Preserving Patient Dignity (Formerly Patient Modesty) Volume 115
Oops! I just noticed that the title of Volume 114 was wrong (missed "Formally Patient Modesty) and didn't follow the recent Volumes correct sequence titles. I hope that error didn't prevent visitors to join our conversations. With this Volume, we are back to our correct title which continues the specific "modesty" issue which started this discussion from 2005. Obviously patient modesty and its apparent ignorance by some members of the medical profession, Bantering's suggestion to enlarge the scope and thus title to "Dignity" was certainly important when discussing how the medical system interacts with their patients.
I would like to continue a discussion I began on Volume 114 and to which JF responded: This was followed by another issue I presented related to citizen's freedom in self-decision making. ..Maurice.
NO FURTHER COMMENTS WILL BE PUBLISHED ON VOLUME 115. CONTINUE TO VOLUME 116 https://bioethicsdiscussion.blogspot.com/2021/01/preserving-patient-dignity-formerly.html
I want to present here a general issue which stimulated me which I read on a clinical ethics listserv. It led me to consider the issue about whether employers had or should have a public health responsibility to require their employees, particularly those who interact with patients or closely with the public to accept being vaccinated with the COVID-19 vaccine or, if one their refusal being removed from their occupation. Is the employer responsible for the health of their employees and to the public who are exposed to those employees? ..Maurice.
I'll let you know if I'm required to get vaccinated. I've been wondering the same thing.
Another legal-ethical question which was raised by the clinical-ethics lisserv to which I subscribe: Should all patients entering the hospital who have not been recently previously tested for COVID be legally compelled to be tested? Would that be Constitutional under that specific circumstance? In general, should COVID testing be not personally voluntary but be considered a legal requirement, symptomatic or not? ..Maurice.
posted by Maurice Bernstein, M.D. @ 12:04:00 PM
175 comments
175 Comments:
From JR posted to 114 after I closed down that Volume.
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JR Issues4Thought.com
They already compell mesa testing for their safety that patient has to pay the bill.
JR, please define "mesa testing". I haven't heard that expression used. ..Maurice.
A new visitor(named Teo and who was the Anonymous I presented recently on Volume 114) would like to present some views and issues and is currently learning how to directly write here and not via e-mail to me.
Here is what Teo wrote me to post here today:
What does this group think about euthanasia in cases of severe and long suffering? I know this is particularly controversial in the States but some more enlightened cultures in Europe (such as the Dutch) have made it a legal option with some strict eligibility rules.
..Maurice.
Yes, the issue of euthanasia does fit in a discussion about the preservation of patient dignity. It does matter who and how and to whom the request is made. ..Maurice.
Dr. Bernstein,
To answer your question from volume 114, yes I am now free of any BPH symptoms. No catheter, no more weak stream, nothing! It feels great to be free of all that. With my PSA at 2.6, no worries about the cancer. My doctor wants to see me in 6 months. I am still avoiding any medication that thins the blood and probably will for the next 2 months at least. I don't want a repeat of the last hiccup.
Still no word from the hospital in re my email.
58flyer
Good day,
Some might only consider this a matter of flavor or point of view but, speaking from a Canadian perspective, we do not have euthanasia but the federal government did pass a bill allowing patients to request medical aid in dying (MAID). A new bill was tabled and has pass through the Commons (first level of approval). This bill is broadening the criterias for who can request MAID.
I personally believe this is a good thing. Endless suffering should not be endured and if someone, anyone, comes to the conclusion there's no hope of improvement to their condition, they should be allowed to end their lives.
It's definitely a touchy subject, I will admit that.
Dany
With sufficient controls I support euthanasia where there is a Living Will or voluntary election by a person of sound mind but failing body. It has been legal in my state for years. Beyond that it becomes very murky given the possibility of greedy relatives looking to get rid of an inconvenient elder. There are circumstances where it would be the humane thing to do, but safeguards need to be in place to ensure it is in the interests of the patient rather than the family.
