Bioethics Discussion Blog: Patient Dignity (Formerly: Patient Modesty): Volume 94

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Sunday, January 06, 2019

Patient Dignity (Formerly: Patient Modesty): Volume 94



Entering the "dirty pond" or "down the drain", these expressions along with accompanying graphics are amongst a host of verbal expressions with their visual analogies which I have used over many Volumes to describe the status of the medical system as brought out in the views presented by the contributors to this blog thread over the years. And now with Volume 94 comes another: the medical system utilizing the conveyor belt image within the process of diagnosis and treating of its patients.  This analogy is spelled out in a "Perspective" description of a clinical event in the January 3, 2019 issue of the New England Journal of Medicine with the title of "Walking Away from Conveyor Belt Medicine".
The story begins and the conveyor belt first starts moving when a community hospital notifies a major medical-surgical hospital that it found in a 70 year old demented patient who spends  his life simply "walking" that his previously surgically stabilized aortic aneurism is enlarging compared to his previous checkup and he was felt to be in need of immediate surgical repair to prevent rupture.  He was on his way by ambulance "and the conveyor belt started moving" in the major hospital to carry out all the preparations involved in what was to happen on the patient's arrival. On arrival "the conveyor belt is speeding up".  Then the "belt was moving fast" as all the many components which were needed to prepare and carry out this risky surgery were proceeding and being accomplished.  And, if continued to the anticipated end-point, the patient, elderly and demented would be dropped off onto the operating room table for the start of this  surgery and..and.. but, fortunately the conveyor belt stopped running when time was taken for communication between surgeons and the family who arrived and that communication changed everything and it was decided that the risks of surgery was too great for this particular patient.  So the patient was sent home with a pair of slippers for his walking and was alive 6 months later and carrying out his life as before his immediate life was governed by that medical system "conveyor belt".


What impressed me about this article is  a suggestion, which some may consider, that the medical system may have a tendency to be employing a "conveyor belt" mentality in its approach toward virtually all patients.  And this uniformity of belief and action may be contributing to a loss of dignity to each individual patient involved in the system.  "It's always done in this way and so that is how we will do it."  That is, hopefully, until the patient or family intervenes  and "speaks up".  What do you think about this analogy?  Do you see that you have been sitting on that fast moving "conveyor belt" within the medical system as a patient?  ..Maurice.

GRAPHIC: From Google Images and modified by me with ArtRage Studio Pro

44 Comments:

At Monday, January 07, 2019 5:16:00 AM, Anonymous JF said...

Dr B ,
There are wonderful doctors that do miraculous jobs. The assembly line work that happens too much is because going to medical school is too expensive and not enough people can pay the price or take the time.
Also too much corruption from insurance companies and pharmaceutical.
I have something else on my mind. Pictures are on the blog on my phone divided up in 16 sections. Forcing me to check fire hydrants or traffic lights or buses. Is that just me or is it happening to other people to. It's obnoxious and time consuming and I don't see how it verifies that it's me anyhow.

 
At Monday, January 07, 2019 10:49:00 AM, Blogger Maurice Bernstein, M.D. said...

JF, I agree that physicians actually do "miraculous" jobs however not every "miraculous" result is a result of knowledge and skill but by patient factors of which no physician or even the patient can fully explain. Medical students should be aware that every positive clinical outcome is not necessarily directly related to their skills when they become physicians.

With regard to submitting a Comment to this blog system, I have no control of the challenges the system has created to protect input source. ..Maurice.

 
At Monday, January 07, 2019 11:09:00 AM, Anonymous Anonymous said...

Hello,

Does stopping the conveyor belt mean leaving w/ o medical treatment; or, will medical personnel be willing to alter their protocols? What "arguments" will be effective in even getting them to listen to an "opposing" view? What will cause them to amend their "evidence-based" beliefs? Why does this feel like David vs Goliath?

Reginald

 
At Monday, January 07, 2019 12:55:00 PM, Blogger Maurice Bernstein, M.D. said...

Reginald, I interpreted the "conveyor belt" as a medical professional protocol upon which each patient sits from the onset of their relationship with the medical profession to the "end" whatever that may be. It is a protocol whose "speed" is set by the profession but in the case presented it took finally the important communication between the surgeons and the patient's family to bring the belt to a rational based stop. Like conveyor belts in industry, it moves the "object" through a series of actions or activities to hopefully conclude with a standardized product. But is that what we want in medical practice from the first placement of the patient on the belt (entry into the doctor's office, for example) through to the 10 minute history taking and onward to the exam room with its structural and other attending issues of privacy and then perhaps a procedure with the attending assistants and so forth. The "conveyor belt", as in the NEJM article is there starting up actually even before the patient arrived at the major hospital to "prepare" for the "endpoint".

The "belt" is for efficiency and meeting some goals set by the profession but are these the goals that the patient or family really need or desire. Once on the "conveyor belt" built and set in motion by the medical profession, even with legs dangling it may be upsetting or even dangerous to try to jump off.

So let's talk about this analogy and what it can do to hurt patient dignity. ..Maurice.

 
At Monday, January 07, 2019 1:56:00 PM, Blogger Biker said...

I suspect a piece of the conveyor is caused by both revenue maximization objectives (treat everything whether it makes sense for that patient or not) and also fear of litigation (why didn't you ......). The only way to get off that conveyor is speaking up, which is far easier to say than to do.

