Preserving Patient Dignity (Formerly Patient Modesty) Volume 113
This is the misunderstanding that I agree, at times, is an unfortunate consequence of treatment of patients by all phases of the medical profession. This sick patient may need to be "fluffed" as part of effective treatment for the underlying disease but, unlike the bed pillow, the profession should always keetp in mind that such "fluffing" may be unwanted and unacceptable by the p1 11amatient and that unlike a pillow, an object, it is as a person, a human subject, the patient, who should be first informed and consulted for permission.
And, if the professional fails in this regard, well.. the patient or the family should "speak up"! (p.s.- I hope this analogy meets our blog thread discussions, but feel free to correct me. ) ..Maurice.
Graphic: From Google Images2
AS OF SATURDAY NOVEMBER 14 2020, NO FURTHER COMMENTS CAN BE
PUBLISHED HERE.. MOVE ON TO VOLUME 114.
https://bioethicsdiscussion.blogspot.com/2020/11/preserving-patient-dignity-formerly.html
..Maurice.
posted by Maurice Bernstein, M.D. @ 9:07:00 AM
211 comments
211 Comments:
As Reginald wrote 3 days ago on Volume 112:
I would suggest that the inhumane treatment comes from specialists, many of whom are arrogant; and, from hospitals and clinics which are too overwhelmed. In the specialist, hospital, clinic setting, most of us would just like to scream, "Wait! I'm a person, not a project!"
As Moderator of this blog thread, I encourage a reader here to join the discussion and challenge the view that Regnald has expressed. Of the number of readers I know come to this blog topic, I know there must be some who have had different knowledge or experience, even working or having worked in the medical profession who can speak to what Reginald wrote.
My own personal experience, as I have recorded here, is that the hospital where I was a patient considered me, to my opposition, as a VIP. I have looked at VIP designation as a "special object" or a "special project" to satisfactorily manage rather than simply a patient along with the other patients on the ward. ..Maurice.
I suppose now would be a good time to post of my experience with the Green Light Laser therapy, otherwise known as a PVP, or photoselective vaporization of the prostate. As I indicated before, I advised my doctor and the hospital of my need for same sex caregivers. I was assured by the hospital OR clinical coordinator that my needs would be accommodated.
I arrived early on the appointed day, which was Friday September 4th. It was a long wait, but I decided it was due to having to arrange the schedule. I wasn't complaining but my wife was. After a wait of an hour and 45 minutes in the surgical waiting room, a male CNA escorted me back to the pre-op area. A lot happened in a hurry. As I was being prepped with the leads and the Nurse Anesthetist inserted my IV line, a male Anesthesiologist bombarded me with questions. My BP was high as a result even though I had taken BP meds that morning. It came down though when they were done. At that point my wife was allowed to be present with me until the time of the procedure. That was another 45 minutes. At one point my doctor came in and we discussed my procedure and he said it was an all male team.
I was taken to the room for the procedure and I recalled that the door sign said Cystoscopic OR. Once inside I was introduced to the 4 men in the room, 2 of whom I had already met. My doctor was not yet present and they said he would come in when I was ready. I said " looks like it's the boys club today, right?" The CRNA said yes it is. I scooted over onto the table from the gurney. I saw stirrups and knew I would soon be in them. The Anesthesiologist took off my face mask and put a regular mask on and said I would be breathing 100% oxygen. I laid there breathing the O2 and then went to sleep. When I awoke I was in recovery. After being wheeled to the prep area a male nurse helped me dress and gave me the discharge instructions.
Continued,
58flyer
I went home with a Foley inserted, and a urine bag attached to my right leg. I had not yet heard from the home health company and I was worried since the procedure had been rescheduled 3 times. That afternoon I got a call from the home health company and I was relieved he was a male. He said he would come to my house the next day and remove the Foley catheter.
Saturday morning came and the day was bright and clear. I heard my neighbors flying their airplanes and I wanted to join them. I went into my hangar and looked at my airplane and really wanted to join them but I was holding the urine bag in my hand. How could I fly my airplane with a tube stuck up my penis and a bag attached to my leg? I thought about it and decided it wasn't a good idea. So, I just went out and watched my neighbors fly without me.
Saturday afternoon the nurse arrived and dc'd the Foley. We talked at length and I had to ask him if he dealt with female patients. To my surprise he said he did and it was unusual that any female patient requested a female to take his place. He said he was never discriminated against when it came to female intimate care. I was surprised. I was somewhat disappointed when he told me that I was just lucky. It just happened that he had the weekend duty. It just could have been easily that I would have had the the female nurse. I explained that there was no way I could have allowed any female to DC my catheter. As it was, we didn't have to go down that road. I would have gone to the ER first before I would have allowed that.
Overall my experience was positive. I called the OR coordinator and expressed my thanks. I am grateful they went the extra mile for me. I got a copy of the postoperative report and my doctor was pleased with the results. My BPH symptoms are greatly reduced and I am pleased with the outcome. Let's hope going forward that the PSA will remain low and I don't have to deal with any further prostate problems.
58flyer
58flyer, thank you, thank you for presenting here your recent/current personal experiences regarding your health and the two-way relationship with your medical professionals and assistants. It is encouraging to read that, at least in your personal case, "things went well". Would you say that your previous initial "speaking up" was an important factor in leading to the course and conclusion? ..Maurice.
I am a retired 78 year old retired physician. I have the reverse of the usual modesty problem. I find my physicians and a recent encounter with a nurse practitioner just the opposite. I complained of pain in my scrotum from a long standing varicocele. Neither of them examine that part of me. I had a female primary care physician for many years and she never did a digital rectal, at least the urologist, a personal friend, and the NP did. How do I suggest they examine me without seeming to be a bit weird, or seeking sexual gratification?
The posting above was from a retired physician who has presented a personal problem interacting with his medical providers. It is a problem that really hasn't been described here previously. In fact, it seems he was being treated as a "VIP" to his detriment with regard to his symptoms.
In an e-mail he had written me, I encouraged him to continue posting but with a unique pseudonym. ..Maurice.
I am the 78 year old Physician in the posting above. I don"t know how many reading this are physicians, so I don't know how many of you know how we teach the art of the physical examination. But, for completeness, When I was first in the examining room, they had me put the gown on opening in the back. the regular nurse came in to do an ECG and asked me to change the gown to opening in the front, I would have been fine chaning it with her n the room, I did have my underpants on, so no big deal. Anyway, I did as she said as she left the room. She did the ECG and left. The nurse practitioner than came in, saw the gown opening in the front and told me to put it the other way around. Now, if she had read my chart, she would have seen that I have a significant heart murmur, I always taught students to never examine a patient through clothing. I even told them that, if I found them doing that, it would be an immediate failure on that portion of the examination. So, this nurse practitioner did examine me through the gown. Also, my initial BP recorded in the office was 163/80, clearly what is called a very wide pulse pressure and something to be investigated. One thing that should have been done, is to take my blood pressure in my right arm as well, and palpate my femoral artery pulse. She did not palpate the femoral artery. So I was a little thrown aback by what was a physical examination below the standard I set for myself over a 48 year practice.
I always found dealing with those standard hospital gowns very frustrating. With the opening in the front I could better examine the heart, but then examining the posterior chest was restricted, so I would have to lift up the gown to the shoulders and have the patient hold it up for me. Examining a female also was always a bit of a hassle, since they invariably left their bras on. Luckily, there was always a female,usually a nurse, with me and she would tell the patient that it had to be removed.
The varicocele was never addressed.
I did get a call from the nurse practitioner, that my PSA was high, although I never requested one be done. At my age, I've stopped having them done. She knew that I just recovered from prostatitis, 2-3 weeks ago, so the PSA was probably elevated from that. I didn't think fast enough when she called. The primary care office is more convenient to me than my urologist's office, so my plan is to go back there in 3-4 weeks for a repeat PSA, and maybe find a way to suggest that I would like my testes examine, to be sure there is no lesion.
I have no problem with the female nurse practitioner, I have respect for the discipline, but was a bit surprised by the lack of compulsivity to the physical. Perhaps I am too old school.
58flyer
I had a fascinating experience with urological procedure after a failed lithotripsy for a renal stone. I develped an acute syndrome and was taken to the ER and admitted. They decided that I should have had a stent placed originally and had not, so they took me to the OR at midnight, that is another story, but probably not germane. The team got together and was prepping me when the CRN came into the room, seeing me being prepped, she said, I will give you some privacy, to which I said, aren't you going to be assisting in the OR, to which she said, of course, and I said, no need to leave, I will be the same body in the room as here. Thatraiss the comon question of what goes on when you are asleep in the OR. There has been, i the past, the belief that students, etc., can do examinations of the patient while under general. That has been discussed many times.
Steven MD
StevenMD, welcome to the discussion. I look forward to insights you have to that which we discuss here.
The CRN that was going to give you some privacy was doing the right thing at that point in time despite the fact that you'd be exposed to her subsequently. As a frequent flyer with intimate exposure in healthcare settings myself, I fully understand that I must be exposed for certain matters. My expectation however is that my exposure be minimized in extent, duration, and in terms of audiences. The CRN did not have a need to see you exposed during the prep and thus she she was correct in her instinct to give you privacy. At the same she erred in just walking into a room without knocking and getting an OK to enter when there was a patient being prepped.
StevenMD, over your years of experience, have you had the opportunity to teach medical students or have a medical student observing your doctor-patient relationship while interviewing or examining a patient? If so, I think it would be of interest to this blog thread visitors something about your experiences in this area. Don't name any names so as to keep anonymity in your response. ..Maurice.
Hello StevenMD,
In your search for a physician to perform a thorough exam, you may wish to consider an older male (possibly, 60+) GP or urologist. This individual will be close to your age range and, hopefully, will be somewhat "old-school". At the exam let him know that you're concerned about a long-stand scrotal varicocele and possible lesion. I think he'll ask to take a look without being prompted by you. This will allay your concern regarding seeming "a bit weird". Check on-line for the physician. Many times a picture or a statement of years in practice will indicate the doctors age, if his age isn't stated. In lieu of this, just call and ask for an older male physician. The buzzword on this blog is, "Speak UP". Many of us have found that this forthright approach does really work. I wish you success. Welcome to the blog.
Reginald
Thanks for the request. My comment will concern more than just my experience teaching, but also as a member of the admissions interviewing team at the medical school at which I worked for 48 years.
As to what is happening in admissions. Over the years, I have seen a shift to requiring students to spend time 'shadowing" physicians in their offices. This seemed okay at first blush, when it was a minority of applying students. In fact, my kids used to join me when I went into the hospital to make rounds. But, they were never in direct contact with any patients. The trend I saw was that more and more the applicant, an undergraduate student, had done "shadowing," sometimes, even starting when they were in high school. They would join a practicing physician into the examination room, with the patient. The patient would be either unaware that the student wasn't even a resident or medical student, but had no role in his/her care, and was really a medical voyeur (my term). Over the years I became more and more concerned about the impropriety, my opinion, of such shadowing. When I raised the issue to the dean of admissions, he responded that the committee actually preferred those with extensive shadowing experiences, because "those students have a better idea what medical practice is like." My response was that I totally disagreed, that such an experience was not consistent with what practice is like, and served very little purpose. When I raised the issue of informed consent, I was told, well, the physician usually asks the patient if it is okay? That is hardly an informed consent. The situation is somewhat coercive, the patient doesn't want to lose the attention of the actual provider and would be uneasy saying no. I wrote to the AMA about this, they have mixed messages about this issue. After I retired, and after extensive discussions about this, I was told that the department decided that interviewers had to be full time employed faculty. They had previously pleaded for faculty to volunteer, and now I was "unvolunteered."
To be cntinued:
continued
Of personal experience with a shadower, I was seeing my primary care physician on one occasion and he had a student nurse practitioner following him. On that occasion, he didn't ask me, he just asked her to leave. As a faculty member, I would have gladly allowed her to stay. I am not an exhibitionist in any way, but I know how difficult teaching can be, so will always do whatever I can to help teach people who are in a training program, that is totally different from shadowing.
As to teaching residents, that is an easier situation to be involved with. They have a group of patients that they are responsible for. So the only problem is the potential for embarrassing the resident by reveling that he/she might not have done something correctly. The risk to the patient's modesty is probably less, since I introduce myself as the attending physician involved with their care. The problem is teaching to a group of residents at a time. In the "good old days," we would all barge into a patients room and I would demonstrate some physical examination skill to the group and then they would all repeat the examination. It was never really an invasive technique, but still, perhaps, somewhat threatening to the patent.
Teaching medical students is a mixed situation. Those actually involved with the care of a specific patient, who has already developed some relationship, is a bit easier. Those freshman or sophomore teaching experiences gradually morphed from using patients on the wards, which was the case when I was a medical student, and was associated with asking permission of the patient, but probably as coercive as the shadowing consents. The trend is to use paid volunteers as "patients" in the introductory courses. That really limited the number of contacts and depth of the examination, often one "patient" to 5-6 students. With the increasing class sizes now being seen in medical schools, this is probably now even worse. Again, in the good old days, we were expected to examine each other. The class was essentially all male, we had only 1 female, so the sex thing was not considered an important impediment back then. Certainly examining eachother's genitals was awkward, but we were expected to accomplish it, partly to desensitize us as well as to learn the anatomy on a living body, not a corpse. That technique has completely disappeared. I would suggest to my group of students that they make sure to examine their significant others and family members to hone their skills.
A few years ago teaching a group of 6 students how to examine the chest and heart, and at a time when we were allowed, encouraged, to examine each other (in this case all males), actually they were expected to examine each other, not me. I was there as their proctor. We discussed what a murmur was and I tried to explain what it sounds like, even playing something I found on utube. I realized that I have a classic murmur and an arrhythmia on ECG, part of the teaching for the day. I asked if it would freak them out and they all said no. So, I took off my coat and shirt and had them all examine my heart, I made sure they each looked, palpated, and percussed before listening. Probably most patients never experience that thorough of an examination, but i still believe in it and taught it. They took my ECG as well. We were able to discuss my physical findings and my ECG abnormality. They all thanked me for the best lesson the said they had ever had.
To make this end and not go on. I continued to teach the introduction to the physical examination, but after my retirement, was told that only full time employed faculty would be involved, by the way that included the introduction to taking a verbal history. My comment to them: are you kidding me, you give up having a 'free" faculty member with over 50 years of clinical experience. Their answer, it s the new rules se by the dean. I will never know if someone hearing of that lesson complained.
Reginald:
Thanks for your comment, true, I could look for another physician, but that sort of avoids the problem rather than dealing with it. My urologist, surprisingly, didn't do a digital this time, even though i was jus over prostatitis. I was surprised, but honestly don't remember if he did the same thing 5 years ago when I had several bouts. He dis cystocope me back then, just to be sure there was no other problem, so there was not the issue of VIP care back then. The nurse practitioner did the rectal, maybe she shouldn't have if the urologist thought he shouldn't for some reason. She didn't seem to know that the PSA rises from prostatitis and can take many weeks to return to normal.
I will have to become a "big boy," and "Speak UP" the next visit.
Hello again StevenMD,
I asked a GP who's about your age, if he was considering retirement. His response was, "They're going to drag me out of here feet first. Why should all this knowledge be lost?" I'm sure that all present on this blog appreciate your iconoclastic position on shadowing. Many here have commented on how, currently, some medical personnel seem to place expediency before patient concerns. I encourage you to explore ways to share your expertise. Maybe there's a free clinic nearby at which you could volunteer. Additionally, please continue to share your story and your wisdom with us on this blog. I assure you that your presence is greatly appreciated.
Reginald
SteveMD, thanks for your worthy descriptive postings.
Speaking of your teaching first and second year medical students, my school (as the group here is aware) USC Keck School of Medicine where I did the same since 1985 or so until "retired" a couple years ago in October (next month) will be celebrating 50 years since starting what is said to be the first school to initiate ICM ("Introduction to Clinical Medicine") where the course was primarily based on the students actually interacting and examining patients in the associated general hospital, rarely "standardized patients" in the classrooms and for each anatomic section practicing on themselves. In recent years, the student groups were of both genders but no genital exams on each other was performed. This part of the teaching was performed on those employed "standardized patients".
I hope shortly to resume teaching from home via computer as I am still affiliated with the course. Again, thanks StevenMD for "speaking up" here. ..Maurice.
reginald
Thanks, I actually volunteered to do that for my own town. I would have had to pay for all my expenses, malpractice insurance, all my licenses, etc. So, no dice. I volunteered to help during covid doing non-patient contact activities, and was told no, because of my age. So I help out virtually.
StevenMD
in response to the comments by Maurice Bernstein:
That is interesting. When mixed, did everyone bare their chest, with draping as appropriate? I discussed with one of my groups what they would feel about it, what about a chest examination, full examination, including external genital exam as well, sort of a "menued" approach. Of course, it was a hypothetical, rhetorical question. The entire group, 10 or 12 at that time, stated they would not be embarrassed and thought it would be a great idea. They said they hoped that their fellow students would be helped learning by the experience and they might end up taking care of one another after graduation and hoped they would be well trained with this exercise included. Yes, they said no limitation, they would rather be one on one, with a proctor, in that case they mentioned me. I wondered if they really would have.
StevenMD, concerning student shadows, a couple years ago my wife told me of a 12th grade girl she met who hoped to pursue a medical career and who told her of how in 9th grade she was able to observe orthopedic surgeries at the local hospital as a shadow. I thought no way could that be correct but then verified the doctor she mentioned was in fact an orthopedic surgeon there.
I made contact with Patient Relations asking about their informed consent policies. I could not get a straight answer. In a nutshell,their policy doesn't seem to go beyond patients have the right to refuse shadows. They do not have a policy requiring the doctors obtain informed consent from surgery patients beyond the patient signs a consent form that has the word "student" buried somewhere in it. To me informed would mean "Mary, a 9th grader at XYZ High School wants to pursue a medical career. Is it OK that she observe your surgery today, including your prep while you will be intimately exposed?".
On the matter of kids being with their doctor parent doing rounds, earlier this year my wife was hospitalized at the local hospital for about a month with sepsis. On a Saturday morning when my wife was barely becoming lucid again, the urologist came by with his 6 year old granddaughter and proceeded to treat it as any other patient visit, and without ever asking if it was OK that the 6 year old was there.