My wife and I have standard language Living Wills executed years ago but just a couple weeks ago we had a related discussion and are thinking of redoing the Living Wills to be much more explicit, and for me at least to allow for euthanasia if I am unable to make that decision myself. I have been clear to her and to my kids that if I find myself slipping into dementia that I will cease all medications and medical care so as to allow mother nature to take me more quickly. I would rather die sooner of a heart attack after ceasing blood pressure meds than to end up in a nursing home with a teenage girl changing my diaper.
I saw my in-laws in nursing homes. I see no dignity in living out your final days that way. I want to die while I am still alive, not years after my mind is gone. I have lived my life with dignity and wish to go out the same way.
It seems to me from what I have seen that the patients at NURSING homes have already been deliberately caused to die. Also when the patients have been dying a whole lot of medicine that they wont live to take is ordered.
This is a different thought but I would like to see a different kind of nursing home created where family members could move into the building also. When the family pays their electric gas and water bill, their elderly parent/ grandparents bill would be included in. The family could wash the patients laundry to save on the laundry bill. Just a thought.
JF, don't you think it would be more practical and realistic for the elderly patient to be living and cared for in the family's own home but have daily in-home nursing visits and service with all the appropriate supportive measures which are presently being currently carried out in the home-hospice patient management? To carry out such patient attention as well as "family management" living within a private nursing institution would seem more costly and complicated. I am sure most of the elderly and sick would rather live and die in a familiar family home environment. ..Maurice.
Dany, thanks for your update on Canadian
"Medical Aid in Dying" political status.
Within the United States, California has been following the "End of Life Option Act" which took effect in 2016 here and has been supported by legal challenges.
Beyond the patient's own personal health burdens, there has necessarily been burdens placed on the patient's physicians for them to comply with the requirements of the law.
There has always been a need to separate such "life-option" acts now carried out in some other states following the initiation in Oregon from frank euthanasia as practiced in for example Netherlands, Belgium and Luxembourg to "assisted dying".
Try this Emergency Room ethical dilemma a thread titled "Ethical Dilemma: Attempt Suicide Refuses Rescue" which I first published in my now inactive "Bioethics Discussion Pages" (1997-2004) followed then with many detailed reader responses including on our current titled "Bioethics Discussion Blog" March 2006.
What do you think in terms of maintaining patient dignity in 2020 when an attempt suicide ends up in the ER? ..Maurice.
That happens already. And it costs roughly the same. I was thinking more along the lines of a business place and a small nursing home ( probably the employees elderly family members ) being one company. Probably there are laws preventing that kind of things since the wrong people are creating/striking down laws. My idea came from seeing a young boy ( born to older parents ) sleeping in his parents room at a nursing home I worked at. I also saw a mother and her mentally challenged daughter share a room. I've seen people with a dog or a cat. Never anymore than one although I don't see why they couldn't.
Doctor Bernstein .
Speaking from personal experience , taking care of your loved one at home will be the hardest thing you will ever do in your life . To care for your loved one while you watch them die will leave your scarred for the rest of your life . The last words my wife said were " No hospitals " . I honored my wife's request , but paid a high price emotionally . I couldn't have done it without help from family . Doing so will give you a totally different view of life .
Stay safe .......AL
My aunt, uncle and I helped my grandmother live at home. For just one person to have done it would have been CRUSHING! But there were three of us and she never had to live at a nirsing home. And we were able to keep her home and property.
What we learn from Al and from JF and that we all instinctively know is that no lives of the very sick or elderly are going to be accepted or carried out in each case by the family members with the same feelings of confidence, concern or even acceptance of the decisions made. Though most likely in every case there is underlying motivation to maintain the personal dignity of that family member. There is no assurance that each such familial responses will follow thw same path to accomplish the beneficent goal of maintaining dignity. ..Maurice.
I really, really would like to read here from my visitors what you think about this emergency room "dilemma" which I presented yesterday the link to my narrative and the visitor responses. I am so eager, I copied my narrative from that 2006 topic and reproducing it here. ..Maurice.
