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.

92 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.

 

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