The fact the breast exams were conducted student female on female through a bra but all on the bare chest of a male conveys to me that within the medical community itself, for its members, there is a recognition of same gender care. It also conveys to me that the patient is bared to the students in mixed company so patient's dignity does not matter at all. A complete double standard exists to which Dr. B. is acknowledging taking part of w/o any hesitation. And why males "obviously with a bare chest" signals it is okay is beyond me. Only the part needing to be examined should be uncovered but there is an accepted double standard in how healthcare is delivered to males and females starting at the training point. It teaches providers that males have no need for dignity while they should be a little more aware that females should have some dignity considerations because we know from history some male providers have an issue with sexual inappropriate behavior. The fact that female providers also have the opportunity and motive for inappropriate sexual behavior is not acknowledged and therefore, is allowed to flourish. However, that recognition does not extend to acknowledging the ordinary patient is also entitled to same gender care especially when it comes to chaperones, observers, or med. students. It is totally a violation of a patient's right for a provider's child, grandchild, etc. to tag along during a patient encounter. Is a 6 yr old child versed in HIPAA compliance or will they tell so and so they saw Mr. Smith's penis or Ms. Smith had a tattoo on her breast? Why is patient privacy treated in such a cavalier manner? Most of the time the 6 yr. relative of the patient is not even allowed to visit in a patient room so this is VIP treatment.
What is very interesting is I now have several doctors and nurses interacting with me and are agreeing with many things I am saying on my growing social media campaign. I also have gotten the attention of a very well-known journalist along with several owners of very large accounts. However, on Quora, it seems those many of those socially uneducated medical providers are hanging on to the term modesty rather than dignity to just the lack of patient respect. Calling it the need of the patient for modesty is part of the victim blaming/shaming game so they don't have to acknowledge the issue is with the medical community and not with the patient as every person is entitled to personal dignity and is a part of basic human rights. Receiving medical care should not erase basic human rights such as dignity, deciding what is done to your body, and not to be torture while receiving medical treatment.
But JR, there is a difference in the society where we live between the way men and women expose their chests and breasts "in public", unless, of course, they participators in a nudist social session. Woman wear bras, either without covering (such as at the beach et al) or along with an overlying garment. Men, either cover their chests with a garment or appear in public bare-chested. It is a factual observation that men are generally less uncomfortable exposing their bare chest than women. The "laying on of others hands" on the patient's chest is more acceptable by men than women. There is a similar difference in sexual arousal connotation between men and women in this regard. It is because of this difference between men and women that is the basis for the different approaches to teaching breast and anterior chest exams Yes, even in male patients, it may be necessary to expose the chest partially to prevent shivering or other clinical reasons but usually not for issues of modesty. Anyway, that is the rationale for our teaching protocol. ..Maurice.
to JR and MB
The technique for examining the anterior chest without undergarments, must be learned at some time. It is possible to examine one side at a time, keeping the other covered. I always used that technique examining my patients. The problem I always had the, was not being able to have complete access to the posterior, since the front was the area with the split. I do not know why no one has designed a gown that allows for both sides to have flaps that can be used. The students I surveyed said they would not have a problem with mixed examines, and the question was not coercive, since it was a hypothetical and not actually going to occur. Whether the students were being honest remains in question.
StevenMD Possibly there should be something to put check marks on what body parts a patient needs checked. The fact that your testicles weren't checked implies that they know many males are modest.
Biker. I'm sorry your wife was treated that way by her urologist. A 6 year old child should not have witnessed that. It's not that I think the 6 year old girl got sexual gratification but there's zero chance that that little girl could feel any respect for your wife. Your wife was treated like a slab of meat. How many patients have suffered needlessly over a long period of time because of the medical worlds abusive dismissive behavior? How many patients have died because of it?
Some have said that third leading cause of death in America is medicine. I have wondered what exactly does that mean. Is it harm csused by surgeries? Medicine at home being found by a child or elderly person taking it inappropriately? Does it possibly include a person opening their medical bill and finding they were charged 10 times more than they should been so they suffer a heart attack or jump out of a widow? Just something I think about.
Dr. B.,
Times are changing and just bc something was acceptable yesterday does not mean it is acceptable to today nor does it mean it is acceptable to that person. You are assigning gender mandated principles that people in today's society may or not agree with having imposed on them. Due to my husband being medically sexually molested, he does not feel comfortable with being bare-chested with a female medical staff member. Young boys often do not feel comfortable being bare-chested. Many men for various reasons do not feel comfortable being bare-chested while it is also a fact that some women are comfortable being bare-chested or having their breasts exposed. You are assuming men do not have an issue with being bare-chested. You are not asking which is what I see as the problem.
But actually I was talking about something deeper than what appeared on the surface. It is an accepted attitude of the medical society to take away more personal dignity rights from male patients than from female patients especially when the patients are conscious. Unconscious they are generally not respectful of any patients right to personal dignity.
JF, The reason why StevenMD's testicles are being checked is probably because it is an example of the VIP treatment. Most males will get their testicles checked as a normal part of the male exam. They are probably deferring out of personal respect bc generally there is no point to the exam unless the patient notices something that needs to be checked. I know of a man here locally who just killed himself because he could not stand how healthcare was being delivered to him anymore. If truth be known, healthcare kills many patients and because of its abusive, harmful deliverance of what is supposed to compassionate care, my husband decided to be one of those who will no longer seek healthcare thus dying sooner than necessary. Congratulations to a system that thrives on paternalistic attitude and self-preservation.
JR, I have never experienced a male patient of my own or a student's male patient who demonstrated concern about being bare-chested as part of a physical examination. Nor have I seen a male medical student rejecting exposing his chest to me and perhaps up to 3 female medical students in the same room.
Perhaps StevenMD has but I haven't. ..Maurice.
p.s.- Banterings, I hope you are here reading and present your views, since we are that subject, of nudity of male chests in public or as a patient being examined.
StevenMD, my experience examining the posterior chest of a patient wearing a chest covering open in the front is to elevate the garment bottom edge with one hand and auscultating the posterior chest holding the stethoscope in the other hand. For posterior chest bimanual percussion, obviously the garment can be pushed up and lifted away from the site to be percussed with the physician's arm whose middle finger lies on the skin and is being percussed by the middle finger tip of the other hand. I would never ask the patient to hold up the gown since the patient must be at physical rest for the back muscles to be relaxed. I agree, a slit in the back of the gown pushed away from the area of examination would be the best solution. ..Maurice.
to JR:
the quotation of medicine causing enormous death is related to adverse drug reactions, and comes from an Institute of Medicine Report called First Do No Harm. I believe that the number is probably even higher than reported, since the actual numbers are probably underreported. Having practiced medical toxicology, I saw lots of ADRs.
to Maurice:
i always have this ethical dilemma, asking if someone is uncomfortable, or assuming they are, may be coercive. the fact that you, and I, have never had a complaint may be because the patient/student was uncomfortable saying anything, sort of my lack of asking about why the physician and nurse did not do a testicular examination. As to examining the posterior chest, how do you percuss the back while holding up the gown? That requires 3 hands. I may sound sarcastic, I am serious.
Dr. B.,
That may be so but have you ever directly dealt with a man who has been sexually violated by medical staff? And also, years ago it was accepted that a man could call a woman "hon" or another term without being charged with sexual harassment. Times have changed and ways of doing things have changed. Would you be comfortable with gender neutral restrooms since medical staff supposedly have no sexual intent then why is it assumed that in everyday life all of us out here have sexual intent on our minds at all times? Also, why are the females exposed equally to the male students if there is no sexual intent of the exams then females would be exposed in the same manner would they not? In not doing so conveys the medical system is committing systemic gender discrimination. If there is no sexual intent, why are there separate changing areas in a hospital for staff? Once they enter the door, are we not told they no longer arrive with sexual feelings in them? The medical community itself is sending mixed signals. Why is the strip as you go exam fine for men in DREs but not for a woman? Why are men to undress in front of medical staff when woman are not? Why are these systemic inequalities allowed to exist? Why does the medical community when questioned about the lack of human dignity allowed for any given patient revert back to it being an issue of modesty thus making it a mental health issue of the patient rather than all humans are entitled to be treated with dignity? One doctor even told a man on Quora that because he is a patient dignity advocate he needs to seek mental health help for his hangup with modesty issues. They always seems to go back to the system problem of blaming/shaming the patient who they do not feel conforms to their way of thinking despite what you are saying they are taught differently.
JR, I can fully and honestly say that I never have "directly dealt" or was aware with a man who "has" or "had" been sexually violated by medical staff previously or as my patient . This is based on about 35 years of active practice followed by "retirement" but neverthepless another 13 years volunteering twice a month to a "free clinic". This does not mean that such misbehavior didn't happen in the past with the patient but I was never informed.
With regard to StevenMD's question to me. Over the years of my practice, the female gowns were open in the back with no problem in palpation or percussion posteriorly. Auscultation of the anterior chest exam was done by serially elevating the exam portion of the thoracic gown with the free hand and percussion was performed by elevating the portion of the gown to be percussed (moved out of the way) with the forearm of the hand whose finger in place on the spot of the chest to be percussed. In any event, I don't perform or advise students to perform heart and lung exam through clothing but only on bare skin, if possible and I am sure Steven you would agree. ..Maurice.
PT was often mean and hateful but I miss his contributions to this blog. Also we haven't heard from EO in a long time or several others. I sometimes wonder if PT had several different alias's on here. I also wonder if he will ever be back.
to maurice
I tell students even more strongly, if I ever see them examine anyone through a gown, they will automatically lose points on the next exam!
I have tried several times to redesign the normal examination gown to have 4 flaps which would seal over and provide modesty for the non-actively examined part. I just haven't made a prototype, yet.
Dt B. We're thinking that sexually abused patients often never come back for healthcare. JR is supportive of her husband but not all wives would be. And possibly many wives wouldn't be aware of the abuse and just mad at their stubborn husbands for never going to the doctors.
Maurice,
Sometimes patient advocacy triggers PTSD, I suffer anxiety attacks and need to walk away for a bit.
As to bare chest; in 1931 (I believe) New York was the first state that allowed men bare chested in public. It deemed that the sight of male nipples was not obscene. Later women legally challenged the ruling as discriminatory and won. The law in NY is that anywhere a man can go bare chested so can a woman (as long as the display is not overtly sexual).
I have walked through Manhattan with my friend from up north and a female friend of his, both of them bare chested. It was at 3AM.
In practice or the clinic, have you ever asked patients (routinely) if they were abuse victims as trauma informed care dictates?
Interesting that you never encountered victims of medical abuse...
StevenMD,
Welcome.
The problem with medical education (as well as public education) is that it relies too much on repetition and memorization. Einstein was often critical of this fact. Even though med school attempts to teach critical thinking (differential diagnosis), that skill is often lost as a physician settles into a speciality and everything becomes mundane and repetition. Even surgeons fall into this doldrum.
It may make a good TV show, but in reality, there are very few Dr. House's. That is why most medical advances are created by research scientists (PhD) and not physicians (MD).
PSA tests are pushed because the biopsies recommended from the vague results are a profit center for healthcare systems. Even though, they are no longer routinely recommended, PSA testing TARGETS are set by government and providers are paid on reaching those goals.
Often, PSA tests are slipped in with routine bloodwork. Providers are trained how to push these tests (PSA test can be easily checked off during routine blood tests), but not trained how to interpret (other referral to urologist for biopsy $$$ in the case of the PSA test).
You can read my research on how a medical education kills empathy in med students and essentially create sociopaths. This is formalized desensitization like you talked about in students intimately examining each other.
-- Banterings
Of course, JF, I miss PT also. He had been a contributor on various blog thread topics (not just this Preserving Dignity) over many, many years. As far as making contact with PT, I don't have his address to write an e-mail to him as I have done to some other participants here. I hope he has not been a COVID-19 victim. As far as PT with different pseudonyms, he always had a distinct writing format which I don't recognize from others writing here. Hopefully, he is not in anyway "turned off" by the content of the current text here. But who knows? ..Maurice.
..Maurice.
to Banterrings
I tend to agree with you as far as critical thinking. We SAY we are trying to teach that skill, but, in reality, it may not really be something that can be taught. I hope that I am wrong, but I see this new generation of graduates from medical school arguing about what they really need to know and really tend to send patients to multiple consultants rather than attempt to problem solve.
I was called "House" at my hospital, and, even before that show, I was often called when people were stumped, because of my trove of medical trivia. My philosophy was that I want a compulsive physician even more than a smart one, one with both is really astounding. One with common sense, would then go house one better.
My 48 years of practice led me to many interesting cases that were solved because of my compulsivity and curiosity. I don't know if it is allowed, but my book Medical Toxicology: Antidotes and Anecdotes is a compilation of 14 of my most interesting cases, someone called them medical Sherlock Holmes. There are other similar books out there, but my book includes ONLY my personal experiences, and shows how I made the diagnoses. It is a bit dense with medical facts, but the lay should be able to understand most of it.
Banterings, in answer to your recent question to me "In practice or the clinic, have you ever asked patients (routinely) if they were abuse victims as trauma informed care dictates?" No, in no way, routinely. However, the issue of a patient's history of abuse by others, both physical and mental, is a session for the entire class in our school and this is discussed in groups but it is not a routine question to be given to every patient unless the presented history or physical findings alerts the student or physician suggesting the possibility of physical or behavioral and emotional signs and if so this should be followed up. My answer to your initial question about "routinely" is "no" unless there is suggestive evidence then I would. ..Maurice.
Hello Dr. Bernstein,
Women are routinely asked re abuse when facial or bodily bruises are noted. Would it be so difficult to ask of all patients, "Are you now; or, have you ever been physically or sexually abused?" The physician wouldn't even be required to take his/ her eyes from the computer screen. Voila!
Reginald
Reginald, asking the patient "Are you now or, have you ever been physically or sexually abused?" would be an appropriate question to ask in the routine Personal History section of the taking the initial medical Past History, however, as I responded to Banterings, I haven't asked this question to every patient routinely but only rarely when appropriate from other history or physical findings.
StevenMD, I agree the physician should see and be able to palpate, percuss and auscultate with the patent's skin visible and not through clothing or other covering.
One example is varicella zoster (Shingles) where the diagnosis cannot be properly diagnosed by examining through covered clothing. Best wishes on your attempted inventions. ..Maurice.
to reginald
you just raised one of my "pet peeve" issues, the health care provider who hardly, if ever, looks up from his/her computer screen. Throughout my career, I endeavored to keep good doctor-patient contact through eye contact and observing body language. I even tried not to take written notes as I took a history, pausing every now and then to summarize and then take notes. I never wanted to seem as if I was staring nor paying particular attention to a specific piece of history. After each section, I routinely reviewed the information with the patient, always asking, have I forgotten anything or do you have anything more to ad, and then recorded it.
One of the reasons I like my current physicians, is that the do not keep their faces in the computer. They just gave me the VIP treatment as Maurice said, and neglected an important part of my body. I often remark to students and residents, that, regardless of the sex of the patient, there is a significant part of their bodies below the waist.
Hello Dr. Bernstein and StevenMD,
To palpate or not to palpate, that is the question? Your problem seems to have been solved with the digni bra (See https://www.digniproducts.com/ ). The patient wears a digni bra under her gown. The top of the gown is dropped for anterior or posterior examination. No breast exposure. Wow! The patient could initially be given the bra with the gown and asked to return with the bra for the next visit; or, the patient could be asked to purchase one before or after the exam. Happy auscultating!
Reginald
StevenMD, my experience in private practice for over 15 years followed by active clinic appointment for 10 years and then followed by 13 years of "free clinic" volunteering, I never was challenged with the current practice of attempting to avoid "burying the physician's face into a computer screen". But like many other physicians, such "burying" does not provide, at the time, full and best attention to the patient.
I would like to know is what experience you have had as a patient with regard to medical scribe workers both taking a history or even present and working during examinations of the patient and thus allowing the physician to "look directly at the patient". I have had, as a patient, the physician whose eyes stayed on the computer screen while questioning me but also did take time to look at me but no experience with a scribe.
In your last posting, I am sorry to read that you had to experience VIP treatment since I reject VIP treatment behavior to others but also reject this "professional misbehavior" to physicians and other medical workers.
Thanks for describing your personal medical practice views and how it is applied to your student-resident teaching experience.
Here is our big question to you: Do you feel that the complaints of medical practice behavior leading even up to PTSD symptomatology represent a statistical outlier population of patients or that most patients feel traumatized by the medical system and their personal dignity is being damaged or taken away? ..Maurice.
Reginald, I am not sure that auscultating heart or lung sounds through a bra is free from interfering factors such as damping of heart sound volume or creating confusing artificial sounds such as "rubs". Palpating (hand on skin) for transmitted true cardiac or pulmonary rubs may readily be inhibited by a bra. Inspecting of the underlying breast skin for a rash which might be origin of pain is also prevented. Anyway, those are some of my thoughts on the subject. I did look at the ad link but I am not sure the product bra prevents the issues noted above. ..Maurice.
Hello Dr. Bernstein,
StevenMD's initial complaint seemed to be that he didn't have three hands to manage a gown while preserving some degree of covering for the patient. Surely a stethoscope can be placed under the bra to position the scope effectively for heart and lungs. Breast tissue can be accomplished by lifting one portion of the bra then, the other. This tissue issue, however, did not seem to be the problem for StevenMD.
Reginald
To several of you:
from maurice
Do you feel that the complaints of medical practice behavior leading even up to PTSD symptomatology represent a statistical outlier population of patients or that most patients feel traumatized by the medical system and their personal dignity is being damaged or taken away?
My answer, I certainly hope so. I hope most physicians are kind, empathetic and understand the needs of their patients.
from reginald:
Surely a stethoscope can be placed under the bra to position the scope effectively for heart and lungs. Breast tissue can be accomplished by lifting one portion of the bra then, the other. This tissue issue, however, did not seem to be the problem for StevenMD.
my answer, no, one should visualize the point of maximum impulse of the heart on the chest wall, then one should percuss the outline of the heart, then one should feel for any "thrills" the vibration of the chest wall from heart murmurs, all before auscultating with the stethoscope. All of those steps are part of a standard heart examination. I bet though, that I am one of a few physicians that did the complete series every time.
StephenMD, does your answer to my question represent your "hope" that such "complaining patients" do indeed represent a group of statistical outliers and that the vast majority of patients find their physicians "kind, empathetic and understand the needs of their patients"--that is, the vast majority of patients are free of the concerns expressed by most of the contributors to this blog thread.
My view is if those presenting their stories here are indeed statistical outliers of the entire patient population, I do think, nevertheless, they should not be ignored and that is why this is Volume 113 with an ethics topic begun in 2005 and continued year after year to the present.
Although all the "negative" about this profession may be from a statistical outlier group and that my personal experience both as a patient and as a physician having had no physical or emotional harmful behavior presented to me nor ever receiving signs of such behavior toward my patients, I, nevertheless, after what has been written here and widely publicized in the newsmedia believe my visitors and their experiences warrant attention by all the patient population and a movement by the public and the medical system to appropriate changes for improvement. ..Maurice.
A key aspect that hasn't been part of the current discussion is that for most patients (male patients primarily), their dignity concerns aren't so much with the physician as it is with the staff.