Attempted Suicide Patient Requesting to Die and Refusing Rescue
The case is that of a 35 year old white single female who was found on her bed stuporous and moaning by her father and mother with whom she lives. There was a note in the room written by her explaining that she had carefully considered her life and what was happening to her and that she wanted to die. There was evidence in the bathroom that she had most likely taken three bottles of different pills including barbiturates. The family immediately called the paramedics and the patient was taken to the nearby hospital emergency room. The physician there was presented with the note and the bottles and since the patient was not fully unconscious began to insert a nasogastric tube to aspirate the contents of the stomach. As he was attempting to get the tube down, the patient became briefly more responsive and cried out that she didn't want the tube, she didn't want any treatment and that she wanted to be left alone and allowed to die. She moaned that she had left a note which said she wanted to die and she meant it. The family arrived in the next few minutes and informed the physician that she had not seemed depressed to them and she had never seen a psychiatrist but the medications were prescribed by her general physician. When told about what she had requested of the physician, the family urged that the doctor continue treatment. The physician realized that if she had consumed the pills in the bottles she would most likely not survive without medical treatment and yet it seemed clear that she did not want any treatment. What should he do next?
The issue is whether the doctor must follow the request of the patient and stop treatment and allow her to die. Does the principle of patient autonomy apply here? Can the physician perform a treatment against the consent of the patient? What is the responsibility of the ER physician in this matter? Must the physician be required to participate in completing a yet uncompleted suicide attempt?
Post script to the above ER physician issue:
I think really think this is a potential example of the issues that JR has been repeatedly posting here regarding the behavior of the medical system with regard to her husband. JR, isn't that correct..and so
what would be your advice to the ER doctor? ..Maurice.
Dr. Bernstein, a patient in control of their faculties should be allowed to make their own choices. An example I shared in the past was my grandfather at age 85 being diagnosed with stomach cancer and choosing not to have surgery. He had another good year and then slowly declined for a year; dying at 87.
In the suicide/ER example, despite having the patient's note, the doctor has no way of knowing if she was in control of her faculties when she wrote it and then took the pills. Not treating her would open him up to major liability if in arrears the parents said she was not in her right mind when she did it. The doctor made the right choice for himself and the hospital even if in arrears the patient felt it was the wrong choice. The patient's rights do not extend as far as allowing her to destroy the doctor's career in exercising her rights.
Using my recent example of my deciding that I will cease all meds & medical treatments if I ever begin a slide into dementia, because a case could be made that I wouldn't be of sound mind once that slide begins, I plan to put it in writing now while there is no question. That way my wishes can be honored without putting doctors and others at risk of being accused of malpractice for non-treatment.
If that girl was serious about wanting to die she should have taken steps to ensure she wasn't found in time to save her. Like after everybody was at sleep for the night. Otherwise how could it even be known if it was a cry for help.
Ours is a bioethics blog which means in most all issues, it is my duty to dissect the topic in established ethical terms and definitions. Therefore, I feel it is appropriate to dissect the topic of attempted suicide into its bioethical components. Certainly, it is worth considering personal suicide or attempt suicide pertinent to any discussion of preservation of one's inherent dignity. A worthy such presentation I found was "The Ethics Side of Suicide"
Here is a reproduction of a portion of the
extensive discussion and the presentations and the contained pertinent references. ..Maurice.
Professional Ethics and Suicide
The conduct of clinicians is guided by ethics codes that provide nominal protection to suicidal clients. The codes draw on these principles:
Autonomy - Respect for the individual self-determination
Beneficence - Doing the greatest good possible
Non-maleficence - Minimizing or preventing harm
Justice - Fairness and equal access to care.
Bioethics has developed responsibilities based on autonomy:
Respect for person - The basis of client rights
Telling the truth and giving all the facts - Disclosure
Confidentiality - Maintaining client privacy
Fidelity - Doing the job" and "being there" for the client.
Beneficence is acting in the best interest of clients. Non-maleficence is minimizing harm. Justice is treating individuals fairly.
