018 7:29:00 PM, Anonymous JF said...

The male doctors are responsible for bringing female staff in the room so how are they so innocent?

 
At Saturday, August 04, 2018 7:41:00 PM, Anonymous JF said...

They will have the ability to bring other staff into the room. Maybe they should ok it with the patient first.

 
At Saturday, August 04, 2018 8:07:00 PM, Blogger Maurice Bernstein, M.D. said...

AS OF AUGUST 4 2018, NO FURTHER COMMENTS WILL BE POSTED ON "PATIENT MODESTY: VOLUME 89. COMMENTS CAN CONTINUE ON PATIENT MODESTY:VOLUME 90" ..Maurice.

 

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