It is the female Medical Asst or LPN or Scribe brought into the room to "assist" the doctor with exams or procedures that involve intimate exposure. These low level minimally trained staff members are not professionals and often their assisting the doctor doesn't amount to anything more than standing there watching the male patient be examined. In hospital settings it is the female CNA sent in to do a bed bath or to observe/assist with showers or the female sonographer assigned to do testicular ultrasounds or the female nurse catheterizing the patient or the female MA clipping groin hair of guys in the cardiac cath lab and so forth.
It is the "you don't have anything I haven't seen" type responses to dignity concerns expressed by the patient that are essentially mocking or bullying in nature and that strip the patient of dignity.
It is all of these things far more than it is the doctors.
Biker,
It could not have been said better.
BJTNT
to biker
Many, if not most, scribes are, currently, at least where I work, individuals who are trying to use the experience to make their resume look better for entrance to medical school. A step above shadowers is my reaction. I haven't worked with any, but have interviewed applicants who have worked as scribes. They ae often allowed much more flexibility as to what they see and do h=then simply transcribers of documentation. Many of my colleagues, who still do ER shifts, say they are a mixed blessing. Their work still has to be reviewed.
A comment such as "you don't have anything I haven't seen" should be grounds for disciplinary action.
I do wonder what it may be like as I age and need assistance in activities of daily living. What will having a female help me shower be like? That might be more of an indignity to worry about if I develop dementia. Hopefully, if that happens, I will not be aware of what I am going through.
StevenMD
StevenMD, you wrote "A comment such as 'you don't have anything I haven't seen' should be grounds for disciplinary action." I fully agree with your "grounds". Actually, if used or interpreted by the patient in the broader context of symptoms and diagnosis, this is a falsehood which can lead to heuristic clinical errors. It has been emphasized to my first year medical students the clinical biases and errors in diagnosis and treatment which can arise from that rapid self-contemplation of symptoms, exam findings and labs followed by direct expression to the patient or family. ..Maurice.
I strongly disagree that the people and experiences reported here are "outliers."
Polls done every year show that trust in physicians has been decreasing every year for the past 50 years.
The New York Times reports that "In 1966, more than three-fourths of Americans had great confidence in medical leaders; today, only 34 percent do. Compared with people in other developed countries, Americans are considerably less likely to trust doctors, and only a quarter express confidence in the health system."
The NEJM reports that "Among 29 industrialized countries, the United States ranks high in patients' satisfaction with their own care but low in public trust in the country's physicians."
Then there is this from Medical Economics, "Physicians are transparent about conflicts of interest" 15% responded "All or most of the time."
Regarding whether "Doctors admit mistakes and take responsibility." 12% responded all or most of the time.
Then look at the number of antivaxers. That represents a loss of trust in physicians.
2/3 of Americans say they will not get the COVID-19 vaccine when it becomes available. They plan on waiting a couple of years to see if it is safe before they get it.
Starting the the late 1960s early 1970s women started choosing to use a midwife rather than a physician because they were ignored/disrespected/abused during labor and delivery. They started using birthing centers instead of hospitals. More and more women are now choosing home births. The medical community places the blame for this on the patient. They refuse to consider their roll in pushing women to choose a less safe option to maintain their autonomy and dignity.
People are going to Naturopaths instead of allopaths. This shows a breakdown in patient trust.
cg
continuing my comment that people commenting here are not outliers -
If you read patient discussion boards, you will see comments like this one that was posted today on a breast cancer board, "I am 67 and after having a lumpectomy I am about to begin daily radiation for 4 weeks. My CT mapping and simulation days have made me feel violated, humiliated and like a side of beef. I've been feeling very exposed and weepy all weekend."
Or this one, "I wasn't told (even though I asked) until my last appointment before radiation started that my treatment center strips you naked to the waist, leaves you that way during set up and during the entire treatment. Then (only because I asked) I am told there is only one female radiation therapist and guess who was going on vacation the day I was supposed to start. They didn't think there was anything wrong with sending female patients into that room, naked to the waist, surrounded by two or three male therapists, touching, adjusting and not another woman in sight. I asked about having my husband with me during set up and they said no. I can't imagine how it was for gynecological cancer patients. I am a sexual assault survivor. Sobbing I told the RO that although he didn't have a gun in his hand that's exactly what it felt like. They delayed my treatment until the female therapist was back. That gave me a week to plan, to cry, to pick myself up and make a plan. I called the RO and told him I had made a modesty band and fully intended to wear it. Also, if I showed up one day for treatment and the female therapist wasn't there I would walk out … that statement got her some overtime. I got through the treatment and even though the female therapist was incredibly kind, it was emotionally traumatizing. What I learned is that they don't tell you that you have the right to refuse pictures, you have the right to refuse tattoos and you have the right to have a female chaperone. My last appointment after treatment I had a long talk with the RO. Almost 40% of women have been sexually assaulted and this needs to be addressed."
Then there is this post from a few months ago, "Two days ago I went through radiation therapy simulation and the radiology tech told me that she had to take some photos of me, one was of my face, and three others were of me bare-breasted, lying on the table. This she said, was for face recognition, and to verify positioning on the table for the radiation therapy sessions. Is this common? I was caught off guard - I had not seen this step mentioned on any of the sites I visited explaining what to expect during simulation. I didn't say anything at the time, but the bare-breasted photos taken were, for me, humiliating, and it continues to bother me. I think they probably could have had me covered up, for I found out later that the purpose of those photos was to see how the knees were bent and the hands were placed gripping the handles. And it could have been easy enough to place a napkin square over each breast for the chest-on photo of the sternum tatoos."
These are only a few comments from just the radiation forum on just one breast cancer patient support site. If you look at the diagnosis, chemo, surgery, reconstruction, etc. forums, you will hear similar stories about patients being traumatized unnecessarily. I imagine other support communities would have similar stories.
Not every patient reacts this way, but the numbers that do are not inconsequential. The medical community is deliberately blind to the trauma they cause. The patient can be lying there sobbing and the medical professional will document that the procedure was well tolerated. Then they wonder why patients are "lost to follow up."
CG
Allowing students to shadow physicians and act as scribes to brush up their resume for medical school is unethical.
The Hippocratic Oath includes "I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know."
Bringing students, shadows, scribes or whatever you want to call them into the exam/treatment room is violating this oath.
It is also violating the admonition to "first do no harm."
If physicians do not guard their patient's privacy, patient's won't confide in them. They won't seek their help. They won't trust the physician.
Here are some examples of how bringing a student/shadow/scribe into the treatment room harms the patient.
Mr. A has been very depressed for months. He is now thinking about suicide. He decides to talk with his doctor. He is sitting in the exam room and in walks the doctor with a shadow and says this is John he is assisting me today. What brings you in today? Mr. A struggled with discussing this with his Dr of 10 years. He certainly isn't going to talk about this with a stranger in the room. He instead makes up some complaint and leaves without getting treatment. Instead he attempts suicide a month later.
Ms. B is a high school student whose boyfriend is pressuring her to have sex. She wants to do the mature, responsible thing, so she makes an appointment with her pediatrician to talk about birth control. She's known him/her her whole life and she trusts him/her. They walk in and say, this is John, he's assisting me today. What brings you in. She's not comfortable talking about something so personal and monumental as her first sexual experience with a stranger, so she makes up another complaint and leaves. Her pediatrician lost the opportunity to talk about whether this is really what she wants or is she being pressured, the opportunity to talk about prevention of STIs, to start her on a safe, reliable birth control, to make sure that she has received the HPV vaccines, etc. She gets pregnant before she finishes high school.
Physicians claim that the patient can always ask the student/shadow/scribe to leave, but patients won't. People are conditioned to "be polite." Telling someone to leave is rude. It will hurt the student/shadow/scribe's feelings. Patients also fear offending the physician or making them angry. They fear getting less than good care if they do that.
Even if the patient is ok with sharing their protected health information with a student/shadow/scribe, they are still harmed. The appointment length stays the same. Now the 5-8 minutes that should have been dedicated to the patient is split between the patient and the student. The physician will use a good chunk of the patient's time to teach the student. The patient leaves without getting his issues addressed or his questions answered.
-cg
stevenMD, I am glad that you too find offense in the "you don't have anything I haven't seen" kind of patient abuse. I wish that thinking was universal in the healthcare system.
I'm aware than many scribes are doing these jobs as a precursor to getting into medical school and don't fault them for taking that path, nor do I fault any physician who finds having scribes helpful. As the patient however, I will not stand there for a full skin exam or urology exam while a college-aged female scribe stares at me. The doctor can either use a male scribe or he can position the scribe where she can't see me. My feelings are the same for student shadows, be they in high school or college. Good for them that they want to go to medical school, but my exams and procedures are not a spectator sport for physician wannabes.
I differentiate for actual medical school students and try to be accommodating so as to help with their education. However I still expect to be asked for an OK that they be there.
The getting older and needing personal care assistance is a tough one. In his early 90's my father-in-law who still had his mental faculties needed help getting in and out of the shower (a bathtub vs a standalone shower) and was a fall risk so he couldn't be left alone while showering. All of the home health care people that got sent to his apartment were women. In the nursing home where he eventually ended up as a dementia patient, I never saw a single male employee the entire time he was there. It is as if these home health care agencies and nursing homes just don't care enough about the dignity of their elderly male patients to have the option of male staffing for personal care.
Wow! Wonderful conversations between our visitors here. I can't argue against what has been written today but if we conclude that we need change in the medical system relative to all of the evidence and stories, the practical question is what exactly should the medical system do to correct and prevent the agony being promoted within the patient population. Take each of the scenarios presented and define a practical remedy that could realistically be taken for resolution throughout the entire medical system.
In medicine, defining the symptoms and the clinical result is not sufficient-- it becomes the prevention and treatment which become the most important. ..Maurice.
to anonymous
I am not really disagreeing. Your examples are only a few which could be listed.
I think the shadowing is particularly unethical, but I struggle against a great number of others, at least in my medical school, who disagree, and have made it a quasi requirement for admission.
The area of consent is as you said, and the concept of coerced consent is discussed in our research community all the time.
Unfortunately, though, the reality is that students do have to learn on patients, and standardized ones don't always really behave the same as a real patient. Many schools are now using simulators, but, I, for one, never feel comfortable using them. Resusci-Annie has been used for decades to teach resuscitation, and the modern versions of it are astounding. But, I find myself more interested in the technology than the learning skills.
StevenMD
StevenMD, just to orient as you to the writer identification here. Some contributors have not officially signed in with a pseudonym and simply, hopefully regularly, identifies themselves at the end of their text such as Cg. Others as you have apparently done, along with Biker and A.Banterings as examples formally sign in at time of entry. ..Maurice.
for all:
There appears to be a "new book," that deals with some of the issues of privacy in medical care. It is reviewed in today's Book Review Section of the NY Times:
https://www.nytimes.com/2020/08/18/books/review/the-organ-thieves-chip-jones.html
StevenMD
And if you want to hear a narration of a few minutes of the book's text, here is the link.
Of course, "that was then" might be an argument presented. What do you think? ..Maurice.
stevenMD, what is unethical about shadows and scribes is not so much their presence, but rather their presence w/o informed consent. "Mary is here to assist me today" is a lie if in fact she isn't there to assist. "Mary is a student observing today" is also not informed consent given the inference that she is a medical student when she is instead a shadow, perhaps still in high school.
As a society we have moved far beyond the horrendous treatment black people received as described in the NYT article but here we are in 2020 and women are still getting vaginal exams in OR's that they never consented to.
Coming back to the examples of women w/breast cancer that cg posted and Dr. Bernstein asking for practical remedies, the healthcare system could address the lack of informed consent tomorrow if they simply chose to. There is no reason for a woman to be surprised by how her radiation treatments will be handled nor how her initial prep will occur. There is also no reason to expose her breasts when they don't actually need to be exposed.
I'll share my personal cystoscopies example again for stevenMD. At my prior urology practice which had 100% female non-physician staffing, though every one of the nurses doing my prep were polite and maintained a professional demeanor, when the prep was done they left me there exposed no matter how long the doctor was delayed, and they stayed right at my hip the entire time while waiting and while the doctor did the procedure. Where I go now has thus far always had a male RN to do the prep (at my request) and each time I am covered up after the prep while we wait for the doctor and the male RN's busy themselves elsewhere in the room rather than stand there maintaining eye contact with my penis. Minimizing exposure in this manner could be universally implemented tomorrow if the healthcare system wanted to.
The problem is healthcare does not see patient dignity was being more important than staff convenience and so these easily implemented kinds of remedies go unimplemented. The "they've seen it all 1,000 times before" mantra used to justify staff casualness with patient exposure and seeming lack of concern for patient dignity is easy to say when they (the staff) are not the ones exposed and/or being treated disrespectfully.
Hello,
CG, via a thoughtful disquisition, has given significant credence to the position that both men and women are psychologically and emotionally “harmed” by medical practices which make no provision for patient dignity. Dr. Bernstein asks, “What’s to be done?” Speaking Up may be beneficial presently, on an individual basis. Possibly in 100 years, the entire medical profession may hear enough patients speaking up that some token change will be “considered”. I’d like to suggest that two physicians, presenting selected blog anecdotes, might be effective in spreading the word to fellow physicians, societies, journals, etc. Any thoughts regarding who those two physicians might be?
Relative to the NY Times book review, times have NOT changed. Medical abuses still exist, albeit more clandestinely. The disregard for patient dignity proceeds unabatedly. (Cf CG above).
Reginald
Earlier this month I had my annual checkup with the urologist [male MD, male patient].
The young female MA escorted me form the big waiting room to the small waiting [as Jerry Seinfeld calls them] with a solo pit stop to empty my bladder.
The urologist was waiting [pandemic?], performed the bladder scan, and interacted with the computer console. The MA stood silently in one spot during the entire exam, performing no duties.
Why didn't the MA stand on the other side of the exam room door?
Nowadays, MDs; dictators; narcos; Hollywood stars; probably oligarchs and apparatchik; politicians many times; and perhaps a few modern day royalty have assistants waiting a few feet away. In the real world, CEOs, chairmen of the boards, execs, managers, and others don't have an administrative assistant or secretary standing a few feet away in their immediate area awaiting orders.
BJTNT
BJTNT, the MA was there as a chaperone and would have maintained full eye contact even if the procedure or exam required you be exposed. She was not there to assist or otherwise deploy any specific medical or nursing skill needed by the doctor.
I understand the need for doctors to protect themselves from abuse claims but chaperone protocols should require same-gender staff be used for anything involving intimate exposure. That rarely occurs for male patients though given the lack of concern for the privacy and dignity of male patients. The female chaperones don't mind looking and so they only use females staff for this role.
However, I am surprised that your male urologist used a chaperone for a no-exposure procedure with a male patient.
BJTNT,
If ever presented with that situation, I would insist that they leave the room. If there was POSSIBLY some remote reasonable explanation why they should be there, I would TELL them to put their nose to the wall to protect my dignity because they seem like a voyeur to me there "getting their rocks off."
As an abuse victim, are they really going to tell me how I should feel?
You think that because the rate of abuse for women is so high, they would be more likely to be sympathetic and understanding.
-- Banterings
Here is an issue which all medical schools are confronted with during this "unending" Covid-19 pandemic. It deals with how first and second year medical students should be taught. My years from medical resident to the present has been at USC Keck School of Medicine which next month will be celebrating its 50th year of Introduction to Clinical Medicine where these medical students were learning how to be a physician to patients (taking history and performing physical examination) on patients sick within a affiliated hospital or clinic under supervision by a teacher like I have been. Now, perplexing all medical schools who have developed programs utilizing sick patients need to make a decision because of this virus infection.
Should all teaching utilizing a live subject be limited to so-called "standardized patients" who may have some chronic physical abnormality or who can simulate an abnormality for the students to interview and examine more safely to both parties in a non-clinical environment or continue, with extreme caution to continue student interaction will true patients not actors and within a hospital environment.
This issue has not been settled in many if not most medical schools and is actually to be discussed by the professionals on an internet presentation.
Where do you see the overall risk? Immediately to the selected true patient or to the current health and experience for future patient responsibilities by the first and second year medical student.
Some decision should be made now or should medical education utilizing actual patients be terminated until the pandemic is gone? Or do you think that utilizing real and sick patients for medical education should now be thrown out and use only simulation teaching.
The current pandemic has affected virtual all of us in terms of personal activity, jobs and education of students from the very beginning to college and post-graduate career education. The challenge for medical school education currently cannot be ignored either. ..Maurice.
How about the issue of "hospital romances" most likely between professional hospital employees but then how about a hospital patient getting involved directly or indirectly. Here is the link to my 2010 blog subject posting. ..Maurice.
Maurice,
I am saddened that the whole issue of COVID has been politicized. I give examples of this on my blog, including how Fauci let 30,534 HIV patients die in the 1980's because he refused to issue interim guidelines urging doctors to prophylax patients deemed at high risk for pneumocystis pneumonia.
My circle all have scientific/medical backgrounds and this is what we have found and I have published My COVID Cocktail (with supporting science).
None of us have been social distancing at all throughout this whole pandemic and we all consistently test negative for COVID.
My point is that medical students can do something to protect themselves.
I think that they should be seeing patients. This is coddling. Again the profession is exempting themselves from doing something difficult (like med students doing intimate exams on each other).
-- Banterings
Hello,
Relative to the pandemic and med school education, soon we will have to take our thumbs out of our mouths, abandon the fetal position, leave our safe spaces and realize that life involves risks. We can't live in our respective caves forever.
Reginald
to reginald
There are variations in risk, but, covid19 is a real risk, over 200k Americans have already lost their lives, and that number is probably actually higher than stated. There are risks worth taking, you take a risk every time you drive your car, but you try to minimize those risks. your comment is being heard around the nation, or something like it, and every time a group decides to "take your advice" there is an outbreak of disease, death and long lasting clinical effects.
to maurice:
I don't have the answer. There is no question that direct "patient contact," provides a better clinical experience, and education, then a simulator. How to deal with the possibility of exposure, is difficult. If the institution can, all students and standardized patients should be screened for virus, with a rapid result machine. There are significant false negatives, but at least the risk would be somewhat lower.
Regarding your question whether medical students should be doing clinicals during the COVID-19 pandemic -
The 1st question the medical school and teaching hospitals should ask is whether the students' presence is safe for the patients.
Unfortunately it seems their primary concern is whether their students will be safe. I haven't seen any concern about whether the students' presence will put the patients at risk.
Currently hospitals are not allowing fathers to be present for the birth of their child. Wives are not allowed to be present at the death of their husband. A loving adult child is not allowed to stay with a confused parent to keep them oriented and safe. The rationale is that they might bring the virus into the hospital and expose other patients and staff. They say that it is not safe for the family member to put on a mask and go directly to their loved one's room and remain in the room during their hospitalization even if they test negative.
If that puts the patients at risk, then surely having medical students going to classes, parties, labs, and from patient room to patient room in the hospital is a greater risk to the patients.