Autonomy and Suicide
Ethics Audit
for Therapists
a) Do you use a waiver of confidentiality?
b) Do you believe that a "no suicide contract" is a preventative measure?
c) How do you ask about psychological pain (psychache)?
d) What would you do if I became suicidal while in your care?
e) Do your assess- ments consist of "Do you intend to kill yourself?"? Does "NO" mean "No Suicide Risk"?
f) Is risk manange- ment your main concern when confronted by suicide risk?
This principle impacts the clinical response to all suicidal individuals. It calls for respect, dignity, and choice. The last often takes precedence.
Respect for personal rights: This duty sanctifies choice. Suicide is the outcome of psychological debilitation. Extending autonomy to those so afflicted facilitates suicide. Respect for the individual is better served by recognizing their vulnerability.
Telling the truth: Clients at risk deserve candor as to their exposure and means of intervention. Clinicians with strong views about suicide should disclose them or refer the client elsewhere.
Confidentiality:This presents many dilemmas. Suicidality and secrecy are a fatal combination. In some states clinicians may breach confidentiality if the client is a danger to themselves or others. Therapists must disclose if the client is a threat to others. Disclosure of suicidality not mandated.
Fidelity: Clinicians are to be faithful to clients. The risk of suicide must be taken seriously and be acknowledged as the primary problem. Fidelity also demands that clinicians update their views and skills. Outmoded views of suicide put clients at risk.
Beneficence and Suicide
"PRIMUM NON TACERE" (First, do not be silent)
Socratic Maxim
Clinicians must be proactive in working for the client's well-being. Beneficence should not be sacrificed to autonomy if the client is suicidal. Beneficence is caring not just treatment. Every attempt at intervention is warranted.
Non-maleficence and Suicide
Clinicians must strive to protect clients from harm. Non-maleficence calls for whatever it takes to assure the client's life.
Justice and Suicide
Clinicians must treat all consistently. Fairness cannot be assumed.
Concluding Comments
Clinicians often equate what's legal with what's ethical. In most cases, the law sets only minimum standards of conduct. Ethics demands more. This is especially true in regard to suicidal individuals.
Dr. B.,
So you are inferring there is a similarity between a person who tried to commit suicide & the family who was urging to save her life and my husband who was mentally healthy who was directing he didn't want invasive treatment but rather opted for a treatment only slightly less effective than their gold standard? Are you inferring that someone who has taken massive amounts of meds to commit suicide is also deemed able to make a coherent decision? Are you somehow inferring my husband after his heart decided he wanted to die? In Indiana, there is a chain they are supposed to follow. If the patient is unable to make a competent decision because they are unconscious, mentally incapable (which a overdose pt would probably be considered that) then they go with next of kin. That's what happened in the situation you described. They didn't do that in my husband's case but rather they ignored his conscious directive and didn't consult with me either so they could totally impose a procedure of their choice upon him. The question in the case you presented should be what is wrong with the GP prescribing all those meds? That seems to be the bigger issue. My husband has not had a change of mind of what they did to him and maybe that lady didn't either. You didn't present that info. The 2 situations have no similarities between them. I remember my sister my trying to kill herself wanted to die at the moment but was thankful later she did not. However, again my husband has not changed his mind that what they did to him was wrong both legally and morally wrong. There were other treatment options and he was capable of making his own treatment decision. He was not their property to do with as they pleased but rather a human with basic human rights. If you do not see the difference I don't know what to tell you.
Hello Dr Bernstein,
"Suicide is the outcome of psychological debilitation."
This sentence is at the core of the issue. It is the assumption that S.I. (suicidal ideation) is a mental illness (likely caused by depression) and that anyone suspected of presenting SI is de facto unable to make decisions for themselves. I contend that this is not the case.
I value individual freedom above all else. And the ultimate expression of this is in my right to do as I please with my life. This also includes the possibility of ending it at a time of my choosing. This life I have, is mine alone, and no one will impose their views or values on me.
(And for the record, because I don't want anyone getting excited here, I am not suicidal.)
But... Current accepted practice are definitely not in line with this. And if you doubt that, just walk in the nearest hospital saying you want to kill yourself, and see what happens to you. And just for funnies, try to walk out of there (non-compliance). Oh boy... I promise you that you will never look at an ER/ED the same way again.