Three examples. At age 85 my grandfather was diagnosed with stomach cancer. He was in decent shape for his age but had a pacemaker. The doctor wanted to operate. My grandfather said no, had a good year or so of normal life, then got sick and died at 87. Surgery at 85 and with heart issues offered no guarantees he'd of gone home again or recovered enough to ever resume his normal life, but the conveyor belt said he had stomach cancer and thus must be operated on. He chose to get off it.

At 67 about 2 weeks before he died of pancreatic cancer I took my Dad for a doctor's appt. at the hospital. He wasn't eating, was down to skin and bones, and was too lethargic to be very communicative at that point. I pulled the doctor aside and said he had stopped eating. Rather than simply tell me this was a normal part of the endgame, to call hospice and take him home, they admitted him, hooked him up to IV's, ran tests, and so forth; all this being an hour from their home and with my mother not knowing how to drive. They finally release him a week or so later and he comes home to die within a few days after that. They knew he couldn't be saved but the conveyor belt said keep on treating him, and we didn't have the knowledge with which to say stop it.

Last example. At age 93 my father-in-law went into a nursing home with alzheimers and with prostate cancer that had spread to his bones. The mind was already mostly gone and the body was trying to follow but his doctor was still putting him through frequent bone density and other tests and appts until my wife finally told the doctor no more, just leave him alone as the tests and appts were more disruptive to him than any possible benefit that might be derived from monitoring his progress. Had she not spoken up he'd of likely stayed on the conveyor belt being tested and monitored for that which couldn't be cured. He died peacefully at 95.

Part of the conveyor belt problem is lack of communication on the part of doctors. Patients don't always know what questions to ask, be it about treatments options and necessity, or how they will be done, or who will be there observing. Part of the problem is the revenue side of this incentivizes doctors (and the hospital systems pushing the doctors) to keep patients on the conveyor belt rather than stop and think what is best for this patient at this time.

 
At Monday, January 07, 2019 3:12:00 PM, Blogger Maurice Bernstein, M.D. said...

Biker, I agree. The "conveyor belt" approach to medical care is due to patient overload from hospital emergency rooms to individual physician's offices. Too many patients, too much financial demands and regulations by HMOs and others including the government, relatively too few individuals entering the medical system in all of its components (of both genders)---not enough time to sort things out appropriately with patients, families and other caregivers. The medical system may find the "automatism" inherent in the "conveyor belt" the most efficient way to deal with the "load". And one can see that the individual dignity of each patient is lost as the "belt" moves along. It would be wonderful to get patients off the "belt" and allow them to sit comfortably wherever appropriate as each patient's diagnosis and therapeutic course is individually considered---and the course need not be the standardized terminus of a "conveyor belt".
..Maurice.

 
At Monday, January 07, 2019 5:04:00 PM, Anonymous Anonymous said...

This conveyor belt approach is even worse with a STEMI. They say time is muscle and they can't properly talk to the patient or their family about options but they can take 30 minutes to completely humiliate, ask stupid questions, and whatever else they deem appropriate. This conveyor belt does not apply anyone but them to know what is going on because it is about money and control. It belittles us as humans and takes away our freedom of choice. I don't believe doctors saved my husband's life but he survived despite all the horrible things done. Doctors perform the duties they have studied for and should do so well. If not they should not be doctors anymore. Mechanics, teachers, cashiers, etc. should also perform their duties well. True life-savers to me is the passerby that risks their life by aiding someone else.

I noticed today that the male tech in the stress test was very respectful but the female reached to unbutton my husband's shirt as he was not fast enough for her. I told her he was perfectly able to unbutton his own shirt so she did stop. He also found the courage to keep his shirt on as it is not really necessary for men to totally disrobe from the waist up. He unbuttoned it and kept it pulled together. That at least gave him the feeling of retaining some autonomy over himself. Small steps but positive ones. I guess that when females in a health setting are dealing with men their inter bully comes out. That's why he had me there. JR

 
At Monday, January 07, 2019 5:18:00 PM, Anonymous Anonymous said...

There is no transparency in healthcare and no one knows where that conveyer belt will take you. One component of the affordable care act of 2010 was to make available to patients online the “ chargemaster”. That is the list of what the hospital charges for every item and/or procedure. As of this week it was mandated that consumers have access to this online for every hospital. Why should the government have to step in and mandate this? You are at Macys department store and you know the price for every item before you buy it. Grocery stores have available to shoppers a scanner so that you the consumer can scan it for the price.

Lately, I have started reviewing websites online of medical facilities, in particular is a men’s vitality clinic offering a variety of services. Now, I’m not in need of any vitality as I’m too busy unfortunately to take time to look into this, however, in reviewing the website it gives you no clue as to who the providers are or what their genders are. There are two guarantees that healthcare offers, you will be ambushed and you will be blindsided with unknown costs. Look at any car dealership online and it will show pics of the employees from the service advisor on down to the salesmen/saleswomen. Why can’t healthcare facilities do this?

PT

 
At Monday, January 07, 2019 7:15:00 PM, Anonymous JF said...

My miraculous cure was because of my surgery. If I wouldn't have had surgery, I fully believe I would have been dead inside of a month or two.

 
At Monday, January 07, 2019 7:33:00 PM, Anonymous JF said...

The fear of litigation doesn't seem likely to happen. Does anybody hear remember Gift bearer and how horribly her doctor treated her? Does anybody remember how cowed the other doctors and medical staff were?
I don't especially blame the other medical staff. There probably would have been some very real consequences had anyone of them stood up to that doctor. Afterwards Gift bearer couldn't get a lawyer to take her case either.

 
At Tuesday, January 08, 2019 5:55:00 AM, Blogger Biker said...