The medical students are in a age group that has demonstrated risky behavior throughout the pandemic. 17 anesthesia residents and fellows at University of Florida Health attended a party in July. They did not wear masks or practice social distancing. They all contracted COVID-19. It would seem that medical students and residents are engaging in the same risky behavior as others in their age group.
The number of potential carriers that a patient is exposed to should be limited to the minimum necessary to provide care to the patient. Medical students do not benefit patients. They do provide an infection source during this pandemic.
If your only concern is whether it's safe for the student, then you could make the argument that the benefit to their education outweighs the small risk. They are probably young, healthy, with no comorbidities that put them at risk of severe symptoms. They will be wearing PPE in the hospital. They are probably more likely to contract COVID in the community than in their studies.
The benefit to the patient (none) does not outweigh the risk though.
CG
I'm surprised that a recent incident at Bristol Regional Medical Center in Bristol, TN hasn't made it into this blog.
In August a cardiothoracic surgeon invited the CEO (an MBA with no medical training) into the OR to observe a surgery. Then he invited the CEO to make the initial incision.
This was reported in Becker's Hospital Review. The link is provided below.
https://www.beckershospitalreview.com/hospital-physician-relationships/ballad-dismisses-cardiothoracic-surgeon-who-asked-ceo-to-make-incision-on-patient.html
I think this case shows how far apart patients and medical professionals are in regards to patient privacy, dignity, autonomy, and consent.
If you read comments made by medical professionals on Student Doctor Network, Medpage, etc., most thought this was no big deal. They said they frequently have students making incisions and taking an active part in the surgeries. Vendor reps with no medical training frequently participate in surgeries and in fact use the patient to train the surgeons on their equipment. The only problem they had was that someone tattled to the ethics hotline.
I don't think you could find a single non-medical person who would think it was acceptable to allow a CEO to participate in a surgery.
I think the vast majority of patients would be shocked and horrified that vendor reps with no medical training were participating in surgeries.
The majority of patients would object to the presence of the CEO in the OR or any patient treatment area.
Patients assume that they will be exposed to the minimum people necessary to provide the treatment the patient needs. The medical profession has turned providing care into a spectator sport with the patient the unknowing object of entertainment.
Actions like this communicate very clearly that doctors view patient's bodies as the medical professional's property to do with as they please.
CG
I read an article in the local news today that is prompting me to ask a question. Is a piece of the ongoing lack of concern for patient privacy & dignity the fact that there are staffing shortages in various disciplines? Do hospitals and others tolerate staff valuing their convenience over patient dignity so as to not risk losing staff?
The article I read was about nursing shortages in Vermont which was currently pegged at 4,000. That may not be a big number in other States but it represents about 30% of the total here. The void is filled with traveling nurses. Apparently our colleges with nursing majors aren't producing enough nurses and there aren't enough nursing educators to expand the programs.
I have read that there are and have been for many years nursing shortages in many parts of the country; and doctor shortages as well. NP's & PA's have filled the void in primary care but the fact that it took the 2nd largest hospital in this State several years to find a new urologist speaks to the doctor shortage not just being in primary care.
Do staffing shortages thus contribute to maintenance of the status quo on modesty and dignity matters?
I fully agree that nobody should be in the OR during surgery beyond the surgeon and his or her regular active participants. I think one or two students simply observing and not "laying on hands:" is permissible. Sometimes, it is necessary for a technician from a company teaching a new tool to the surgeon may be in the room with ability to demonstrate technique to the surgeon. BUT, I think the technician should have a session with the patient along with the surgeon prior to surgery with introduction and detailed explanation and opportunity for the patient to object. Patients should know and approve who beyond the regular team should be present, also if a video will be taken and this should part of the pre-op informed consent. Otherwise, the word "informed" should be deleted from the "consent". ..Maurice.
With regard to the true "learning experience" there is a great difference between learning from a "standardized patient" who essentially an "actor-teacher" with the basic motivation and salary "to teach" and a patient in a hospital bed who is looking to end and recover from the illness and symptoms. The difference between the "standardized patient" and the real patient to the student is the "standardization" when not interacting with a real patient. There is a whole spectrum of interchange between the real patient and the student whereas the interchange between the "standardized patient" and student is for the most part a "mechanical" process. I know since I have sat silently and watched both and regularly observed the difference.
Though the "standardized patient" meets occasional teaching goals, that "patient" fails to expose the student to the host of future real patients and learning, and by direct experience, how to verbally interact and physically attend to them when the student has graduated into the responsibility of fully attending to the real needs of their own real patients. ..Maurice.
to Biker:
Shortage of health care providers is an interesting conundrum. Totally, for the country, we may not really have much of a shortage, it is the distribution that is really the problem. The newer graduates profess to want quality of life jobs, thus may choose disciplines where their work stress is perceived to be lower, and work environments where their work hours are more predictable, and better for the lifestyle they desire. Unfortunately, for much of the country, that eliminates some geographical locations. I have found that potential income IS a factor in the choice of some disciplines, and if we are ever to have a real health care system, this had to be addressed.
to Maurice:
I fully agree, there is nothing like a real patient to spark a students interest. In the golden days, we were included as part of the team, junior member for sure, but were actively involved. We sleep either in an on call room or on the ward itself. Today, that rarely happens, even during so-called sub-intern rotations. The issue regarding ethics however, isn't easy to reconcile. A patient is more likely than not to want to please his/her health care provider, so isn't likely to refuse.
StevenMD
OK, I have a challenge to put to the visitors to this blog thread. It's a simple question but is super-important in the developing of physicians and nurses and hoping to improve our current medical system and diminish the bad behaviors of the system described and described on this blog thread.
The Question: What is your suggestion to medical school and nursing school ADMISSION COMMITTEES as to the questions asked and history evaluated of those candidates who want to enter the school for their future profession. What questions? What answers? What personal criteria to be considered and investigated? There are schools actually looking for re-evaluating criteria which has been used in the past. ..Maurice.
,StevenMD, I was referring strictly to first and second year medical students who participate in an Introduction to Clinical Medicine Program such as the 50 year old program at USC Keck School of Medicine.
The entire course for the first 2 years has been based on interacting with real hospital patients, one student-one patient with 15-20 interactions each year, each interaction with a different patient, different disorder. At our school, in the past, standardized patients(SP) were only rarely used except particularly a couple times during the year for demonstrating student skills and the SP who were teaching genital and women teaching female breast exams on themselves.
These first and second year students were not involved in lab or other procedural patient test or in treatment.
What they learned was how to interact with a sick patient to obtain a complete medical history and progressively through the years perform a complete (except for genital and rectal) physical examination. There really is no substitute to learn history taking and physical exam without learning by interacting with a sick patient. ..Maurice.
StevenMD, sent me this link to an article in the JAMA Network which reminds us all of the need to preserve patient autonomy but also fits with the title of this blog thread regarding "preserving patient dignity". The article is titled Recognition of Research Participant's Need for Autonomy Remembering the legacy of Henrietta Lacks" whose cervical cancer tissue was used in numerous rewarding studies but without consent of the patient or family. There still is no protecting legislation fully preventing tissue experimental use without permission by patient or after death the patient's family. ..Maurice.
Concerning Dr. Bernstein's request for medical school interview questions, I need to think on that more but I will throw out that for something as important as that interview is, a good percentage of the students are going to be giving answers that they think the interviewer wants to hear. Its just human nature. A really good interviewer might be able to see through it and know how to get more honest answers but not everyone is a really good interviewer.
For example, any savvy student knows that current political correctness demands that women who want all-female staffing for their procedures be celebrated as empowered. At the same time current political correctness demands that any man who wants all-male staffing for their procedures be condemned as sexist. These students know what the expected correct answer is to any gender-based question of that nature.
Would a male student who aspires to be a urologist or dermatologist ever get into medical school if he said his goal is to establish a men's health center with all-male staffing? Or even that he'd purposely hire male staff to better serve the privacy and dignity considerations of his male patients? My guess is no. Both applicant and interviewer are expected to adhere to the "medicine is gender neutral" mantra even when both know that it isn't true.
Not only does there need to be better medical school interviews but there needs to be ongoing mental health tests administered by a 3rd party entity on a regular basis. There also needs to be regular drug/alcohol screenings administered by a 3rd party entity. We need to protect patients from medical workers who dangerous issues which lead to patient harm. We need standards in place to protect patient's rights such as dignity; autonomy; and real, true Informed Consent. The patient needs to be recognized as having the ultimate say in how healthcare is delivered to them. Healthcare needs to cease being a biased, discriminatory system as in part of it females are discriminated against while in other parts males are discriminated against. Medicine should not be corrupt and should not intentionally set about to harm. The public also needs to stop idolizing doctors and nurses and acknowledge they are humans and have human characteristics which can contain good, bad and everything in between. Without all this, we just have the medical mafia system we currently have where harm happens and not anything is done about it.
Tomorrow on Twitter, we are going to do a Twitter storm about medical harm. We are growing and we are going to be noticed. How healthscare is delivered has to be changed. It is not acceptable for so much patient harm to be happening and when it does happen, nothing is done about it. My following is growing so not only I am going to speak up and out but I will yell and scream if I have to in order to get change.
On reading Biker and Jr's followups on my questions about changes in the practice of medical and nursing school's student admission standards, I just thought of a possible addition to the staff of the school admission team. How abut applying students being interviewed and participating in selections by PATIENTS (not affiliated with the school) with ongoing chronic medical illness or who have had serious illnesses in the past which had required extensive interaction with the medical system but who have subsequently been cured? They, as patients and not as medical or nursing school professors, know what they expect from a doctor or nurse and will use their own experiences to guide their questioning of the medical or nursing school applicant. And the admission staff could include some of those who have been writing to this blog thread with their own experiences.
Dr. Steven, as I recollect you have been a member of a medical school admission committee (I have not) what do you think the supplementary input from student interviewers by patients with long term repeated contact with their physicians and nurses would provide a value to the selection of an appropriate "medical or nursing student-in-waiting"? ..Maurice.
To Maurice
Most applicants can "hold themselves together for the time of an interview." The standard older interview, that I did, was often not a good predictor of ability, but it probably did rule out the sociopaths.
I have to think about you suggestion a lot. On first blush it might be an interesting research subject.
I used to ask an applicant a few succinct questions, what sort of physician would they like to have take care of them, what life style would they prefer as a physician. You would be surprised at the strange answers I sometimes got. One young female applicant said that she wanted to go into emergency medicine, because she wanted to work only 2-3 shifts a week and have the rest of the time off for herself, and be paid a lot of money. I was flabbergasted, thanked her for being honest.
We always had current medical students do an interview of the applicants as well.
StevenMD
Hello,
What interview questions should have been asked of the staff members at this UK hospital?
https://www.dailymail.co.uk/news/article-8763747/Essex-care-home-staff-dragged-slapped-kicked-patients-police-investigate-two-workers.html
Reginald
StevenMD,
Unfortunately I am not flabbergasted that your applicant "said that she wanted to go into emergency medicine, because she wanted to work only 2-3 shifts a week and have the rest of the time off for herself, and be paid a lot of money." I'm surprised she admitted it.
My impression is that this is a very common desire among this new generation of physicians. They want to have "a good work life balance" and be at all the little league games and holidays while making a lot of money. They want to clock in and out but be paid as a professional. You see this in hospitalists and intensivists. They want to work 2-3 12s and then sign out the patients (not THEIR patients but THE patients) to the next shift. Primary care has midlevels field after hour calls and send everything to the ED or urgent care. No one takes ownership of a patient anymore.
It's not unique to medicine though. It's the millennial generation. Work life balance is really important to them.
CG
From the article "eginald posted:
"Some staff who had witnessed this abuse did not escalate it. Although they may have feared the consequences of speaking out against colleagues who had abused patients, their failure to act perpetuated abuse and allowed a culture of poor care to become established."
This is what we have discussed multiple times. Healthcare is no different than any other industry where insiders protect their own. It is the Dr. Sparks syndrome where all of the OR staff laughed and went along with her sexual assault of unconscious male patients in the OR for years, and administrators who were aware laughed and looked the other way, and the Medical Board itself wouldn't go further than a short term slap on the hand/don't get caught doing it again reprimand. If the system doesn't protect patients from obvious abuse, what are the odds of them taking seriously the more subtle things we discuss of staff erring on the side of convenience vs patient privacy/dignity?
Caution: since I find on Google inspection there are a number of physicians designated as "Dr. Sparks", it may be more appropriate to define which specific "Dr. Sparks" is being exampled, such as using the full name identification "Dr.Twana Sparks". This caution is absolutely not a defense from me about what Dr. Twana Sparks did nor what happened regarding her "punishment". ..Maurice.
Good catch Dr. Bernstein. Yes I was referring to Dr. Twana Sparks.
Here is a challenge to all participating on this blog thread as I found in my readings of posts on a bioethics listserv to which I subscribe. Here is what the contributor wrote:
"I know that a number of medical schools have worked with their students to rewrite or reflect on their professional oaths (most notably the Hippocratic Oath). I've read several of the end products and the press releases, but I would like to understand better the details of these processes. In other words, if you were to give a roadmap to a medical school that wanted to engage students in this way, what would it look like? (And to be clear, I'm much less interested in decisions made by administration without input from the student body.) One of the aims would be to have adequate representation from students with diverse professional aspirations and backgrounds."
What would be your suggestion for a Hippocratic Oath text to be spoken and followed by medical students as they move into responsibilities with patients in face of all the sad stories and concerns described on this thread over the years.
Can anyone here write a "Hippocratic Oath"?
I may even contribute your contribution to that bioethics listserv for the ethicists and and physicians around the world to read. ..Maurice.
I want to add to my request above. The initial issue might be should medical students even be given the opportunity to rewrite the Hippocratic Oath to have themselves to express and promise to follow?. Should medical school teachers do all the writing of a "new" Oath? Or should, as I have challenged you here, come from the patient public. If the latter, well.. that's my request to the visitors here in my prior posting. ..Maurice.
To Maurice
My medical school, over 50 years ago, decided that the Hippocratic oath was outmoded and inappropriate. Instead, we recited Maimondes' oath.
Maurice,
Oaths mean NOTHING! They are nothing more than marketing fluff.
Even if one takes the oath to first do no harm, it is NOT legally binding. You can promise the moon, but you are not going to deliver if it is inconvenient, you don't want to, etc. What the oath really means is that your medical education was a success and it has destroyed your conscience because to can take the oath to first do no harm, then you go out and break it daily.
-- Banterings
And here is the original (1948) Declaration of Geneva "Physician's Oath"
Physician's Oath
At the time of being admitted as a member of the medical profession:
I solemnly pledge myself to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude which is their due;
I will practice my profession with conscience and dignity; the health of my patient will be my first consideration;
I will maintain by all the means in my power, the honor and the noble traditions of the medical profession; my colleagues will be my brothers;
I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;
I will maintain the utmost respect for human life from the time of conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity;
I make these promises solemnly, freely and upon my honor.
Are you happy with prospective physicians taking this Oath? Anything missing?
How about in
I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;
How about gender or patient defined gender?
Interesting subject related to what we have been discussing here all these years. The bigger question: Is it important that students in medicine speak these Oaths and follow these Oaths as they continue on with their careers or are these Oaths meaningless based on how medicine is practiced in our era and the increasing role of the "business and politics" of medical practice? ..Maurice.
I did not see anything about respecting the rights of a patient such as patient autonomy, patient dignity, respect, and to actually listen to a patient and not change a H&P or MR narrative to suit the purpose of the medical provider. This oath assumes they know the laws of humanity which apparently judging from the harm inflicted and imposed upon patients, many do not the common laws/codes of humanity. Some also have no honor to take an oath on or to swear to abide by. I dislike "my colleagues will be my brothers" as that is sexist and also create an atmosphere of a secret society which is part of the problem now is that the medical community protects the bad and corrupt from discovery even at the cost of harming patients. Not only the health of the patient should be first priority but the patient's right to receive unbiased information and the patient's right to decide course of treatment. Nurses also take oaths to protect patients from harm but they also fail so I would say oaths are meaningless. There needs to be a contract that has consequences.
to JR and Banterring
I don't know if it is just that you are so angry at what you have been through, or if you really believe that so many physicians lack empathy. Maybe I have been blind, but most physicians that I have known are very compassionate and caring individuals. The "oath" they take is not a binding one. Today, most medical schools have a "white coat" ceremony on the first year, usually at the end of a week's introduction to becoming a medical student the week usually consists of lectures and small group sessions which deal with precisely the issues mentioned. The oath, whichever version is used, is an attempt to put a capstone on the orientation, and to impress upon the students, the awesomeness of the future they are embarking upon.
The first 2 years was classically only basic science, but recently the "patient" contact begins in the first week. Such thigs as patient autonomy is covered in multiple ways. This is generally handled in BOTH lectures as well as small group settings.
There is usually some formal recognition as the student moves into his/her clinical rotations. Again the concept of consent, etc., is covered multiple times. Under supervision of more senior physicians, the students are gradually given increaser responsibilities, and is judged on the abilities not just to do the delivery f care, but also compassion.
The oath is retaken as a capstone of the education, usually at graduation.
We can't graduate 100% perfect physicians, but we try. If you you have a problem with your physicians, you need to find a way to discuss your feelings.
StevenMD
Oh! Do I have a great suggestion to our current blog thread for the participants here to perform.
How about displaying here your version of a medical profession Oath which students should speak out at the first day of medical school and the student should repeat at the time of graduation.
And then, not to push an Oath only on those in the medical profession, how about following that with an Oath to be repeated periodically by all patients.
If some of you do this, it will certainly add as a summarization of what views are trying to be expressed on this blog "Preserving Patient Dignity" topic.
Your presentations need not be long but make them free of ambiguity. Remember, ambiguity in an Oath can lead to excuses of "not to follow".
How about that as a challenge for all our contributors here? ..Maurice.
StevenMD
Yes, I am angry abt what happened to my husband but even be4 that I knew many in healthcare really did not care abt patients but I really never thought abt the criminal element functioning in healthcare. I always stuck up for myself but my husband usually was silent and went with the flow so as not to cause trouble for himself. But of course, that didn't work because he was medically battered 2x and sexually abused. He learned the hard way as have I through his suffering. It won't happen again because he will avoid healthcare such as EMTs, ER, and in-hospital care. This is the decision that abusive, heinous healthcare has forced him to make.
Dr. B.
Pls explain why patients should take an oath? What type of oath are you proposing they should take?
JR, in answer to your question "..why patients should take an oath?".
I look at the physician-patient relationship, except under unusual circumstances, for example, when the patient is totally incapable of being aware or participating in any way in their own concern of their illness or make their own decisions, that both parties should be working together to reach a goal which is set by the patient and supported by the medical system. Therefore, it would be unthinkable for both parties reaching for the agreed upon goal NOT to demonstrate their moral and ethical beliefs to reach that goal with an oath of behavior and action.