My beliefs are that our life is ours, from beginning to end. In this ethical dilemma you present, the best approach is to allow this woman to die. It is her life. Her choice.
Dany
JR, I was trying to express that by your husband entering the hospital (just as the female entering the ER apparently not her desire but that of her family), her request on entry was to allow her to die became a challenge for the ER doctor and the issue became what should be the doctor's next response.
In the case of your husband's requests and limitations to management were also challenged but in his case overridden. Unless the patient is unconscious with no surrogates present, what clinical response and limits set by the patient must be considered, documented and followed or patient discharged to the care of others.
Patient autonomy: the patient, seen to be fully informed and coherent has every ethical (and hopefully medical right) to make final decisions. And that would apply to your husband's experience.
In my example narrative, the patient, within the ER had the capacity express her want to be medically left alone to die as she had intended prior to her family's decision to have her sent to the ER.
What is essential for all doctors and nurses to learn is to LISTEN to the patient unless the patient is found not to have the capacity to understand and make their own decisions at the moment. ..Maurice.
Dany, laws should follow clinical ethics which permit under patient autonomy that a physician should interview for the necessary length of time and detail with the patient to establish that the patient has mental understanding of the request, consequences or any presented clinical options and thus has the capacity to make their own decisions. If so, the decisions should be clinically accepted unless the decision is clinically unreasonable. That is true autonomy in medicine. ..Maurice.
Maurice,
What you talk about are ethics as defined by the profession of medicine, not those of society (by which the profession is bound). I totally agree with Dany.
Just look at KMD and hear all the crying of how physicians have lost their autonomy, yet they have no problem telling society how to live their lives.
Revolts are starting against the second wave of lockdowns, the targets are the leaders )governors, mayors, etc.) public health officials, and those doctors and nurses calling for lockdowns.
I applaud, support, and encourage the vaccine efforts for providers, especially when so many don't want the vaccine. There can not be one set of rules for medical professionals and another set for everyone else.
The Hemlock Society and others have a lot of good information on "death with dignity." Notice that they use the term "dignity." As I have demonstrated (just by the name change of this thread) that dignity is missing from healthcare.
Thankfully I have seen the term dignity beginning to appear in more and more policies. If not in practice, at least there is an awareness.
-- Banterings
Hello everone!
I am a relatively new reader here, a 30 something blue collar Swedish guy.
I have been reading a bunch of the backlog on this blog over the last weeks, and have read maybe 40% of the content.
Before I add my two cents to the pile I would like to salute Maurice for hosting this blog and the time&energy spent engaging with its posters and content, likewise a salute is in order for all the great contributors!
So I guess I will start by describing my general sense of this blog and its content, as far as I can tell the majority off content is focused on personal experiences, problem descriptions, cause identification etc etc. A smaller chunk is about actions taken mostly by individuals in their personal interactions with the medical system, websites created(this one included), a few youtube videos and lastly individuals calling hospitals/filing complaints etc.
I get the sense that although there have been some battles won and some minds changed, the overall war is still being lost.
I have seen a few suggestions on what can be done to get the ball rolling on system wide change, inc legal action, personal advocacy etc.
What I have not seen mentioned(maybe I just missed it) is information outreach to potential “natural” allies such as religious communities(mormons, jehovas, amish, muslim etc), libertarian types, abuse victim advocacy groups, elder care groups, equal treatment type groups etc etc.
What is not information outreach: Creating a website/youtube channel and hope that people stumble across it, that generally does not happen.
What is information outreach: Compiling information concerning the issues brought up on this blog into a nice slick packet that can be sent out to people/organisations, pref with a link to an online resource with an expanded knowledge base.
I think I will leave it at this for now.
Swede
Swede. we welcome your joining our blog thread and will welcome your additional views.
You know, in addition to the absent demographic of writers here, I miss having equal numbers those in the medical profession: physicians, nurses and medical executives participate as the numbers of those already writing here as "objects" of the profession.