PT, that new pricing transparency law will prove to be useless. I took a look at my local small town hospital's site. The list of billables has 21,199 items on it and doesn't include the charges for the doctors who work at the cancer center, in anesthesia, the pathology lab, or that otherwise aren't employees of the hospital. What patient without insurance is going to be able to navigate their way through that to figure out what something will cost? It does note that patients w/o insurance will get a 10% discount and that if you don't have insurance and you prepay the estimate you'll get a 20% discount for those services you prepaid for.

Of course they want to make it easy for people so they also have a list of a mere 459 inpatient procedures giving you an average price billed for those procedures, but not including the associated professional services billing. Again, what average person can figure out what the hospital will code their services as, and even if they could there is still the doctor's charges.

 
At Tuesday, January 08, 2019 8:47:00 AM, Blogger BJTNT said...

Mentioning prices brings up the integrity of the medical community. Two and a half years ago, a medical center billed $50,000+ for my surgery with an overnight stay in the medical center. Medicare and my secondary insurance paid $2,000+. Even though I brought my own pills, the staff was under obvious pressure to provide the pills at inflated prices. Pity the poor schmuck who doesn't have insurance and is happy when he negotiates $24,000 to be paid over ten years at $200 per month.

I remember 50-60 years ago when car dealers advertised that they were honest. Dealers soon learned that they were simply informing the public of car dealer's reputation for dishonesty. You don't hear dealers advertise honesty today, but are they any different?

It's amusing to hear medical institutions advertise that "we care". This simply results in telling the public that the medical community has a reputation for not caring, but "we are the exception, we care". Sometimes there is truth in advertising even if's not the intended message.
BJTNT

 
At Wednesday, January 09, 2019 5:31:00 AM, Anonymous Anonymous said...

Prices are out of control. When you are billed for lab worked the needle prick itself is an extra cost. Maybe I should just cut myself to save an extra thousand dollars? On my husband' bill for a pci, it was around $475,000. That was 2 nights in the hospital of horrors and doesn't account for the procedures they tried to bill for that they didn't do or the room he wasn't in that they tried to charge for. One Dr said the tavr they tried to charge for was for billing purposes. Out here it is called fraud.

Everyone should go over their bills and make sure they are correct. Everyone should read their medical records although you don't get all of them bc there are notes referring to something else that is not included. This is how we found out the nurses lied about what they did and the extra procedures they tacked on to the procedure report. JR

 
At Wednesday, January 09, 2019 8:29:00 AM, Blogger Maurice Bernstein, M.D. said...

Now that JR has been writing about the monetary expense to the patient and family set and attempted to obtain by the medical system, I think that the following Abstract of an article"Dignity and Human Rights: A Reconceptualisation" in the 2017 issue of the Oxford Journal of Legal Studies which sets a definition between "inherent dignity" and "status dignity" and the behavior of the medical system can be challenged with the definitions. Here is the Abstract of the article:
Abstract
Human rights are often defined as entitlements that human beings possess just by virtue of their inherent dignity. This conceptual link between human rights and inherent dignity is as popular as it is unhelpful. It invites metaphysical disputes about what, exactly, endows human beings with inherent dignity, and distracts from the core function of human rights: placing constraints on powerful actors, especially states. In response to this difficulty, I reconceptualise the relationship between human rights and dignity in a way that maximally serves human rights’ purpose. I do so by distinguishing between ‘inherent dignity’ and ‘status dignity’, and by linking human rights to the latter, not the former. First, I argue that human rights articulate standards for respecting the status dignity of the subjects of sovereign authority, rather than the inherent dignity of human beings qua humans. Secondly, I suggest that not only individuals but also corporate agents possess status dignity. In particular, states that violate human rights lose their status dignity, thereby becoming liable to interference.


I would say that "corporate agents" can apply to those working within the medical system who by their demands and actions will "lose their status dignity and thereby "become liable to interference." This could apply not only to financial aspects of medical care but the other misbehaviors toward their patients. What do you think? ..Maurice.

 
At Wednesday, January 09, 2019 4:13:00 PM, Anonymous Anonymous said...

Not much preservation of patient dignity at this facility:

https://www.theguardian.com/us-news/2019/jan/08/phoenix-woman-coma-gives-birth-hacienda-healthcare-ceo-resigns

REL

 
At Wednesday, January 09, 2019 9:22:00 PM, Blogger Maurice Bernstein, M.D. said...

This Comment was attempted to be posted today on Volume 86 of course closed to further comments but I thought it was worthy of publishing it here on Volume 94. ..Maurice.


At Wednesday, January 09, 2019 2:30:00 PM, Blogger sam said...
As a child sexual abuse survivor it's hard for me having surgery and being without my undies on. I am having a hysterectomy and am already having a hard time with the nudity I will suffer through. For me the idea of taking off undies makes me feel vulnerable. There are sterile maternity mesh underwear that I have had to wear before due to being on my period with previous surgeries.
My previous history of abuse os just something for every nurse and doctor to keep in mind when dealing with patients. Not all are ready to admit to our past. Speaking about it makes it real. Not all of us are ready for it to be real yet.

 
At Thursday, January 10, 2019 6:41:00 AM, Anonymous Anonymous said...

REL

I should mention that the facility you mentioned was investigated and given a reprimand by the state because staff was violating the privacy of the residents while they showered prior to the latest incident. Which prompted the resignation of the CEO. These kinds of incidents are nothing new and happen not only at nursing homes but hospitals as well. Sometimes the public hears about them, sometimes we dont.

PT

 
At Thursday, January 10, 2019 6:55:00 AM, Anonymous Anonymous said...