JR and others, here is maybe a better description to answer JR's question both in terms of "why" and "what":
"The Patient's Oath" by Richard N. Foster
Again, no matter what, and except for unusual circumstances as noted above, there is no doubt in my mind that the doctor ( or medical system)-patient (and family) relationship should be a "togetherness" to reach a agreed-upon goal. Therefore, the behavior of BOTH parties as they work together to meet that goal should be supported by some sort of ethical and moral agreement (an oath) of attempting to reach that common goal. ..Maurice.
JR. I kinda think patients should practice as much prevention as we possibly can. Maybe we could actually reach a point were they would need us MORE than we need them. Then we wouldn't have to tolerate bad treatment from them.
Hello,
I realize that the medical profession prefers “oath” for its lofty connotations – i.e. reference to a pledge before God or, the gods. However, since an oath in our present jurisprudence has almost universally excluded “so help me God”, a better term might be “contract”.
Although the medical profession recoils from this term, this is what medicine has become – witness the many forms signed (contracted), before medical services are provided. However, a contract dispute may involve lawyers – the bane of the medical profession. I would submit that for this reason, the use of “contract” almost never appears on medical forms – albeit, medical forms could be viewed as unilateral contracts. The medical form states what the patient will do, provide, etc. It does not state what specific medical services will be provided. Thus, there is difficulty holding doctors, hospitals, etc. in violation of a contract. They will be held culpable only for negligence or “violation of medical standards”.
Faced with this quandary, the inapplicability of “oath” and the undesirability of “contract”, what can be done to affect a positive patient/ physician relationship. Would mutual respect serve the task? This respect would acknowledge the physician for her/ his knowledge and experience; and, the patient would be treated with regard for her/ his dignity and values. From a personal example, the doctor states, “I’d like to prescribe X but I know you wouldn’t do that, so how about Y?” Here, after many years of interaction, the doctor knows his patient and has been creative enough to provide a “work-around”, in consideration of the patient’s values. Both individuals respect each other. What oath could accomplish this?
Could this mutual respect become the model for patient care? Under current circumstances, I submit, probably not. The current standard is volume. Even payment based upon outcome is affected by volume. Assuming 50% positive outcomes, the payment is ten times greater, if 100 patients are seen, verses 10. Why would a physician spend more than 15 min. with a patient? How could a physician really get to know a patient under these circumstances? The art of medicine takes time. Great physicians are leaving the practice because to these and other constraints. Due to intervening entities (Gov., insurance, employer), patients have little power to affect change. It will take the fortitude of medical professionals and their organizations to wrest medicine from the inimical business perspectives that have infected it. Oaths be damned! Physician, will you heal thyself?
Reginald
Maurice,
How about this for the oath:
recite whatever oath...
...This oath that I take creates a legal binding obligation and contract between myself and all my future patients. I waive all legal immunity and am bound to act in a manner that is in accordance to the oath I have just taken.
StevenMD,
It has been researched, proven, and discussed on this very blog how empathy decreases in 3rd year med students. Maurice has even blamed this on the "hidden curriculum" in discussions previously on this thread.
I have even posted my research that shows the
medical education kills conscience and creates sociopathic behavior among medical students.
You question:
I don't know if it is just that you are so angry at what you have been through, or if you really believe that so many physicians lack empathy.
If physicians are so EMPATHETIC, then why in 2020 does the
lack of explicit consent for intimate exams by med students still occur?
If you are not part of the solution, then you are part of the problem.
Let make an analogy that is current, healthcare providers like the police (in light of the recent protests) are either part of the solution or part of the problem.
Here is an excellent article that explains the reasons why. For providers to say they are acting in an abusive manner is simply NOT enough.
Just as with physicians, the police can’t solve the problem. because they are the problem.
The profession of medicine has a poor track record of self regulation.
I now take the approach that I am the client (customer). Healthcare providers offer me ADVISE, but ultimately they do what I say and in the manner that I dictate it. That protects me and my dignity. Healthcare providers created my PTSD, so now they must deal with the mess.
-- Banterings
Good day Dr Bernstein,
(It would appear that my opinion piece is longer than anticipated. And I must do this in multiple parts.)
I admit I was intrigued by Mr. Foster’s essay on The Patient’s Oath. I read the whole piece, going back a few times over specific areas that seemed salient. While reading, I kept asking myself how would this shape the relationship between a doctor (okay, technically a PCP) and his or her patients. I came to the conclusion that it would remove much of the free will of the patients and put them under the near absolute control of their providers. “Do as I say, or else…” but with teeth. Seeking compliance is one thing, but enforcing it with a shotgun approach seems… Well, just plain wrong. Forget about consent; patients will no longer have a say in their care (or so little of it as to be near inconsequential).
Think I’m overreacting? Push that reasoning a little further. Follow the natural chain of consequences of what he propose (I know, it’s purely theoretical but it does raises serious ethical questions).
Admittedly, Mr. Foster’s suggestions for patients’ responsibilities (I refuse to use the word “duty” here as I believe there is no such thing, as least when it comes to patients) is based – at least on the face of things – on good intentions. But, again, I have to wonder who gets to decide what is best? Who gets to decide if treatment A is better than treatment B? And based on what criteria?
Looking at each items in the proposed Patient’s Oath, I cannot help to wonder if these aren’t meant to line the pockets of the “system” (no going to harp on doctors specifically) with more money. Or perhaps… It is only a veiled attempt to give back power and authority to those who believe they should have it.
“I will seek to understand the causes of my adverse conditions as best I can with the assistance of my doctor and those s/he recommends to me.”
No mention of patients doing their homework and seeking information on their own (they could, but only if that is vetoed by said doctors). Granted Doctor Google has a bit of a bad rep but one would be amazed at the sheer quantity of medical information available to those who bothers to look. It is not uncommon for a patient to arrive at a medical appointment armed with far more information than their own doctor is. That doesn’t make us “professionals” or “experts” but it sure give us a leg up when it comes time to argue the merits of a recommended course of action (or simply understanding our condition). But that just won’t do. How dare we, lowly patients, argue with our betters?
“I will regularly see my doctor for routine physical examinations which are among the best early signs of disease. I acknowledge that early diagnosis is an essential element in cost effective treatment.”
Now that’s a very clever bit of manipulation. It’s been proven that, while routine physical examinations, does improve, over time, health outcomes, it doesn’t mean that one should have a medical examination on a yearly basis. Young (ish) and hale patients do not benefits for yearly checkup (no really, they don’t. That is a myth perpetuated by the medical establishment). While this item doesn’t specifically mention a frequency, I will counter this by asking who would get to decide how often it should be done. To put very crudely, less checkups means less income.
(Yes, I will concede that, in some circumstances – mostly in the cases of chronic conditions – frequent consultation would be beneficial. There; ass covered.)
(continued in my next post)
Dany
(part II)
“I will question my doctor about the causes of, and cures for, my disease until I clearly understand what needs to be done to cure or abate or alleviate my condition. “Given my understanding, I will promise to follow the advice of my doctor, or doctor’s advisors, for the full length of time recommended.”
Again, have faith. Do as I say little patient and don’t ask too many questions (but if you do, ask them to me for I, and I alone, truly knows what’s best for you). But what if I don’t like your advice? Well, too bad. What if I don’t like the side-effects of the drug you recommend? Well, there really isn’t much choices here and I think you should take it. But – Too bad.
“I agree to monitor and verify my compliance with my agreement with my health professionals in a way acceptable to both my healthcare professionals and to me.”
Guilt-driven compliance at its best. I suppose it’s more convenient when the patients themselves are the ones doing the policing. Did you noticed that “healthcare professionals” came before “me”? Now, I wonder why that is…
“If, after starting my treatment, I discover side effects that were not anticipated in my discussions with my doctor, I will consult with my doctor to determine whether my current treatment protocol should be changed.”
Side-effects not “anticipated” are going to be side-effects not mentioned (pharmacology has been around for a while now). It’s been a long-standing practice to carefully dance around certain side-effects (or downplay them) when knowing it might change a patient’s mind. I present exhibit A: placebo and nocebo effect. Note that there isn’t any mention here of the patient plainly stopping the treatment. No, no, that won’t do.
“If I fail to adhere to my doctor’s recommended course of treatment, I will immediately inform my doctor.”
I have addressed the issue of self-policing (and guild-driven at that). That’s kind of like asking a criminal to call the police after he’s committed a crime (isn’t that what a good criminal is supposed to do?). I can see the rationale behind informing your doctor if you are stopping a treatment. But if the only purpose to this is reinforcing compliance (shotgun) and really, really, really convince you patient that they ought to get back onboard, it’s not really a choice, is it? And consider if a “contract” has been signed. This could lead to all kinds of nastiness.
I am pretty sure there is no ‘g’ in doctor. There is, however, an ‘o’ and a ‘d.’
Dany
Dany, I am glad you read and "dissected" (performed an autopsy) on the published example of a "Patient's Oath".
However, I think it is true that, if physically and mentally possible (by the way, even patient economically possible), there should be a formal coordination between the patient and the medical care provider. This coordination (which is something essential to attempt to cure the disease) might best be expressed to all of society in the form of a Patient's Oath.
But I am not sure, as expressed by you (Dany) was written in a form satisfactory to you and perhaps many of our visitors.
So, let's go ahead and create our version of a Patient's Oath to attempt to maximize the possibility of a hopefully common
goal, recovery from illness and return to a healthy and happy life. As you all know, except if the patient is physically and mentally unable at the time to follow a Patient's Oath, it is up to the surrogates (family members or friends who know the patient's pre-illness wishes) for the patient..and if,rarely, there are no surrogates, well, as occasionally happens, it is up to a hospital ethics committee to support the Patient's Oath but..and this is important, also to assure that the Doctor's Oath is followed. ..Maurice.
Maurice,
As to the patient's oath:
I promise to pay you the provider as long as you meet your obligation and my expectations as a CONSUMER.
Dany,
The Patient's Oath is an attempt to regain the paternalistic power that the profession once enjoyed.
Not in the American Medical Association's Original Code of Medical Ethics (1847), In Chapter I, Article II (Obligations of Patients to their Physicians), (section) § 6 states:
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.
I go by the "Golden Rule;" he who has the gold (pays), makes the rules.
This arises from the psychological mechanism of self preservation. Of course they grant themselves absolute power, they wrote these rules. The profession was able to perpetrate this hoax on society.
Why do doctors get to decide when the patient pays the bills? (It is called customer service.)
Now as I advocate, the patients (as the consumer) get to dictate how the provider behaves. The transition is called patient centered care. I prefer the term "patient paternalism."
Turnabout is fair play...
-- Banterings
Hello again Dr Bernstein,
I do agree that a certain amount of cooperation is required. So here's my vision of it: you (the provider) come up with all the possible options. And I (the customer) will decide which one I like best. Oh sure, you can talk about the ones you believe would be the most appropriate (and, perhaps more importantly, why) but don't assume I will go along with your plan. And if choose, after carefully weighing my options and their consequences, to go in a different way than what you think is best, understand that I am simply exercising free will. Nothing personal.
As far as pledges goes, the only thing I can think of would be to agree to treat the provider with respect. No point in being uncivilized (that is, until provoked or threatened).
Of course, one must always keep in mind that "respect" is not the same as "deference."
Dany
With two exceptions, my experience in recent years with doctors, NP's,& PA's has been collaborative, and regretfully I have seen more than I wish were the case. They have told me what they would like the next step to be and why and asked me if I am OK with that. I have been provided options as appropriate. At the same time I have respected their expertise and did my best to be cooperative. When PT sessions for a presumed vertigo problem were making it worse, they accepted my feedback to that effect, and shifted gears with additional testing and other disciplines with different expertise looking into the matter. My ENT doctor was honest enough to say that while all my rather exhaustive test results were abnormal w/o an MRI or CT showing any physical problem, he didn't have a diagnosis but he was going to take my case to a weekly multi-discipline meeting that reviews difficult cases. I appreciated the honesty and extra effort.
One exception was a male Dermatology Resident who was dismissive of my not wanting to stand there fully exposed while a female LPN and female scribe observed and utterly unprofessional in his conduct. My subsequent complaint triggered some changes there. The other was an internist who filled in for my regular primary care and really wasn't interested in addressing the issue I was having. I just made a mental note to never see him again.
My point here is that all the good ones (the majority) and the two bad ones took the same oaths. Taking these oaths is more ceremonial in nature than they are what governs subsequent behavior. I'm not convinced changing the wording would yield much change.
Biker,
That is exactly my point; they are NOT legally binding. So what is the point other than marketing fluff for the profession.
I wonder how many times the oath has been used as a legal defense?
Your honor, my client took an oath to first do no harm. There is no way he would have done the tings that he is accused of...
I would love to see some lawyer for the plaintiff turn it around and say that is a binding contract.
-- Banterings
This discussion has really gotten interesting. I waited to respond for several reasons, but now feel the need to put in my 2 cents.
1. as a physician, one trained extensively in what I did, I would have liked to be respected for my knowledge, and remunerated for the work that I did, not for providing an answer to a specific question, or writing a prescription. I never thought that I had any monopoly on knowledge, or common sense, but I was/am considered an expert in my field.
2. I always considered the practice of medicine interactive and collaborative.
3. I prided myself in educating the patient. This often meant explaining both what I didn't know as well as what I did know.
4. the decision to treat was always made as a collaboration between the patient any myself. The problem would arise when the patient demanded a specific therapy which I either thought was inappropriate, or downright dangerous.
Obviously, I was not the kind of physician that many here encountered, and that is sad. My "brand" of medicine is what I tried to instill on the students and residents with whom I interfaced. I hope that I succeeded.
You know.. what StevenMD just wrote may readily explain why I really never personally got negative professional behavioral complaints from all the years of my internal medical practice. All, 1,2,3,4 represented my interaction with patients. And without personal (and even about my patients' other physician encounters) negative feedback from years of interaction with so so many patients, early on this blog thread I made the assumption that those writing about their complaints here were statistical outliers. And, as with StevenMD, my view of doctor-patient relationship carried on to my clinical teaching with first and second year medical students. However, in recent years, I did refer my student group to this blog thread and the views presented and was discussed in class. Yes, they were informed about my blog thread contributors' experiences and views And, obviously, as with Dr. Steven, I taught them my personal professional views and behavior too. ..Maurice.
Hello StevenMD,
I am glad to see another medical professional join our discussion group. I would like to welcome you here (albeit belatedly).
I am no sure how far back you have read in the past volumes so you may not have read much about and from me.
I'm a somewhat irregular contributor to this blog but will "jump in" whenever something tweak my nose, so to speak, or interest me. I am sure others can confirm that I have a rather direct approach.
To give you some context, I am from Canada. I am a serving member of the Canadian Armed Forces (or CAF). Been doing this for a while now. In fact, I'm getting close to retirement.
There are, obviously, stark differences between the Canadian and American medical system but enough similarities to make me interested in this discussion regarding patient dignity (formerly modesty).
My two earlier posts were in the context of having a Patients' Oath implemented unilaterally, as was suggested by Mr. Foster. I am well aware that it is not the case now (and thanks the gods for that). Bad enough as it is, I can only imagine how worse it would get if patients were forced to adhere to a set of rules devised, as I have explained, to benefit "the system" more than the patients themselves.
I hope my latest outburst will not deter you from sticking around.
Dany
StevenMD,
We're not so much complaining about MDs as we are objecting to the medical culture. My main objection to MDs is that they are not advocates for the patient.
Even if MDs aren't as compassionate as you expect, patients can tolerate one demigod. What they can't accept is all those in the medical community that interact with patients [not just touch labor, but receptionists among others] considering themselves acolytes of the demigod and therefore entitled to similar rights for their job.
Why should a 18 year old high school dropout, being an uncertified MA with one week of OJT, get her jollies not only controlling patients with impunity, but retaliating with impunity. Of course, an extreme case [using a receptionist as an example would be too easy], but it's possible and does make my point. If the workers do their assigned tasks, the administrators/bureaucrats couldn't care less how they deal with the people they serve [short of physical abuse].
There are outliers in health care that have a personal value system that overrides the medical culture and serve patients the way they want to be treated. These outliers receive the letters of appreciation. The bosses, being bureaucrats, think this validates their business model [bureaucracy with profit]. If the model were business, managers would say lets find out what these caregivers that receive the letters of appreciation do [respect, dignity, consideration, modesty] and then train and enforce all caregivers to act this way. In this regards, current bureaucrats above "practice manager" just occupy a slot on the org chart.
BJTNT
BJTNT, do you think physicians, irrespective of gender, but physicians whose occupation is to attend to their assigned patient in all the aspects of maintaining patient dignity, autonomy and providing empathy, education, diagnosis and treatment have another responsibility toward the care of the patient and that is to be responsible for the relationship, actions and behavior which the physician submitted the patient to the care of the physician's various "helpers" (nurses, techs, etc.etc.) And it is the patient's physician to be attentive and involved in "diagnosing and treating" his or her "helpers; behavioral illness" with regard to how they interact with the physician's patient? Shouldn't the "helpers" misbehavior be considered an associated "illness" which has to be diagnosed and treated?
In my experience, I really don't know how much of this added responsibility has been taught to medical students. Treatment of a patient's symptoms and disease is usually not a simple physician-only responsibility. Professional others are usually involved and their behavior should be under physician's watch. Or is this adding unnecessary "work" for all physicians as they care for thier patients? ..Maurice.
Dr B. Attitudes are contagious. The physicians could mention patient modesty at a staff meeting including male modesty. He could inform his staff that its a requirement from them. SOME would listen up and change their behavior.
One thing that is really benifitual about this blog is that nobody gets robbed of their chance to speak. In real time people can interrupt and often they do. Nobody is able to drown out what somebody else is trying to say. Maybe we should make Presidential debates be done on.blogs.
I want to expand a bit about what JF just wrote about "chance to speak". Virtually, every contributor does. I see, in advance, the posting and authorize it's publication. But for me to prevent publication is exceeding rare, in fact it is almost nil except for the dozens of gross "spam" writings usually written currently to some old blog thread but sometimes to our current Preserving Patient Dignity volume.
For Presidential debates to be carried out on classical blogs still, though, depends on the willingness for the blog Moderator to permit publication of all information and expressive behavior. I think having a debate live on TV with criteria of performance agreed upon by parties in advance and a Moderator who firmly sees that the agreement is fully followed is the best for conveying views in a Presidential debate. Anyway, that is my opinion. ..Maurice.
JF,
While what we write is posted, does it matter because no one is listening except in the selective listening mode.
JR,
I assure you that people are listening. Maurice regularly posts these threads on bioethics listserve. I have seen language that is exclusive to those who post on this thread making its way into healthcare policies.
I will let you in on a dirty little secret; new text is RARELY created from scratch anymore. With the dawn of the internet and it becoming mainstream, policies are copied from other organizations, tweaked, and published.
Since 2000, I have been doing this very thing for my clients. Now, I raised it to an art form. I would take 2 or 3 policies and blend them into a work of art. It is no surprise that concepts are copied from places such as this thread.