I feel for Blogger Sam. We should not have to explain each and every time that we need to be treated with dignity and why. As for underwear for surgery, The Covr Medical Garment should be something that all institutions use. There is no reason that private areas not needing to be accessed cannot remain private areas. It is merely a power play that use to make us vulnerable, intimidated, and compliant. Naked people normally don't challenge a person in uniform. As it stand, violations have shaped our life and how we react. Although my husband (he doesn't remember what laughing nurses were doing to him as he was drugged) and I haven't been sexually assaulted, violations did occur. Even though he was drugged, he has underwent hypnosis and some memories resurfaced. One of his most vivid memories was of lying there naked and cold and wondering what was happening to him. He had no clue why, what, whom was doing it, and wanted me there for reassurance. He said he felt powerless and wasn't able to speak his concerns. He knew that he had had a heart attack but wondered everything else was happening and no one was talking to him or offering reassurance. They left him this way for around 20 minutes. There is no documentation of them doing anything within this 20 minute span. Even though I was there, they didn't acknowledge my presence until they had him in a procedure he did not consent to. They didn't tell me what they were doing. Instead they sent a warden to guard me (that's how I view it). He was a hatred minister and neither I or my son is religious. I asked him to leave 3 times. He refused. He did not offer comfort nor did he give us details of what was happening even though they called him and he on speakerphone walked away from us and announced to the whole public hallway my husband's name and what was happening to him. This went on for almost 3 hours. We were only told he was in a procedure and finally they were done. What and why were never answered. The warden accompanied us to the rude dr consult where the dr said he was upset that his Sat. night had been interrupted. The warden again invaded & violated our privacy by not leaving this consult. This is only the some details of the 1st part of our story. These violations will be with us for the rest of our lives. I feel that wouldn't let me see him as they had been called in and they were going to perform a PCI no matter what. No was not an option to them. Money and the conveyor belt type of thinking. Even though our kids are grown, they know what happened and they too will carry the scars with them forever. The lies, the manipulating, coercion, the lack of compassion, the lack of personal dignity, loss of autonomy, and the wondering if the care was lacking of quality will forever be with us. So much so that each time we encounter new medical people, we must explain why we are what we are now. It is being afraid of what will come bc we know as we age, it normally follows you encounter more of them. That is until you are put into a "nursing" home where you eventually become a total object and just are waiting to die without any dignity. Jr

 
At Thursday, January 10, 2019 5:27:00 PM, Anonymous Anonymous said...

www.azfamily.com

Former Hacienda manager speaks about patient abuse the CEO swept under the rug.

A patient in a vegatative state recently gave birth, police are investigating this rape case.

In another incident female nurses were standing around a non-verbal male patient’s bed
talking inappropriately about his genitalia.

In yet another incident the state reprimanded the facility for staff not giving residents privacy while
showering.

Oh, but we’re all outliers on the blog and Oh, this kind of shit never happens in hospitals and nursing homes.

PT



 
At Thursday, January 10, 2019 8:59:00 PM, Blogger Maurice Bernstein, M.D. said...

But, PT, what should I tell my first year students? Should I say "Do you know you are entering a cesspool of crime, cheating, squandering patient's money and dignity? How dare you do that if you know that?"????

Do you see any value in my students continuing on or they should quit and move into another but "clean" occupation such as religion, politics or business?

Or can we be realistic and say that there are "outliers" everywhere and the job of future physicians is to identify and do something about these "outliers" and in the meantime try to avoid being one of them and attempt to do the best you can for your patients. ..Maurice.

 
At Friday, January 11, 2019 4:56:00 AM, Blogger Biker said...

Dr. Bernstein, I would take a different twist than what you said. Simply telling them that there are outliers and not to be one of them more or less says most are good guys and a few are bad apples. That may be true for the most part but the larger problem is that the good guys look the other way as the system protects its own. The casualness with which healthcare staff accepts inappropriate and undignified banter about patients so long as the patient doesn't hear it more or less says it is OK to sexualize patients if the patient doesn't know. The same goes for exposing patients more than is necessary when the patient isn't conscious. The patient doesn't know so no need to protect their physical privacy.

Your students should be taught to not look the other way and to take whatever action is appropriate to the situation, be it confronting their co-workers or reporting them. It is no different than teaching children not to look the other way when they see other kids being bullied.

The other thing to teach the students, some of whom will rise to positions of authority in hospital systems, is to actual do something about weeding out the bad apples. The Denver 5 are still there working with nothing more than what amounts to a "don't get caught again" warning. Twana Sparks retained her hospital privileges and access to nude male patients. Staff who sexualize their patients rarely get fired or lose their licenses. Teach your students to change that when they're in charge.

 
At Friday, January 11, 2019 7:17:00 AM, Anonymous Anonymous said...

PT,
If the place you are talking about is in TN, then I believe the state legislature is trying to pass a bill that female pts. cannot be attended by lone male(s). However, this is sexist bc males should not be attended by lone female(s). Females are not all pure and kind either without any sexual intent. The world needs to get real. Men should have the same kind of consideration as females. Equal rights and all that should be given to all.

Dr. B.,

They have to be taught that they are not gods and they do not have complete control over their patients. Patients still have autonomy. I think most of the issues occur when medical people think we are mere pieces of clay that they may shape at their discretion. This can happen in any walk of life such as a small town mayor or police officer that power goes to their head. It is up to men and women like you to instill the correct thinking into the younger ones. Respect at all times for the patient and their family. Medical people merely give us the decisions we need to make and they have the ability to carry out what we decide needs to be done. Our treatment is our decision not theirs. They also need to be aware that someday they or someone they care for may be lying there looking for compassion, respect, and expertise from a medical person. They also need to learn how to listen. Why ask us questions if they do not listen and make notes? We know ourselves better than they do. If we say no painkillers bc they have bad side effects then make the note. Don't neglect listing it bc you know it is the standard to use them.

To all I believe how medical treatment is delivered needs to change. My husband was present during my emergency C-section when my gut was cut into w/o any prep. I didn't get an infection from hair or from him being present. He wasn't in the way. There is no reason why patients cannot have an advocate with them or behind a glass wall where they can see and hear everything. If what happens was more upfront and not so secretive then half of the battle would be won. I think if medical people knew there were witnesses to their actions then they would be more respectful and compassionate. JR

 
At Friday, January 11, 2019 12:13:00 PM, Anonymous Anonymous said...

Maurice

First of all as you may know I like you and I respect what you do but, healthcare has a bevy of problems!

A healthcare facility in Arizona called Hacienda healthcare operating a long term care facility recently had a young woman in their care for 10 years in a vegetative state suddenly deliver a baby. For 9 month no one knew she was pregnant, apparently she was raped by someone while in the care of the facility. The CEO immediately resigned.

The complaints made to the state before this were that residents at this facility were constantly being observed while bathing and showering. Complaints about this facility prior to this were that female nurses were making inappropriate comments about the genitalia of non-verbal male patients.

The CEO of this facility never took action against staff who acted inappropriately and thus over time this kind of culture fostered by a lack of leadership. Healthcare these days are managed by schmucks who only care about dollars and cents. A recently know of a pre-med student who after being given the opportunity to observe surgical procedures decided it was ok to take selfies of himself with the nude patient in the background while he is smirking.

What the F$&k is wrong with people these days, you know this problem is rampant. No one wants to admit it’s rampant so it’s convenient to refer to those or the issues as outliers. Is there an expected collateral damage and is that an expectation of doing healthcare business? The CEO of the facility I’ve mentioned has over 30 years suppressed complaints about inappropriate behavior and tried to cover up the rape of this patient in a vegatative state. The pregnancy of these woman was leaked to the police and the state.

If I had my way I would burn it to the ground and sweep the ashes into some little corner in hell and start over. In the very least staff need to be fired with license revocation, none of this well I’ll just go work someplace else. This goes for everybody, physicians on down to housekeeping, administrators as well.

PT

 
At Friday, January 11, 2019 5:57:00 PM, Blogger A. Banterings said...

Maurice,

I would start with your students by saying that




-- Banterings




 
At Saturday, January 12, 2019 12:21:00 PM, Blogger Maurice Bernstein, M.D. said...

I don't want to turn this blog thread into a political battle, but I was wondering whether all the "bad behavior" throughout the medical system described here has a political origin and political sustenance. Is there an existence of political cruelty toward citizens and specifically patients or patients-to-be which is responsible for all the humaneness repeated described here? Shouldn't Presidents and politicians pay more attention to the way the citizens and citizens-to-be are treated when they become or are already sick? Could their attitudes be filtered down to these patient "uncaring" publicized or experienced medical actions described on this blog thread? ..Maurice.

 
At Saturday, January 12, 2019 6:02:00 PM, Blogger Biker said...

Dr. Bernstein, in answer to your question I'd say no. If anything patients are treated better than was the case decades ago when the political discourse can be said to have been more civil. Patients have more rights now as well. There was no consideration for male patient dignity in my younger years. Professionalism has improved even if males continue to be 2nd class patients when it comes to their privacy and dignity.

 
At Sunday, January 13, 2019 10:28:00 AM, Blogger Maurice Bernstein, M.D. said...

You know, it would be of interest to compare the views of a now second year medical student with a year more patient experience to how the student evaluates the student-patient relationship.

As some of the visitors here will recall, having participated on my blog thread "Difficult Patient vs Difficult Doctor" , my first year student Surabhi Reddy started the discussion of the topic with his researched commentary and followed with comments several times during the ensuing discussions by myself and participants from our patient dignity blog thread, particularly Bantering. I haven't as yet been in contact with Surabhi since he moved on to the next year but I might contact him and see how his views have changed, if they have, with his further medical school experience and perhaps he can contribute to the current discussions on this Patient Dignity thread. Any thoughts about this suggestion? Do you think that the views of a second year medical student has any bearing on providing perhaps a different perspective of the medical system chaos which is steadily being noted and discussed here? ..Maurice.

 
At Sunday, January 13, 2019 2:23:00 PM, Blogger Maurice Bernstein, M.D. said...

I want to enter a new "wording" which may explain much of the non-frankly criminal problems or maybe even allowance of criminal problems that have been described here. That "wording" of the concept is that of "moral distress". Think about the personal conflicts of both physician, nurses and others in the medical field when they have seen or know of an action by a colleague or supervisor or medical executive who is or has been performing unprofessional or seemingly patient hurtful action. What does that observer do, what can that observer do within the limits of the system environment in which they work and participate?

This "moral distress" concept was first publicized in the nursing profession environment associated with a fear of "speaking up" when they asked to do or saw some behavior or action on their patient by their superiors which, to them, was unethical, immoral or attacking the dignity of their patient. The "moral distress" concept has now extended to others in the medical profession including even medical students. Think of a 3rd or 4th year medical student, working on the hospital ward, faced in this "hidden curriculum" with an order by a superior which defies what the student learned in his professionalism course in his first and second years but also his own concept of moral behavior. The condition called "moral distress" may start early in the medical career and may affect many workers. The challenge for these professionals is either to "speak up" and possibly adversely hurt their work or even lead to "occupational burnout" or remain silent to the system as though they were "not there". What do you think about this concept as an explanation of the patient harms within the medical system which are not treated or prevented? ..Maurice.