Think about it, if you are writing a policy for a large, advanced, cutting edge facility, you want your policies to reflect the most up to date thinking. Just look at how many patients' bill of rights use the word "dignity."
I have a transgender friend (of my friend up north) who is currently looking for a new prescriber for her HRT. She too has been abused in healthcare settings and has stopped all preventative care. Part of that, she can not tolerate needle sticks for blood draws due to past adverse events.
She has been looking around and doing preliminary contacts to see if there are any who can meet her needs of prescribing and not doing any blood draws. Saliva testing is an option, but so far all the providers/facilities that she approached lack critical thinking skills only know what they memorized in med school, and insist on blood tests.
I gave her the Americans with Disabilities angle and told her how to request an accommodation. She had a large, world renowned facility respond that they would accommodate her needs. The medical director is taking her on as a patient personally. I also showed her how to go "black market" and "cut out the middle man" so she has something to fall back on.
I asked her to write a piece for my blog after her appointment. If this is true, it will be the first report of a provider that I have encountered who is part of the solution.
I am priming her on everything that she needs to know about patient dignity, and how to be the one in charge of her healthcare.
This is probably something new for this facility to deal with: a legal obligation to deviate from standard of care guidelines.
-- Banterings
Lol. Sometimes it gets quiet on this blog. Hopefully people will start posting again soon. It doesn't need to be in response to what I said.
Banterings.
I have to agree with you about somebody is always listening I discovered this blog about four and a half years ago. I also went back to earlier posts. Back to Patient Modesty volume 2. I can't say that I read everything because I didn't. And a lot of what I read I really wanted to chime in on. Possibly I will mention some.of it currently although the people who posted probably won't hear it.
I think at this point it would not be a bad idea to develop discussion into the topic of the consideration and role of human dignity into political decision-making in the area of medicine and medical care. Should human dignity be a main point of consideration in political decision-making? In politics, who should define what is undignified and what is dignified as applied to the humans who may be affected by such decisions? Should politicians set the limits? Should every policy decision be run through a "political ethics committee"? This emphasis I am now bringing up is essentially important during these times of world and individual country crisis. Or, does such consideration only lead to social division and not arriving at a beneficent goal? There is much going on currently in our country and the world which warrants the consideration of human dignity as expressed particularly in terms of the political effect on patients. ..Maurice.
JF, it is a great idea to go back to specific Volumes (identify the Volume number and whatever visitor by pseudonym wrote the response) and then write on Volume 113 your rebuttal or agreement or addition to the point brought up that interested you.
Great idea! Thanks JF. ..Maurice.
His started as a discussion about medical modesty, so I apologize if I drag the current ethics into a discussion. Forget about whether or not HIPAA rules allow it or not, what are everybody's feelings about how much information about the president's health and that of the other 25 in the close inner circle of POTUS's should be told to the citizens of the country?StevenMD
JF et al, if referring to a prior posting, indicate Volume number and the date of the visitor's posting. This will facilitate the review by our current readers. ..Maurice.
Actually, StevenMD, your question is where is the limit to protect a patient's or potential patients' dignity. Actually, your specific question fits in with my posting at 4:06 pm regarding the relationship between maintaining patient or potential patient's dignity within the political system. Is disclosure of such personal information, within the political environment such as personal COVID infection or potential exposure to infection ethically wrong? What is the ethical limit of retaining personal dignity of the public official by withholding from the public medical information about the individual? ..Maurice.
I'll weigh in on the HIPAA matter. I think even Presidents have a right to privacy. Given the unique power of the President and this country's position in the world, advertising his health details for all to see, friend and foe, could have geopolitical consequences far beyond the public's "right to know".
Yes, an inner leadership circle needs to know the pertinent details of the President's health given the roles they play or may be called upon to play, but that is a very small group.
I don't feel it is my business to know the nitty, gritty details about anyone's health unless they are willing to share. The people in the POTUS's circle I don't need their health info nor is it my business even if they choose to tell me. I don't need to know how much the Pres. weighs. I think it is a tricky balance of personal privacy and our right to know if the Pres. is ill. If the Pres. is ill, then we do have a right to know but again we don't need to know every little detail--just the basic info.
Maurice
I am glad you consider my last post, question as germane. The question is when do the individual rights of a person stop for the good of the community.
There should always be the acceptance that an 8nd8vidual has certain rights of modesty and privacy and is capable of participating in decisions related to his/her care. The problem occurs when thosebtights impinge on The rights of others. In the early to mid 1980s the concept of second hand smoking came up. We had a great deal of difficulty limiting where smokers could smoke. It is now pretty well understood that it dangerous for a non-smoker to sit in a room full of smoke from smokers' use of tobacco. So, laws are almost ubiquitous banning smoking in public locations. Now we are facing new complaints that the government should not force us to wear masks.
The information as to prevalence of covid is, arguably, the most pressing problem. In my town, the governing body, and the local health officer, claim the state has told them they may not release information about deaths in the community, will not allow geographical information about where covid patients are residing. Although this may not seem like modesty, it is very similar. No one wants to embarrass anyone, but wouldn't it be wise to assure turban infected individual is actuallybquarantined, not allowed to leave his/her home? When I was growing up, if a case of measles was in a home, a sign was placed on the door. I don't necessarily want to go back to that, but our reluctance to identify a victim, presents the possibility that there will be secondary or even tertiary cases.
I assume this post will liven up discussion. I don't admit to having answers but, one does wonder where the interest of the public "trumps," pardon the term bit I can't find a better one, the interest on tye individual?
StevenMD, Maurice, et al,
In respect to COVID and individual rights, the following will answer your questions:
Michigan governor's virus powers upended with court ruling
Wisconsin Supreme Court strikes down Wisconsin's stay-at-home order that closed businesses to limit spread of coronavirus
Federal Court Rules Pennsylvania's Lockdown Order Unconstitutional
The Constitutional Reckoning of State Lockdown Orders
As to the question of who decides what constitutes dignity, that is collectively decided by society. Some decisions are in direct response to attacks on human dignity (such as intimate exams without consent) and others protect dignity with existing laws (such as battery; unauthorized touching without consent).
The profession of medicine exists within society and is bound by the rules of society. All those (like Fauci) who say "follow the science" are only showing the limited scope of their intelligence because society is NOT bound by science.
The threat of death does NOT frighten real Americans. Real Americans value things such as liberty above life. This is most evident in the motto, "Give me liberty or give me death."
The failure of the profession to self-police lead to bad doctors continuing to practice. That lead to more malpractice lawsuits which lead to higher insurance premiums. When independent practices could no longer afford the high premiums, the practices were absorbed by large healthcare systems and those doctors became "retail" employees which lead to where the profession of medicine is at today with burnout and suicide.
This is an example of the axiom of all systems seeking equilibrium.
Someone, please tell me how a profession of alleged intelligent, caring, learned, and compassionate people can morally justify and think it socially acceptable to perform intimate exams on unconscious patients without consent?
How does this still happen in 2020?
This is only one of many issues.
THE PROFESSION HAS NO MORAL AUTHORITY!
Ethics committees, are a joke. If you are not part of the solution, then YOU are a part of the problem. Very few are part of the solution. If the members of the profession really condemned the practice, it would NOT exist.
Judgement is coming. It came for the clergy. Now it came for the police. Guess who will be next?
-- Banterings
StevenMD,
The issue of secondhand smoke was a compromise. Instead of outlawing tobacco all together (which is what government SHOULD do if it truly poses such a health risk), society has accepted limitations (in the name of liberty) to keep the product available.
The canibus and vaping industries are pushing back on some of the secondhand smoke restrictions, mainly because vaping (in its many forms) does not use smoke.
-- Banterings
Banterings,
Great piece!!!!!
StevenMD, It is not about modesty not releasing the names of the ones who die of COVID. It is simply no one's business. We don't release the names of others with transmittable diseases so why should they be singled out unless you do for all? Modesty as you call it but it is really the right to personal dignity is a right recognized by the UN and others saying all humans are entitled to personal dignity whether they are modest or not. The terms are different. Modesty infers it is an individual requiring special accommodations while again all humans are entitled to personal dignity and if that was totally respected, those most modesty issues would be taken care of naturally. When you have neighbors policing other neighbors, bad things happens for example the Salem Witch Hunt to name just one.
I see Joe who was exposed to COVID positive people didn't self-quarantine for 14 days but tells us he wants a mask mandate. You have the CDC reversing positions almost daily. You have misinformation like don't wear a mask, wear one, wear one but it doesn't help, etc. You have info that germs are self-policing by only going a distance of 6" but then when Trumps stand alone on his balcony he becomes a super spreader? People out here are tired of all of this. Yes, we could get it and die but funny thing is you die eventually anyhow. You can also die from flu and even the common cold can kill some so maybe no one should ever venture out but somehow I think death will eventually come.
You have the mayor of NY who outlawed big soft drinks but yet still allows alcohol and tobacco sales along with Ding Dongs and Twinkies. Big Brother thinks they have the right to police our lives as does the medical community with their false science. Have they seen the side effects of the drugs they prescribe us? What about the really obese ppl riding around the grocery stores in carts? Should I tell them to walk. What about healthy young women making use of WIC and then having to listen to the grandmother say when she was on WIC they let them buy more things or watching them pay for alcohol or cigarettes with cash? Do I have the right to police them? Really would like to have that right.
We will always have dangerous diseases. There is no way around it but we don't have to become so paranoid we turn into a country afraid to live by hiding in our basements. We are told to wear masks to protect others--do they work or not? The ones who are truly sick w/ COVID aren't running around but are sick either at home or in the hospital. Ppl w/ flu are out and about infecting and many, many people including children and the vulnerable die each year and that is despite having the flu shot.
I, for one, am happy Trump is up and around. It proves with better care than most who died received, you can recover and faster. It is very encouraging to see that in a man of his age despite whatever the politics are. Instead of all the criticism, perhaps science should study his case and see what went right. PS. I asked on Twitter about Joe and quarantine to some of his supporters but so far no answer.
Speaking of quarantines, the assisted living home where I work ended Monday. Visitors still can't come into the general population but there's a room for them to visit their family members. They have to make an appointment. But there hadn't been visitors for more than 6 months.
As far of these kinds of facilities keeping elderly safe, I don't think enough was EVER done
Signs were posted on the door for visitors to not come and visit if visitors had symptoms but if we workers tried to call off sick the bosses would yell at us over the phone and threaten to fire us.
StevenMD, JR, ,
To really understand the difference between dignity and modesty, you need to go back to 2017 thread and see when I proposed to Maurice to change the name of the thread. The logic and facts were so compelling that Maurice changed the name. It was over the course of 3 volumes as I remember...
Patient Modesty Volumes 2 to Volume 92. Patient Dignity Volume 93.
( I looked it up.)
JF, you are correct, the title to Preserving Patient Dignity was changed for Volume 93 in October 2018.
To all:
I still would be interested in what our current readers found interesting replies in the earlier or very early "Patient Modesty" volumes. Read then return and display the previous writer's comment and add your own, identifying the Volume number and the date of the writer's comment. This return from the past may be interesting. ..Maurice.
Dr B. I intend to post something in response to an earlier post but I'm having a hard time finding it. I'm thinking maybe it wasn't even on this blog because it was something said by a Dr Joel.
This blog is beneficial for a couple of reasons. First it has empowered certain patients to know how to find their voices and speak up. Secondly sometimes it helps patients identify a medical encounter that could become a dignity violation. The internet doesn't always give the needed information.
I believe JR is doing something tangible for the improvement of medical care. Also Bantering and Mistie and some others. What we SHOULDN'T be using this blog for is stoking anger. At least not without doing something further
Something I have thought about is writing down posts describing well what the problem behaviors are and the impact
( often it's patients avoiding needed care ) Suggest a better way of doing it. And MAIL the comments to the places where the violations happened or could happen. A letter with a signature would be best. Better credibility. But SEVERAL posters here have written multiple letters and felt that they were talking to a wall. It's exactly like medical staff don't care if those patients ever return for care. Just the staff persons victory for the one encounter only.
JF,
My transgender friend said that she has used the Americans With Disabilities Act to receive "reasonable accommodations" since I taught her how to use it. She reports that the responses are either sympathy and accommodations. She was accompanying her cousin to a colonoscopy and was refused entrance due to hospital COVID restrictions. The gatekeeper (receptionist) had NO clue who called the charge nurse who also had no clue. At her request, I am going to address the issue with the hospital.
These are the legal tools we need. The ADA has been the most successful tool.
-- Banterings
JF, Dr. Joel Sherman may be who you are referencing. He has written here periodically over the years and the blog "Patient Modesty & Privacy Concerns".
..Maurice.
Let's get down to the "nitty gritty" of the ethical issue of the "moment" regarding Presidential dignity. Is there any difference between what we all should consider as elements of "patient dignity" and "Presidential dignity" when the President of the United States has become a patient. The answer to this question should not be a political answer but one of what is ethical for the President and for the People of the country he (or she) serves. In other words, does the President retain every single bit of the "rights" of any other patient but still retains and maintains the responsibilities of a President for which no other citizen can hold? I am not sure that we have all specifically answered that question so far on this blog thread. I think this is important since our President appears to be holding on to his dignity as a patient and likewise supported in this regard by his military physicians.
Again, the answer to this question should not be looked upon as purely political but represents defining the ethical relationship between the President and the people. ..Maurice.
To Maurice
I don't remember when it happened, but I remember something called the Texas Bell Tower decision. In essence, a physician has an obligation to report an individual who is likely to cause harm to others. That was often used during the AIDS epidemic.
Here is a current essay regarding the relationship between the President and his physicians' decision regarding disclosure of the President's medical information, HIPAA and the classical California (and later other state's) laws regarding the Tarasoff decision--exposing patient confidentiality when of life and death importance to others. ..Maurice.
Hello Dr. Bernstein,
Thank you for the article, “The Limits of Trump's and Your Own Medical Confidentiality” by Robert Klitzman M.D. I was somewhat amazed at the doctor’s statement, “I was unsure whether I should report her to Child Protective Services .…” Dr. Klitzman’s bio indicates that he graduated from Yale Med School in 1985. This was over ten years AFTER Congress passed CAPTA (Child Abuse Prevention and Treatment Act), which essentially codified Dr. Klitzman as a Mandatory Reporter. How could he be UNSURE whether he should report the mother’s child abuse? What does this say about the medical training between 1974 and 1985; notwithstanding that of the present? Furthermore, Dr. Klitzman’s un-parallelism to President Trump’s condition is astounding. The doctor’s final statement is amazingly absurd - “Trump needs to realize this fact as well, and allow his records to be released.” The mother in Dr. Klitzman’s article committed a crime and he (the doctor) was obliged to report that crime – i.e. release private medical information. The doctor released the information not, the patient. Additionally, a crime was committed. Aside from those who view the President’s birth as a criminal act, how do these circumstances apply to Mr. Trump’s situation? Obviously, regardless of Dr. Klitzman’s muddled thinking, there is no parallelism. To be anywhere near consistent, the doctor’s final statement should have been, “Mr. Trump’s DOCTORS (as mandatory reporters) should release his medical records to the proper authorities.” Would this also apply to Presidential candidates; or, is Dr. Klitzman’s politics shining through his ignorance of who should report or be reported?
Reginald
In 1974, the United States Congress passed the Child Abuse Prevention and Treatment Act (CAPTA), which provides funds to states for development of Child Protective Services (CPS) and hotlines to prevent serious injuries to children.
Too bad because Children Services are a few steps below WORTHLESS!
JF
Maurice,
In regards to "Presidential dignity," this is the same issue of COVID and all those touting "science." The profession of medicine exists in society and is subject to the laws, norms, mores, and expectations of society.
So HIPAA, as the law of the land applies to the President. HIPAA is trumped (no pun intended) by the Constitution which defines our power structure and the rule of law. The people have a right to elect their leaders and know who is in charge (thus, if the failsafe of the Vice President has kicked in).
So the President's physician has the right and obligation to make certain disclosures so that the people know exactly who their leader is. This right and obligation is also due of the congress because they can remove the President and the Speaker of the House is 3rd in line for succession followed by the President Pro Tempore of the Senate.
This may be tempered or overridden by other laws and the Constitution. National security is one issue that comes to mind. If the appearance of weakness or disability of the President may embolden or excite to action enemies of the state, then the disclosure may me overridden and even the facts altered.
Proof of my assertion lies within my previous post with references to where the lockdowns in Wisconsin. Michigan, and Pennsylvania were declared unconstitutional.
There is no simple answer to Presidential dignity.
-- Banterings
Concerning our discussion about presidential dignity, how about a candidate for the presidency? Biden's physical AND mental health has been largely covered up. Shouldn't it be just as important for Americans to know about his health limitations before the election as well? He seems to be losing it mentally. Nobody seems to be talking about that.
One thing I appreciate about this blog is that although it seems clear that Dr. B leans left politically (being a college professor in southern California probably doesn't help), but unlike a typical liberal he doesn't try to censor the opinions that he may not agree with. Thank you for that.
LC
LC. If Dr B is left leaning, then he is a minority on this blog. Which is suggestive to me that most of the posters here are white. If Joe Biden is less healthy than he claims, he has a vice president to step in for him if he becomes too sick to work. But maybe that isn't the point? I think possibly the mental problems you speak of are nothing more than occasional stuttering. If we think we should know about the health of the presidents or people running for president, we need to take it up with lobbyists and lawmakers. Its for sure that the American PEOPLE should never be allowed to make those kind of requirements.
LC,
I agree that Dr. B. is very left leaning & so is most of the medical community hence the mess we now find ourselves in as they are trying to control us using healthcare. Hillary once said that whoever controls the healthcare controls the people. This has been done & is being done. I, for one, does not want the government controlling healthcare as they have made a mess of Medicare/Medicaid. Politics and healthcare is not a good mix no matter which party is in control. Government should be doing the job of protecting us from healthcare rather than just being rubberstamp of healthcare's wrongdoings as well as the justice system should be doing its job to rectify wrong once it has been done but justice has failed us too.
Been doing a lot of talk on social media abt the concept that healthcare claims ownership over patients. They seem to think we are beholden to them. They seem to think they can order us around & we must obey. They seem to treat us as naughty children. This falls back to the thought they don't believe patients have rights such as personal dignity which covers many things besides bodily privacy and autonomy. They seem to cop a superior attitude. They seem to believe they can do no wrong even though clearly that is not the case. We know no career category that is perfect as we know cops, teacher, clergy, politicians and all those not mentioned have people within them that can be labeled as "bad". Healthcare is not immune to this but seem to deny and deflect from it. There are systemic issues within healthcare that needs to be addressed but healthcare is resisting change. We must pound down the doors and open it to scrutiny. No more secrets and hiding behind smoke and mirros. Healthcare is an important part of every individual's life so healthcare needs to become friendly to its users.