 
At Monday, January 14, 2019 4:16:00 AM, Blogger Biker said...

Moral distress is a good term so long as it also includes violation of basic privacy and dignity of patients. In the article the thrust is almost entirely over what the course of treatment is that a patient is getting. Much of what we discuss here is instead how that treatment is delivered.

The question then for your students is are they morally distressed if they see a patient being exposed more than was necessary (vs convenient for the staff)? Are they morally distressed if the patient's body language tells them he is embarrassed by the presence of the female MA observing his intimate exam? Are they morally distressed because they fear the gender politics that may ensue if they dared speak up for male patients?

The answer to these questions perhaps hinges on whether your students understand that gender is an issue for many male patients. Modern day gender politics perhaps doesn't even allow such a question to be asked.

 
At Monday, January 14, 2019 8:28:00 AM, Anonymous Anonymous said...

I really don't think that they think it is a problem when they see a male patient being exposed or being subjected to person dignity degradation(s). However, if the patient is female I think the story is different. It is accepted in the medical community that males do not have the right to personal dignity. However, females do have the right as there are legal ramifications. If an unconscious male is sexually assaulted, then a maybe slap on the hands (ie. taking pics of penis). If an unconscious female is assaulted, then it becomes a legal matter.

Men are discriminated against and it is an acceptable practice. Men and their advocated need to be more vocal and not be afraid of being labeled unmanly. Men do have feelings and these feelings of self worth and those feelings are as important as the feelings we females have.

There needs to be more education out there as to what really happens during medical encounters. More education would make people aware and be able to be proactive rather than reactive. We will be proactive in the future but the feeling of being violated will never go away. You always wonder why those people who were supposed to be compassionate in their care of you were so mean and abusive. To me, it goes back to control. When you enter their realm, they think you are totally under their control. That is why they give you meds like Versed. It makes you compliant and more importantly, you have no memory of what they have done or how they have done it. It also makes it so if anyone might have objections then it can be justified that the patient won't remember it. No memory--no harm. The harm only comes if someone is aware and makes a fuss. And the majority of time, it is not a man filing a complaint. However, I would say that the majority of medical people will go back to the violating and abuse as it is a control thing.

My views are hardened bc of what happened this last time. The laughing nurses and the nurse who didn't care about exposure have forever changed my view of what is supposed to be a caring, trust worthy, and compassionate group of workers. I can't bring myself to say professionals bc they are only professionals of abuse and violators. JR

 
At Monday, January 14, 2019 10:42:00 AM, Blogger A. Banterings said...

Maurice et al,

First, my comments did not fully publish. In response to your students, you should say:

...you are either part of the solution, OR part of the problem...


Second, you have asked if this blog has made a difference? My response has been that concepts put forth on this blog and concepts that are uniquely my own, have been making their way into the lexicon of the medical profession. One such is the recent discussion of dignity vs. modesty, appearing in more provider literature such as Patient Bill of Rights.

Another example that I have just seen in the "Moral Distress" article that you have presented is the concept of the patient-physician relationship (as opposed to the archaic, paternalistic term of the doctor-patient relationship).

I am not sure exactly which volume I have brought this up in, but I argue that this is a more correct term as the patient is the primary member of importance in the relationship and thus put first. The term physician is also a more accurate term describing a person that is licensed to diagnose, treat, and prescribe.

Three articles focus on the importance of shared decision making in individual patient-physician encounters as a means of mitigating moral distress. In response to a case in which a physician feels conflicted about applying hospital guidelines that recommend using a reduced dose of a drug in scarce supply to treat patients newly diagnosed with bladder cancer, Edmund G. Howe III discusses the importance of transparency as a way to preserve the patient-physician relationship while relieving the physician’s moral distress. Bonnie M. Miller, responding to a case of a student who feels conflicted about performing a procedure on an unwilling patient, argues that medical team members can respect the patient’s right to autonomy by being transparent about the student’s role. And Nancy Berlinger and Annalise Berlinger discuss moral distress that arises in situations in which unexamined “cultural” assumptions about a patient, family, or group might conceal larger structural problems or bias, arguing that students and clinicians should learn to think critically about such situations.

These are just 2 examples of concepts discussed here making their way in current terminology. I can NOT say that the enlightenment is coming from people at institutions reading this site, it may be that this site is being pushed by the currents of the enlightenment sweeping the profession. Personally, I am seeing these concepts appearing AFTER appearing here first.

I suspect that there are lurkers whose opinions carry considerable weight in the shaping of the corporate and professional culture at some very prominent institutions (such as the AMA).




-- Banterings



 
At Monday, January 14, 2019 12:50:00 PM, Blogger A. Banterings said...

Maurice et al,

Here is another thought that I forgot to mention. In regards to the "Moral Distress" article, I have repeatedly put forth that part of the burnout that providers face is due to the moral distress from the way patients are treated. Those who have any assemblance of a conscience left after medical school realize that patients are routinely abused.

Much of what is happening in healthcare structurally (physicians becoming employees), MOC, etc. is a societal reaction to paternalism. The solution is "patient paternalism", that is physicians (and other providers) handing over complete control to patients.

What the profession fails to see is that with power and control comes responsibility and accountability. Even if you reject the notion that the patient as a client, there is always going to be an element of consumerism in the transaction thus requiring customer satisfaction.

Technology is making providers irrelevant:

— home testing
— AI (IBM's Watson)
— overseas pharmacies
— Rx's being made OTC
— midlevel providers
— robotic surgery
— enlightenment (dignity vs. modesty)
— etc.
— iwatch, fitbit, etc.

When we examine healthcare we find much of healthcare is ritual as opposed to science. The biggest problem is that healthcare has never owned up to its infractions on human dignity, asked forgiveness, AND made amends.

In 2018 we are still talking about pelvic exams on anesthetized women without their consent.

Forgive me, but I am justified in my criticism and my feelings...

How f***ing stupid are these supposedly intelligent people that ANYONE of them can think that this is in anyway acceptable, allow any part of the profession to continue to do this, AND not think that they will be just as culpable???

I did not even get to the apology. How many physicians in practice today participated in this practice? Do they NOT owe society or their current patients an apology?

So what is a patient suppose to think of a physician who they know went to medical school when pelvic exams on anesthetized women without their consent was business as usual and the physician has made no statement on this?

I will tell you, the patient will always have suspicions of that person and will write their own narrative of what happened.




-- Banterings




 
At Tuesday, January 15, 2019 7:11:00 PM, Anonymous Anonymous said...

A. Banterings


I just have to add to your comments as well. How F**king stupid are the people who year after year keep voting the nursing industry as the most trusted profession. Who keeps F**King doing this?


PT

 
At Wednesday, January 16, 2019 6:43:00 AM, Anonymous Anonymous said...

PT,
I agree. Who are these people who think nurses are the most trusted? I certainly did not get to vote.

Banterings,

What, in your opinion, is the best way for someone like me to help? I really want changes. However, it is going to be an uphill battle. There seems to be such an anti man attitude in this country right now. I think that male patients are more likely to be mistreated now than before as nurses may feel more empowered especially against older males. I, too, believe in inequality but not at the expense of another class of people like men.
Things I would like to see change are:
1. Everyone treated with dignity and respect. This encompasses personal dignity and respect of the "patient" and the family. No more calling the patient by their first name unless permission has been granted and no more trying to undress a patient or staying in the room while they are undressing unless the patient is unable to perform this task.
2. Realizing that the "patient" is the ultimate decision maker in their medical journey. No coercion, bullying, etc. allowed. Information should be delivered clearly and without bias. The patient and/or their rep. should be the ultimate decision maker unless they are unable and the rep. is not able to be contacted in an true emergency situation.
3. No more secrets. Patient info should not be kept secret from the patient. It is about them so they should know everything. Making notes about what they say should be mandatory like them not wanting certain meds like Versed.
4. Consent forms need to be made easier to delete unwanted items. None should be signed when drugged. Conscious patients but drugged should not be subjected to hospital's signing consent in their place and saying everything was explained to the drugged patient. The family should be informed in this case.
5. Patients should have the ability to have their advocate with them throughout the whole medical process.
6. Billing should be clear and upfront.
7. No more personal electronic devices should be carried by personnel carrying out patient care.
8. There are more but these come to mind first. Please feel free to add.


JR









 
At Wednesday, January 16, 2019 8:41:00 AM, Blogger BJTNT said...

PT

Because people want those that care for their health and even their lives to consider them as human beings. They can't accept that patients are just objects to be processed at the convenience of the bureaucracy. Consider how people treat their family and friends when they are sick. These people can't imagine that anyone, with rare exceptions, wouldn't care for patients with the same respect and dignity.

BJTNT

 
At Wednesday, January 16, 2019 10:24:00 AM, Blogger A. Banterings said...

JR,

I am moving to educate personal injury lawyers about how mistreatment of patients creates side effects, thus allowing them to litigate.

This will change the system when it costs them money.


-- Banterings


 
At Wednesday, January 16, 2019 11:12:00 AM, Blogger A. Banterings said...

As I stated previously, the systematic mistreatment of patients by the profession of medicine rises to the level of a Human Rights' violation. Here is a case of organizations being held accountable for Human Rights' violations from the 1940s.

Read about Johns Hopkins, Bristol-Myers must face $1 billion syphilis infections suit.

Yes, that is Billion with a "B".

How much longer before personal injury attorneys start going after teaching facilities for pelvic exams on anesthetized women or subjecting patients to a conga line of doctors in training?

I want to see jail time for Human Rights' violations.

Do you think that the public will have sympathy for any who has committed Human Rights' violations under the guise of medical education?




-- Banterings

 
At Wednesday, January 16, 2019 9:06:00 PM, Blogger Maurice Bernstein, M.D. said...

Have we talked here about FF ('Frequent Flyers"), individuals (patients?) who repeatedly enter emergency rooms and seek attention of the ER staff and whether they are a result of system mismanagement or patient misuse of the system? Here are 3 links to the subject with some varying views of the issues involved.

https://www.ncbi.nlm.nih.gov/pubmed/16781914

https://www.verywellhealth.com/what-is-a-healthcare-frequent-flyer-2615173

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729222/

Could the repeated presence of such "patients" whether in need of "drugs" or even unwillingness to schedule an appointment with a primary physician be a factor leading to or caused by the medical system malfunction? Where is this population part of what we are discussing on this thread?
By the way:
I can also imagine that the use of the term "frequent flyers" might be an insult to those of you who are frequent aircraft passengers. ..Maurice.

 
At Thursday, January 17, 2019 3:46:00 AM, Blogger Biker said...