It has been suggested that the 25th amendment that Nanci Pelosi is proposing is a way for the congress to remove President Trump if he wins again. A political insider friend has told me this is a way for the ultra-radical wing of the democratic party to usurp the election and get Kamala Harris the presidency.
After the presidential debate, Vice President Biden denounced defunding the police, the New Green Deal, and many other ultra-radical proposals that he had previously agreed to with Senator Bernie Sanders.
Even though Biden is liberal, he is (very) old school and respects the Constitution. He is fearful of some of the ultra-radical proposals being pushed like the 25th Amendment and stacking the Supreme Court as these will do irreparable harm to our rule of law.
He is caught between a rock and a hard place with his advanced age and trying to secure a legacy other than repeatedly losing the presidency.
-- Banterings
Well, I take a deep interest in the medical profession and how healthcare is managed and performed to the patient--especially me. Since I will become 90 years old on November 6 2020, I have that special interest as you can imagine. Having been in medicine since 1965, retired from active practice in 2000,
and volunteering in a "free clinic" for immigrants for the past 17 years, And, finally teaching medical practice to first and second year students for about 30 years, I feel I have contributed to the profession and the affected lives of patients. As you know I have been all participating in medical ethics for over 30 years and publishing this ethics blog for over 16 years with the contribution of my reader participants on a whole host of ethics subjects.
But, now once again I am a patient, having survived a coronary artery by pass grafting 22 year ago, unfortunately, the grafts plugged 4 days ago and underwent 4 stent coronary artery opening which prevented an established acute heart attack. And now I am at home recovering. As you see, so far, I have survived.
And yes, this hospitalization had VIP issues which, of course, I rejected as I did with my last hospital admission which I had experienced with my last two including failure of the hospital to allow my family members to know that I was a patient
there. I fixed that.
Anyway, this has been all about me. Now, I will be looking forward to visitor comments here about the issue of preserving patient dignity in these trying times.
..Maurice.
Here is a dignity matter, sort of. A good friend had a significant stroke several months ago at age 66. She is in an assisted living facility now and continues to slowly improve with physical therapy. She will hit her limit for allowable (by Medicare) therapy sessions by the end of the month. She can well afford to bring in a private therapist but the facility she is in won't allow anyone in due to covid. At the same time she can't leave the facility to get to private-pay therapy sessions elsewhere due to the asissted living facility's lockdown. She can't go home and get the services she needs from there on account it just won't work for her physically. So, she won't be eligible for more therapy sessions at the facility, can't bring in anyone private-pay, and can't go offsite for private pay therapy either. The healthcare system is essentially telling her to get used to life in a wheelchair because we won't allow you to get better.
She is well off and will buy herself a solution somehow but someone less worldly and of less means would be stuck between a rock and a hard place. How is this dignified healthcare essentially telling a patient you need more therapy but sorry you can't have it.
Biker At the Assisted Living Home where I work at we often walk patients who are somewhere between wheelchair bound and walking unsteadily. We aren't required to and for the most part we don't even have nurses around. Just our Director of Nursing and she's not around much on second shift. Probably not on third shift either unless at the tail end of the shift. What MIGHT be good for your friend is a Merry Walker. But I'm not sure they even exist anymore. The last time I remember seeing one was in 2006. Maybe you could Google about it. Once the staff person helps the patient get into it they can walk around safely without help.
JF
Are you saying that non-whites aren't intelligent enough to think for themselves and have common sense? That they aren't capable of having dignity? How do you know what color my skin is?
LC
LC. I absolutely am not saying anything of the kind or thinking either. Do you know whether I'M black or white? This isn't a political blog. If you want to argue with me about racism or politics send me a friend request and we'll argue and troll each other on Facebook.
Hello Dr. Bernstein,
I'm sorry to hear of your recent hospitalization. I'll pray for your speedy recovery. Take care.
Reginald
Dr. B.,
Finally, something we can agree on 100% but I am wondering what your medical definition of preserving patient dignity is vs. what preserving patient dignity really should be? To be clear though, patient dignity of certain religious groups and even gender is more closely preserved than for others not fitting into this group. So are you saying all should be equal no matter what?
JF,
To be fair, you have labeled me as a Republican bc I have openly criticized some issues. When I flagged a Tweet by a Dr. who said if the current was "her" patient she would have called security & had him physically restrained, I did post that as an example of how little control the ordinary patient has in their medical care. I started out with "politics aside" it was a scary scenario when some lowly doctor was willing to force on the Pres of US based on their over inflated view of power they had been granted. With attitudes like the one of that doctor, it is no wonder patients are harmed because they truly think they are the greatest power put on this earth and have final say over any patient. It is indeed a scary world made even scarier when entering the doors of a medical facility when "gods" like those are in charge. No wonder there is a lack of patient dignity and denial of patient autonomy. They really believe they have ownership over patients. By the way, that tweet caused quite the stir as it represented to even Trump haters the power medicine has over the normal patient. In another post, I tweeted about an article where ER patients are being registered to vote as I am totally against the mixing of politics and medicine. It is a lethal and/or heinous combo as evidenced by what happened to my husband. Supposedly in the ER they don't have time for Informed Consent but somehow have time to register voters, then something is going on that should not be going on is my opinion.
Dr B. Dignity in infants? I don't know what you mean. Infants are kinda like Lady Gadiva in the sense that she didn't care if the whole world looked. Infants don't care either.
There is more to patient dignity in infants than whether they are seen nude. Dignity in infants would be damaged if they were considered and treated by anyone at some time that they are simply objects..such as in
medicine as a "sick object" to be treated. Dignity goes beyond bodily exposure ..Maurice.s
Agreeing more than twice in one day but yes, dignity is more than just exposure. It is how you are treated. Are you respected as being an equal? Are you addressed properly? Are involved in the conservation or talked at or down to? Are you really being listened to? Are you respected as the most involved person in your care? Are you recognized as a person not just the last patient of the day, the patient with a rash, or an insurance number? These are some prime examples of patient dignity but not all. Of course, all of these are deeply tied to if they respect your bodily privacy. If one part of patient dignity is not respected, chances are other parts won't be respected too.
Dignity must include not speaking about people in a derogatory way or in a complaining fault finding way. I once heard that gratitude and complaining attitude are incompatible and can't exist in a person's heart at the same time. Im not sure I agree though. But speaking in a derogatory way, whether or not your victim hears it is actually abusive because it influences how the listeners veiw that person. Many people are guilty.
I hope all my regular participants here are healthy and still have something to contribute to this blog title topic. I miss the day by day participation. I look forward for upcoming views.
My own medical condition remains stable.
..Maurice.
I agree with the others that dignity is multi-faceted and will say that too many who work in healthcare conflate being polite with being respectful. Being polite is an important aspect of being respectful, but it is but one piece of the puzzle.
Pay attention to what I am saying and tell me the options to the extent there are valid options, but also give me your recommendation. If you don't know the answer, that's OK; just be honest in that regard.
The polite vs respectful aspect covers many things, large and small. If I am not fully clothed, opening the door simultaneous with asking if it is OK to enter is not respectful even if you are being polite and friendly in your greeting. Respectful is waiting for an OK to enter. Walking in the room with a student in tow & asking if it is OK that he/she observe is not respectful no matter how politely you pose the question. Respectful is asking before the student enters the room.
Another aspect to this is what is convenient for the staff and makes for the most efficient protocol is not necessarily synonymous with being respectful. This too can be big things or small. If all I have on is a gown and you need to examine my abdomen, cover my lower half with a sheet first and then lift the gown from under the sheet exposing only the abdomen. Intimately exposing a patient, even for just a brief moment, is not respectful if the procedure didn't actually require exposure. Perhaps prepping a patient for say a cardiac cath can be done a couple minutes faster if the genitals are exposed, but being the genitals aren't part of the procedure, erring on the side of efficiency is not being respectful.
It is sort of like the old business mantra of price, quality, service; pick two. No business can be the best in all three. The most successful ones know which two they've chosen for their business model. Healthcare similarly can't choose as their top priority both convenience/efficiency and respecting patient dignity. It would be great if you could, but it is all but impossible to do. Urology and dermatology practices only hiring female staff is a perfect example of choosing staff scheduling convenience over respecting the dignity of their male patients. So they choose convenience over dignity.
Biker
I can't agree more. As the physician, I was always sure to have the curtain drawn around the patient even though i was walking out of the room, and always knocked before entering, even with the curtain there. I always worked around the patient moving the gown to try to be sure there was minimal exposure, but there was no way to totally avoid some open nudity.
I would avoid ever having a student follow me, unless there was a very strong reason to have him/her with me. Most student observation is, my belief, not worth while. They really don't get "close enough" to gain much from the experience. When it comes to a resident, that is slightly different. They most oftne, in the clinic anyway, serve as the primary physician and I am there to check that they did everything correctly, and didn't miss anything, so the roles played were always explained to the patient. Unfortunately, the patient really had no choice, it was the nom in the clinic to be seen by a resident.
StevenMD
StevenMD, I have no qualms about a Resident serving as the primary with another doctor such as yourself observing and don't expect to be asked if that is who has been assigned to me. I do expect to be asked beforehand for tech, nursing, & medical school students that are just there as observers.
Having had more intimate exposure medical exams & procedures than most will ever have, I also totally accept necessary exposure, including with female staff in the absence of a male staff option. I am a very cooperative and polite patient but in turn I expect to be treated in a respectful manner as if my dignity matters to them.
When I ask for a male nurse to do my cystoscopy prep for example I know the answer might be that one is not available and will accept the answer but I won't accept attitude from the female staff member I am dealing with for having asked. I also expect that those who are doing the exam or procedure will err on the side of minimizing my exposure rather than maximizing their convenience. A simple gesture that I appreciate at my current urology practice is that as soon as my cystoscopy prep is complete, the nurse covers my penis with a towel while we wait for the doctor. There is no reason to leave me exposed while we wait and so they cover me for those few minutes.
Based on my experience the culture of different hospitals in this regard varies greatly. Some such as the one I moved all of my healthcare to a few years ago seem to really get it, but even there the dermatology dept struggles with the male patient respect/dignity concept. Interestingly, that dept is not in the main structure but rather about a mile away in a separate building. Perhaps that allowed a different culture to develop. I have made waves there however and some changes have been made as a result. It amazed me that they didn't understand why a male patient might be uncomfortable having a full skin exam while a female LPN and a female scribe just stood there and watched.
http://www.outpatientsurgery.net/outpatient-surgery-news-and-trends/opinions-and-editorials/ideas-that-work-infection-prevention--08-
Just received this article from Outpatient Surgery talking abt how germy personal cell phones are when carried into the OR. They said vendors are the most germy followed by CRNA. My question is what in the blazes are personal cell phones/devices doing in any patient care area at all? How is that even remotely HIPAA compliant? Who controls those cell phones and controls who sees those pics? No one is the answer. This is a violation of any patient's right to privacy/dignity. An unconscious patient is not able to defend themselves. There are plenty of news articles of personal cell phones being used to take pics of patients so medical staff could share them on FB or w/ their own family/friends. There are absolutely no way a personal device should be used. Most hospitals ban the use of patient cell phones to record the encounter as they don't feel patients have the right to take pics/recordings but yet they allow patients to be used as porno entertainment? There needs to be regulations on pics and patients must be given copies of pics, why, how they will be used, and any info regarding the pics but the first thing is patients need to be given the right to say no.
I don't know if this fits in with what everyone else is talking about but one indignity is low wages. What I do is important. Whwn I actually worked as a CNA in nursing homes the work load was often CRUSHING! But low paying. But it doesn't require a lot of education. ( if any other than knowing how to read )
I don't think people are consciously aware of it but the common mindset is better wage equals better person.
JF, I concur that CNA's are not paid enough for the work they do. When my wife was hospitalized for about a month earlier this year, and unable to tend basic hygiene matters on her own for much of that time, the CNA's bore the brunt of that work. Nurses did some of it in the early days when her condition was critical but once things stabilized and she was in a regular room, it was the CNA's there for all the unpleasant work. We let them know how grateful we were for all that they did.
I am pleased to announce that I have a report of a provider who is actually part of the solution and not part of the problem.
A transwoman friend, who was introduced to me bu my friend up north has also had very bad experiences (and even abuse) with blood draws. Her situation is similar to mine. She can no longer tolerate intravenous needles, especially blood draws.
Because of this, she was getting her female hormones "black market." Her best friend convinced her that she should be seeing a doctor for this care. She did not want to disappoint her friend, but she could not tolerate needle sticks.
I stepped in.
Although blood work is in the guidelines for gender affirming therapy include blood work. Guidelines are ONLY recommendations. They are the care that most providers provide.
There is no law that the provider must follow guidelines. It is their choice. Because the medical education teaches repetition and memorization, critical thinking skills severely are lacking in the medical profession).
GENDER AFFIRMING HORMONES CAN BE PRESCRIBED WITHOUT BLOODWORK!
(Especially for someone on them 10+ years.)
I had her sit down with a psychologist who saw PTSD symptoms and she is in therapy for it. I told how to word inquiries to different LGBT clinics. She inquired (so as not to waste the clinic's time (or her's), if the clinic would grant her an accommodation under the Americans with Disabilities Act (ADA) a prescription without bloodwork.
One provider agreed. She was actually high up in administration, but took on her case personally. She was given a prescription without bloodwork. She is waiting for the provider to give permission to allow her to publish names of her and/or the facility.
She did tell me at the beginning of the appointment, a nurse tried to draw blood. He was getting pushy, and after ignoring the second "NO," she felt threatened, got extremely defensive, took a defensive stance, and said that she "felt her body swell up."
She said the first mistake was the nurse was TELLING her what he was going to do (not asking permission). When he ignored her refusal, she took that as a threat of assault and violence against her person.
Her friend who was there as her support person later said that he was "on autopilot" (a drone, just doing his job, etc.). He was unaware of the arrangements made prior to the visit (obviously).
He should have been asking (not telling), and just like with dating; NO means NO!
The provider, a nurse practitioner did palpate her abdomen to check for an enlarged liver. That is it.
I put this MP in the "part of the solution" category.
-- Banterings
JF,
CNAs may not have the piece of paper learning but they have something better--common sense. They do the majority of care for patients so they are better as knowing when a particular pt is not feeling well or something is wrong. Nurses don't take the time bc it is beneath them. Yes, they need better pay but the learned class think they are the only ones worthy of bigger pay. The diploma means nothing to a patient when it is the CNA caring for them in a compassionate manner when the nurse ignores their calls. Without CNAs, many medical facilities would grind to a halt. Stand proud knowing you gave the best care you could while those with degrees never really helped except to boss and doing a poor job of that.
Banterings,
Great news! Every victory brings us closer to claiming back our right to receive safe, humane medical care.
StevenMD, I have always felt that the Introduction to Clinical Medicine (ICM) carried out yearly for decades at the USC Keck School of Medicine for first and second year medical students, represents truly how this early medical student education should be carried out. From the first week, each medical student begins to interact with a real hospitalized patient, with the patient's informed permission and under clinical instructor's supervision, the student puts into direct practice how at first to take a productive medical history and later as they learn techniques add on the performance of a physical exam. The students are not only monitored by their instructor for their clinical developing skills of history and physical examination but the interactive personal behavior with the patient. This is one step in learning about caring and understanding about patients. Two years of this training interacting with 15 patients on weekly sessions each year. It is the real patient, not one standardized patient after another or reading skills from some book.
Feedback, of course, comes from me, their instructor, but also from the hospitalized patient him-herself. Each instructor monitors their stable group of students regularly for their behavioral and physical skills and all students are given feedback.
This, plus their anatomy lessons, learning about pathology within the various systems also goes on elsewhere in the school during their week. Yes, standardized patients are most useful in semester tests of history taking, physical exam and behavioral interaction with these "patient simulation" individuals who also grade the student who interviews and exams them.
All of this is NOT "shadowing" a physician which I personally find terrible for any patient whether the student is a "pre-med" or actual medical student in the first two years. This is NOT how a beginning student should start the learning process.
(more to come) ..Maurice.
"Getting close enough" is not wandering with a doctor interacting or examining a patient who really doesn't know who that "student" is. It is the medical student's direct interaction with a patient based on the patient's acceptance of the student and the expressed goals for the session.. which is what ICM is all about. Nothing more, nothing less.
Yes, all first and second year students are monitored by their instructor for physical, emotional and behavioral problems as each year goes on and supportive or therapeutic attention is carried out. None of this is possible if student education regarding real patients is carried out by "shadowing". But it is direct, supervised, interaction as one student and one patient that can build early medical student confidence in their medical and patient-interactive skills. More to come. ..Maurice.
And yet, for some medical students introduced to medicine and patient in other ways can induce "horror" of the now and the "unknown" future. I want everyone of my visitors to go to "The Horror of Medical School Captured on Film". Click and sit for the few minutes long medical school video drama and read and think about what the medical student "producer" has experienced and concerned about other medical students experiencing. Then, of course, what I previously wrote and this article/video can be discussed here. Remember, "patient dignity" is also set by the experience and trauma of the student, now doctor, during their medical school education. ..Maurice.
A friend of mine on Twitter found this site that med students use to talk about patients. Really informative piece.
https://9gag.com/gag/aAdy8P0
Piss them off and get harmed is the theme. Shows the immaturity of med students and for some, they never loss that need to harm.
Also, found this article abt how the Indiana State Medical Board licensed a convicted felon to become a doctor in Indiana. However, he did not give up his life of crime. It is nice to know that convicted, violent felons can give medical care to unsuspecting, defenseless patients. At least that is the case in Indiana. No wonder my husband was the victim of multiple counts of medical batter and sexual violence. There is no real oversight/guidelines to prevent medical harm.
https://abcnews.go.com/US/story?id=91055&page=1
Also, found this article (one of the few ones) addressing patient harm the side effects it has on the patient and their family.
http://www.ihi.org/communities/blogs/adding-insult-to-injury-addressing-the-long-term-impact-of-patient-harm
Quite a few on Twitter can identify with this articles. Victims of person dignity (modesty) violations also fall into the harmed patient category.
For those who read the brief article I referenced and looked at the brief student-production video, I can tell you that the content. while representative of an occasional medical student, based on the instructor's monitoring of each student's psychologic behavior (part of our job), we don't see this in any large fraction of students. And. if we do find such an emotionally upset student, they are actively attended to to attempt to relief their uncertainties or frank depression. We teach clinical medicine but we also are alert and have resources to provide emotional support and hopefully resolution.
Our behavior is NOT like the terrible professional behavior of the teacher/counselor in the video. ..Maurice,
Speaking of medical errors my younger sister had surgery for a kidney just a couple of days ago. When she was opened up, instruments were found inside of her from another surgery 12 years ago. She mentioned to us wanting to sue the doctors who did that to her but worried the the statute of limitations might make it impossible.