Dr. Bernstein, I can understand that druggie and mental health type frequent flyers can frustrate ER staff and contribute towards a jaundiced view of the general public, but they are no excuse for treating the rest of us with anything less than respect and dignity.

In my small town elected position I deal with the general public. There are a few frequent flyers for whom nothing will make them happy or who see problems where problems don't exist. I handle them gingerly so as to bring the interaction to a conclusion as quickly as I can, usually with no action on my part as either what they want can't be done or they really just wanted someone to listen to their complaints. While they may be a drain on my energy I don't let them prejudice me against the rest of the community. I go on assuming anyone coming to me is OK and has a valid request or issue to discuss, and recognize the few exceptions for what they are, exceptions. That's how healthcare staff need to do things too.

 
At Thursday, January 17, 2019 5:37:00 AM, Anonymous Anonymous said...

Banterings,

Our case would be a perfect fit for that kind of a lawsuit. There was blatant disrespect of personal dignity for my husband both in physical and mental aspects. There was also blatant disrespect of his medical information and a lack of informed consent. There is also blatant disrespect of us, his family. There are also downright lies in his medical records to the point of entering wrong procedures. There is omitted information that was vital to him having bad reactions to painkillers and Versed in the past. There was an entry saying he had a husband whether than a wife that was sent to the Catholic hospital which turned into the show of horrors. We feel that may be the key as to why they mistreated him so badly and wouldn't communicate with his "husband" (me, his female wife). We need the right fit with an attorney bc we have so many issues. JR

 
At Thursday, January 17, 2019 1:00:00 PM, Blogger A. Banterings said...

JR,

Find the right lawyer and go for it!!!

I would also refer the lawyer to this web site for direction.



-- Banterings


 
At Friday, January 18, 2019 5:30:00 AM, Anonymous JF said...

Dr B ,
As a CNA taking care of elderly , even if a patient gets under my skin and I would get noticeably agitated that still isn't going to cause me to be grouchy towards another patient.
It SHOULDN'T cause me to be rude or grouchy towards that same patient later on in a later encounter after the incident is over. I seriously doubt that there is a connection between people over using the ER. I DO think some of the abusive behavior might have to do with staff being tired from over work or being hungry. Tired or hungry people, often aren't on their best behavior. Even if the abusive behavior is caused by being upset with patients for something tangible that the patient(s) do , I still wouldn't think that normal people would out or retaliation expose that patients naked body to other people on account of it.

 
At Friday, January 18, 2019 6:33:00 AM, Anonymous Anonymous said...

Banterings,

That's just it. All the attorneys we have spoken for say we more than have a case but they don't want it bc it would be an uphill battle. They only want "easy" cases such as death or injury beyond horrific. We are still looking for the right fit attorney and hopefully we will find one. If not, I will publish everything the 2 hospitals did and let the chips fall where they may. In any case, I think things like what happened to us should not stay quiet as that lets them continue to happen. We have filed HIPAA privacy violations and suppression of freedom of choice/religion with the OCR. We have also filed 2 complaints with the state's nursing board on 2 different nurses. None of those complaints have been resolved yet. The complaints on the nurses were very serious as one didn't know what procedure had been done 2 minutes after the procedure ended and the other nurse did not know how to hook up equipment and made more than 20 false entries on his medical records. This is in addition to the lack of personal dignity which the one nurse willingly admitted she did not know how to protect him from exposure in a room full of people, the 2 nurses alone with him while he was drugged and they were laughing hysterically, forgetting for hours that he had a family waiting to see him, etc.

I am invested in getting changes done. That will be my therapy. I cannot trust any medical critter in any way in any form. That trust has been shattered beyond repair. However, since they saddled my husband against his will with lifelong medical issues we must deal with them but it is under extreme stress in any encounter with them. He too feels that no one else should suffer as he and we did. That's a lot for him as he normally isn't an activist but these encounters have changed him forever too. As I have said before, the heart attack wasn't the worse thing that happened that night but the treatment was. The scars of the treatment will never go away. How is that good medicine?

JR

 
At Friday, January 18, 2019 9:31:00 AM, Anonymous Anonymous said...

I think for some in the medical field, exposing a patient's body is just easier for them to do. Taking extra care to be respectful takes more of their energy and they would rather not spend that energy towards making a patient more comfortable. Some attitudes are may be that you are here so suffer the consequences bc we here to offer medical treatment and not respect or compassion. That is an extra itemized cost that insurance does not pay for. Some may do it bc they form an opinion about a patient or some may do it bc they do not like men. Some may do it bc they are uneducated in the way to compassionately give care. Some may do it bc it is an inside joke or prank they have within the hospital. Some may do it to get back at a patient. It really doesn't matter bc they should not be unnecessarily exposing patients. Most patient exposure in hospitals are males being exposed bc women if they are conscious will mostly complain or do something about it. Most men will not bc they think that will make them look like they aren't being manly. And truthfully when you mention this to a doctor they only give you blank stares like "What is your problem? I am godlike and I am saving your life."
However, I do not believe they save lives but rather are doing their jobs properly. Sometimes doing their jobs properly isn't enough. And to do their jobs properly they must treat all the person including their mental well-being. If they mentally abuse a person while helping them become physically well is there still harm? Of course there is bc they have created another malady. They forgot we are not objects but we also have brains and most important of all, feelings.

My sister recently went into a nursing for recovery. It was horrible! They had men helping the women with showering and toileting and vice versa. They had men and women in the same halls w/o any thought to personal privacy. The person in the first bed had no privacy from their roommate or the roommate's visitors. Curtains were never pulled. People no longer people but objects just waiting to die. Sad!JR

 

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