JF,
As far as I know most have a 2 year window unless special circumstances apply which rarely are recognized.
Doctor SteveMD and others, please read the opinion of KB written to the blog thread dealing with COVID-19, it is also pertinent to what was written on this thread. ..Maurice.
JF,
With regards to your sister, the 2 years starts from the day the instruments were discovered. The harm and malpractice has continued for the last 12 years. I would find a good lawyer and consult with them on the issue. You may wish to discuss these alternative approaches that I will mention.
If malpractice in your state will not allow the date of discovery, then if the surgeon is licensed in multiple states, your sister can sue him in one of the other states he is licensed in that is more favorable to patients.
Here is one example: Legislation Aims to Prevent Venue Shopping in Pa. Medical Liability Cases
You may want to consider a lawsuit for battery (unwanted touching) where as your sister never agreed to "permanent medical devices."
You may sue under the RICO statute, especially if the surgeon was NOT an employee of the hospital. Multiple entities shared in the same funds (your sister's insurance payment) and the base crime was collusion (in that there were other people in the OR that should have been aware of the instruments but said nothing). You can also civilly sue for collusion.
You can also sue for (accounting) fraud. Did you ever watch a lottery drawing and see the note "lottery drawing audited by Xxx Accountants?" Accounting is much more than just money. It can be inventory. 12 years ago, facilities were counting instruments before and after surgery. Somebody fudged numbers somewhere.
You can also sue for fraud of unregulated, non-FDA approved, implantable medical device. Surgical instruments are considered medical devices, but they are NOT approved for implantation (they were NOT meant to be left in the body). You can sue on this aspect as fraud.
Again, all these base crimes count towards a RICO (civil) suit. You can also file a complaint with the FDA that the doc and facility are using non-FDA approved, implantable medical devices.
My logic is (technically) accurate, but may be a harder sell to a lawyer or jury. (Just ask JR.)
Make sure that your sister asks her new surgeon for the instruments OR to preserve them as evidence.
Finally, if you cannot get justice, you can still get a pound of flesh (if the facility/doc refuses to address the issue and they are not compelled to): Get an attorney that specializes in news conferences/PR. Go on every news outlet (don't forget internet only news outlets (like Vice) AND outlets that take a special interest in bad healthcare and bad providers (like the Atlanta Constitution Journal).
The bad publicity costs more than settlement.
If you have any questions, feel free to contact me. Email Maurice, and he will give you my email or you can get it from the profile section of my blog.
-- Banterings
Happy 90th Birthday Dr. Bernstein! Your continued vibrancy and good work is an inspiration to all of us aging baby boomers and no doubt to the many doctors across the country that you nurtured as students. More than you may realize, what you have done on this blog has helped both many of your readers and contributors as individuals but also the general collective awareness of patient dignity and respect in the healthcare world. Thank you for being you. Happy Birthday!
Just wanted to wish you a Happy Birthday from a long time viewer but infrequent poster . May you have many more . AL
Banterings. Thanks for the advice. I have passed it along to my sister. I hope she takes heed of it because that was a rotten thing for them to do to her.
To All: Yes, 90 is a lot of years but after my recent acute heart attack and rapid reconstruction of the coronary arteries with stents, I hope and anticipate at least a few more years.Thanks, thanks for Biker and Al's wishes. I also wish a safe and productive next 4 years to all...regardless of your direction of interest in the results of a
Presidential election regardless of your political orientation. Finally, may patient modesty always be preserved. ..Maurice.
'
Maurice,
HAPPY BIRTHDAY, AND MANY, MANY MORE...
I find it amazing the things that came to pass in my lifetime. I can just imagine the wonder that you experience with the advances that the world has made.
Some fun facts:
1930 History, Fun Facts And Trivia
What Happened in 1930 Important News and Events, Key Technology and Popular Culture
Of note in 1930, Karl Landsteiner won America's second Nobel Prize for medicine in 1930 for his work identifying the blood groups.
-- Banterings
Thanks Banterings for the Birthday wishes for me.
I have a question to all which I don't think I presented as an issue of the maintaining of patient dignity... maybe I did but I haven't dissected earlier Volumes about this.
As I may have told you, we teach first year to student to identify the patient in the first line of the history and physical with description such as "The patient is a 35 year old white unmarried male who is a press photographer and was admitted for symptoms of chest pain of 4 hours duration"
But the question is should that first line to be complete having spelled out one or, in some cases other than one of the following: LGBTQ+ and then, of course, detail the sexual orientation history in the SEXUAL ORIENTATION located in the PAST HISTORY of the full patient history?
How is patient dignity affected if the sexual behavior or interest was part of the first descriptive line of the writeup? ..Maurice.
p.s.- if any of this thread's readers want to scan all 113 Volumes, by some technique I missed, for the presence of a discussion of the exam same topic, please let us know.
I think how sexual identity which may be pertinent in medical actions is initially presented to the reader is very important to the patient, clinician or others starting out with the question regarding this important factor in patient dignity.
Maurice,
To put characteristics that help define a patient's identity so that they will be treated with dignity SHOULD be in the first line:
...35 year old caucasian, married male (his husband present)... so as NOT to mistake his sister for being his spouse. His support system is important to treatment.
...51 year old Latina trans woman...
In NO way should LGBT, race, ethnicity, etc. be assumed, put in if NOT relevant OR if the patient refuses to disclose.
DO NOT:
...51 year old Latina woman (suspected to be MTF transgender)...
...35 year old caucasian, married male (I suspect is gay or same sex relationship due to the male accompanying him)...
40 year old African American women who is refusing to disclose her birth gender, sexual practices, and genitals present...
Some things are none of ANYONE'S business, especially if the patient doesn't disclose. I have a transwoman who is a good friend that will tell people when they question her about gender, preference, genital situation, etc. that "...the only the only reason that we would discuss this is if YOU want to have sex with me..." If the person does not drop it immediately, she will tell them that they are sexually harassing her and file a complaint with management.
Just because one has a magic white coat on does NOT mean that they are entitled to ANYTHING and EVERYTHING.
Based on that reasoning, one can apply the same standard to providers:
I need to know your sexual orientation and sexual practices so that I am being THOROUGH in being cognizant in protecting myself from abuse and to know whether you have a puritanical attitude that would make you judgemental of my person.
Honestly, I advocate and teach people that it is perfectly ACCEPTABLE and how to lie to providers. One person told me his PCP was pressing him on his sexual practices (he is quite promiscuous). The PCO was pushing his denial and refusal questioning if he even masturbated (was having ANY sex).
He told his PCP he is not having sexual relations with anyone now or the last 10 years and when he masturbates he wears a condom because he doesn't know where his hand has been. Reluctantly his PCP recorded his answer (patient saw "not sexually active" in his records).
That sent a strong message. PCP never asked about intimate details again.
In light of the fact that providers can NO longer promise confidentiality (duet to consent forms, disclosure notices, insurance billing, EMR, etc.), patients have a right (THAT MUST BE RESPECTED) not to disclose certain information OR outright lie (if the box needs to be filled in).
One other item, just like the Miranda rights, and just as a patient should be told that they can refuse any procedure or part of a procedure, they SHOULD be told they can refuse to answer any question. This assures that the patient has NOT been coerced.
-- Banterings
I think there was a discussion a while back about the patient summary descriptive but it never hurts to revisit an issue given what people think on certain issues evolves over time.
I just took a look at how the most recent 4 doctors that I have seen did this. They each stated my age & gender and then a high level overview of my current & pertinent past health and why I am there. That seems sufficient in most instances.
Certainly it might make sense at times to include marital status, sexual orientation, or employment status if perchance it was somehow pertinent to why I am being seen or if it somehow affected possible courses of treatment. For example when my wife was hospitalized earlier this year with sepsis, that she was married & I was retired was pertinent to her doctor's decision-making. It added a 3rd option (sending her home somewhat earlier than desired) to the other two options (keeping her in the hospital or sending her to a rehab facility as the covid situation was unfolding). There was thus a reason to know this additional information in this case.
In years past I can recall descriptives including my current & past employment status but none seem to be using this anymore.
To clarify our process in teaching first year medical students how to write the initial compressive writeup of the patient's history: starting with the Chief Complaint, History of the Present Illness and finally the Past History. All of the material in this document is responses and words presented to the student by the patient. (Remember, the patient must be awake, able and willing to answer questions and also in the first introduction presented by the student, the patient must voluntarily participate to help that student with his or her education. The answers which come out of the patient are the patient's words in response to pertinent questions by the student. Nothing is forced upon the patient.
The "Chief Complaint", few words, should be the patient's words, in quotes or noted in a few words of interpretation, if needed.
The second is the initial line of the the clinical basis for admission in just a few words, often in quotes by the patient or noted in a few words by the student's interpretation. The third section starts the History of the Present Illness with the first line set by the response of the patient "JK is a 50 year old Hispanic married male former taxi driver (note: all responses are from the patient's mouth) who was admitted last night for chest pain." And that's the first line of the History of Present Illness. This is then followed by additional history obtained from the patient's words but interpreted by the student. (More to come) ..Maurice.
Finally, begins the extensive Past History in which the patient may or may not want to or detail the many categories including past illnesses not pertinent to be in the HPI., One section of the Past History of which under the category of the patient's life is Sexual History. But it is up to the patient to speak out any details asked in the various categories of the Past History which also involves the sub-category Review of Systems (systematic questioning about past history of organ system symptoms in sequence from head to toe.) and finally the category of Personal History covering any points that the patient want's to add to the history already expressed but not asked by the student.
Yes, clinical information (including test results and treatment) on this admission not recalled or presented as yet to the patient by the physicians can be included in the History of Present Illness.)
This history taking may take up to an hour, depending on the patient's responses or non-clinical discussions such as football teams. It becomes shortened as the student learns how to conserve time but get the pertinent facts.
But the introduction brief category from age, marital status, sexual orientation, occupation and the clinical issue in a few words comes out of the patient's mouth. No words or interpretation by the student.
The final diagnosis based on what is known and unknown (remember at first the student hasn't learned how to perform sections of the physical exam) is listed as the student's conclusion at the end of the writeup followed by the student's comments regarding the interview and/or exam which could be performed. But the words of the History basically come from the patient's mouth as, of course, understood by the student. Any interpretation of gender life come from the patient's own words. I hope this detailing of the medical student "starting out" is informative to our topic.
..Maurice.
How do like the following American Medical Association Survey to me as an ongoing member. I am sure this will generate so conversation here. I will not respond to AMA on this one. ..Maurice.
Personal Details
The AMA is committed to representing all physicians. Knowing a little more about you helps us better support you and reflect the makeup of our diverse community. Your answers are completely voluntary and will be kept confidential. We'll continue to update this page with more options in the future.
Gender Identity
What is your gender?
Sexual Orientation
Which of the following best describes how you think of yourself?
Transgender is an umbrella term that refers to people whose gender identity, expression or behavior is different from those typically associated with their assigned sex at birth. Other identities considered to fall under this umbrella can include non-binary, gender fluid and genderqueer—as well as many more.
Do you identify as transgender?
Dr. Bernstein, concerning the AMA, I consider that line of questions to be none of their business. It strikes me as just another facet of the identity politics movement that is balkanizing the country.
Why won't you respond to AMA as you expect patients to respond even though it oftentimes is truly none of their business?
I agree with Biker, it is NONE of the AMA's business. except for their own personal use as part of a published professional behavior statistic for the public's general knowledge. I am not happy about even publishing a statistic to the general public to say
"so many" lady physicians have another gender outlook. This should not be a published general statistic. SteveMD, if you are stil around, what do you think.
JR, I really don't expect my patients to have HAVE to respond to any of my questions. If I explain necessity to the patient, the response still could be absent or anything.
Look what the laws in some states (old news stories) requiring a physician to ask any patient but especially if there were children in the household, whether the patient had a gun or rifle at home and if so where located.
From Wikipedia
https://en.wikipedia.org/wiki/Physician_gag_law
In the United States, a physician gag law is a law that prohibits physicians from asking their patients about whether the patient owns a gun. In some cases, these laws may also restrict the ability of physicians to counsel their patients about gun safety.[1][2][3] The term was first used to describe the "Firearm Owners' Privacy Act,"[2] a law that was supported by the National Rifle Association[4] and passed in Florida in 2011, which prohibited doctors from “making written inquiry or asking questions concerning the ownership of a firearm or ammunition by the patient or by a family member of the patient.”[5] The law passed in Florida was later challenged by the American Academy of Pediatrics, and was blocked in 2012 when judge Marcia G. Cooke, of the United States District Court for the Southern District of Florida, issued an injunction against its implementation.[6] In 2014, Cooke's decision was reversed by a three judge panel of the 11th Circuit Court of Appeals, which ruled to uphold the law.[1] The plaintiffs petitioned the court to be heard by the full panel of judges. In 2017, the court found the law to violate physicians' 1st Amendment Rights.[7] Since 2011, twelve other states besides Florida have introduced similar laws,[3] and although Florida's is the most restrictive in the country, similar (albeit watered-down) laws have been enacted in Minnesota, Missouri and Montana.[8] ..Maurice.
Hello Dr Bernstein,
Much like Bantering and Biker, I too believe that not all information is medically relevant to know. I have a tendency to "play with my cards close to my chest" as the saying goes, disclosing only what I deem relevant to the current purpose of the visit or appointment.
The sad truth is that confidentiality doesn't mean what it used to be and, frankly, I am not comfortable with the notion that any number of unknown persons (people I have not met or been introduced to) may access my medical records. To me, that is not okay. So I don't necessarily disclose everything.
Could I be wrong? Sure I could. Would not revealing some information lead to a mistake? A misdiagnosis. It's always a possibility. But the odds are pretty low and I am more than willing to take that chance.
Dany
Dr. B.,
Asking the ?s of sexual preference is standard on most hospital admitting forms. It was asked several times throughout my husband's mound of paperwork. If you do the research, most medical providers feel this answer is a requirement. Some may not be outright asking it but are marking the answer on their own. Another one asked is are they sexually active. They will ask how you identify yourself and if what sex do you prefer to have sexual relations with as standard ?s.
Asking abt having a gun in the house is different. Do they ask if you have knives in the house? Do they ask if you have drain cleaner in the house? Do they ask if you have prescription pills in the house? Do they ask if you take care of your children in a safe manner keeping them from all levels of harm like a meteorite dropping out of the sky? Singling out guns is showing a lack of ignorance on their part as many things in life are dangerous to life like doctors/nurses who force procedures without consent.
I have also read articles of late saying many patients don't like having a white doctor who doesn't look like them. But if skin is not a quality that one should be judging another on than why is this an argument? Around here, the reverse can be said there are no doctors that look like me around here so why am I not allowed to say the same aloud? In fact, I would be labeled for that remark if I would to make it but the reverse is not true. Why?
For those with modesty concerns, knowing the sexual preference of a medical provider could be important so that you would feel more confident that even a provider of the same sex was not checking you out sexually. My point is if patients are routinely asked about their sexual preferences etc. then the same should be required of those giving care to them.
My other point is that what is fair for one is also fair for the other. But there is not equal fairness for all but rather a one-sided view of fairness.
JR, "Asking the ?s of sexual preference is standard on most hospital admitting forms"
Sorry, JR but this is NOT what we teach our students and is unnecessary on any hospital admission form as some "routine" question. The sexual preference should be a voluntary expression by the patient and no in any admitting form. It should, if the patient desires, after understanding the clinical needs of such information as presented by the patient's physician. On an admission form, only the patient's description of his or her gender should be noted.
This issue is just what upset me with the
personal AMA request. It is only the gender description, if needed, to be part of the initial communication between physician and patient and not a self-description for some statistical presentation later to the public. Those physicians who responded "by
name" to the questions are foolish..any sexual detailing either by the patient or the physician should be only as desired or needed part of a doctor-patient communication. ..Maurice.
I have the paperwork to prove this was done. My husband did not answer these questions but these questions were answered by them for him. It appeared several times in the medical records of the hospital from hell. So although while you may not teach this, if you do some research you will find this is perfectly acceptable by most medical institutions. The one question specifically asked who he preferred to have sex with after it established if he was born a male or female and what he identified himself as being. Also asked if he was sexually active. He answered none of these questions but they had answers. You can disagree but this type of invasive behavior is happening on hospital admission forms. He would have told them it all was none of their business but apparently they feel everything about him was their business as they knew no boundary they would not cross. I have done research on this and have found this is becoming standard procedure for these questions to be on hospital forms.
I don't recall ever having been asked about sexual orientation, though I have been asked on forms if I was married. What would be more appropriate is to instead simply ask for emergency contact. Depending upon what my health issue was it could be appropriate for the doctor, if I was going to need some assistance, to ask if I lived alone but even that needs clarification as to whether your spouse or whomever was capable (and willing) of providing that assistance.
If anything about gender is appropriate for an admission hospital document, it can be the term "birth gender" nothing more. Any details, offered by the patient, should not be on the admission document but presented to the patient's physician personally, face to face and can be incorporated in the patient's chart as the patient's detailing after the physician explains any clinical importance to the patient for that information to be displayed to others. Within the hospital record, this information can be of clinical value and this should be detailed to the patient, but it is the patient to decide after informed and questions by the patient answered.
The hospital chart is a dissection of the patient and the illness and it should be up to the patient to be aware and be able to modify any non-clinical facts which has been incorporated within the document... just as we teach our first year medical student patient writeup. ..Maurice.
Based on a country-state-and city screening problem for all of my blog threads, I know that many more are reading this specific blog thread volume than are speaking up in writing. I do appreciate what has been written by you all on this topic but I want to encourage others reading to express their anonymous views. Based on what JR wrote and what I experienced from AMA, I think this matter of preserving patient dignity should be of general interest.
Please write anonymously but end your message with a unique pseudonym.
If anyone thinks I am overdoing this issue of "compelled" full sexual interest and personal identification, please let me know. Anything you don't want published, you can write me e-mail: doktormo@aol.com and our conversation will remain confidential. ..Maurice.
GO BACK TO THE FIRST LINE OF MY LAST POSTING.
PLEASE CORRECT A TYPING ERROR:
THE WORD "problem" SHOULD READ "program"
..Maurice.
Move on to VOLUME 114. ..Maurice.
My guess is questions on admissions forms such as JR points out would not stand up to any legal challenge. No hospital could possibly justify why they need such information in the absence of a relevant diagnosis. They might still be asking because that's the way they've always done it and nobody has challenged them.
I would think that risk management staff would want such questions removed because it is one more piece of personal information that needs to be protected, and is something that could cost them dearly if it is inappropriately divulged. Asking for non-necessary personal info also sets them up for discrimination claims in a "you wouldn't have asked for that information if you didn't intend to use it" manner. The hospital loses the ability to say the info wasn't anything they used, because why would they have asked it otherwise. The old maxim "less is more" applies here. Less personal data is more legal protection.
Until they smarten up, I suggest not answering irrelevant personal questions.
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