Sure, in the last Volume we had the input of StevenMD and in the recent past a medical system administrator (forgot his pseudonym) but that's it in recent years.
JR, in your internet activities which you say you interact with physicians, couldn't you suggest they come and post here? I want to hear more from the medical profession about the issues described on our topic. And the rest of my visitors here, can't you help in this respect?
As you may recall, I have been a regular reader and participant on 3 clinical ethics listservs and one medical education listserv and have repeatedly presented views written here and my blog address is always identified.
Anyway, Swede. thanks and keep watching and writing. ..Maurice.
Dr. B.,
Having a sister who has tried to drink herself to death many times over, I can't really say if the woman truly wanted to die. At the moment, probably yes as my sister did. She has been saved numerous times but each time would try it again bc mentally not all motors were functioning. However, she has reached a decision within the last 1 1/2 years to remain sober and no longer wants to die. So it is a slippery slop to save or not to save based on the wishes of someone who took pill/alcohol/attempted suicide bc at the moment they wanted to die but later may have a change of heart. I don't have a concrete answer bc I think each case is different and as a someone who has a loved one in the bowels of mental illness, I know I am glad to still have her around and she is living her life in a manner she now wants. Does this works for all--I don't know. However, on the flipside for ppl physically ill who want no medical intervention and who have had this directive, saving them would certainly be morally wrong. From what was said in your post, the woman did not have a long history rather the family knew nothing was wrong. Some pills make ppl suicidal so saving the woman in this case was probably the correct decision. If she truly wants to die, she will do it again only she may plan it better which will signal she is truly wanting to die. My sister always called to let us know what she was doing so she could make a statement but be saved. During the drunken episode she would always assert she wanted to die but once sobered, her story would change.
There was a world of difference between her and my husband. He never intended on dying or denying treatment but rather chose one of the 3 treatments suggested but the one he chose was not the one they wanted to do for profit's self. He just wanted to have a say in what happened to his body. They on the surface seemed to be agreeing with that basic human right. He wasn't telling them how to do their job like give a shot now and 30 minutes later saying this needed to be done but rather he was acting like he had ownership rights to his own body which they defied and imposed their treatment on him much like a rapist imposes bodily invasion upon their intended victim bc that rapist feels that victim is entitled to whatever the rapist wants to do to them. There is no difference in the violence inflicted upon a rape victim or a medical harm victim as my husband is. Having the treatment my husband chose was not a choice between living and dying as in the case of the female so there is no similarity between the two. He was mentally competent too and I was there agreeing with his choice as I knew his personal belief system. What happened to my husband was a case of criminal medical battery pure and simple. He did not intentionally have a heart attack to die and would not be intentionally having another to try to die again. Big difference between the situations.
Swede,
While I agree some of the things who have stated, in practice what you say is not that easy. Websites are good ideas because you have the info for all to see. Handing the info out is costly and most will just throw it away so talking to the ppl you mentioned is great and having some info printed is also great, having the bulk of info on a website is a better investment. Also, a website lends to the idea you are serious in your endeavors. It is also is most cost efficient bc you can update w/o reprinting costs. I agree reaching out to those you mentioned is a good idea but right now most are not receptive bc they have another issue on their mind and that is how to survive all things COVID. Of note, those in elder care I have reached out to have not been receptive bc they get nervous when you mention personal dignity bc there are huge personal dignity issues in elder care. Lawmakers either are totally dismissive or have the excuse nothing can be done because the medical lobby is so large, powerful and controls via $$$$$, however, I am not giving up on them. I will also take into acct the others you had mentioned bc a few of them I didn't think about yet so thank you for the suggestions.
Dr. B.,
On one site you aren't allowed to give links. Are you going to join my Twitter and FB in posting concerns of ethics? I welcome any input. My Twitter acct is growing but I slowed it down due to being flagged by Twitter a few times as growing too fast. I don't make political remarks and do not help spread political comments bc medical is already too political and needs to have a definite separation so everyone and anyone can have safe medical care especially in these divisive times. You have my twitter id as being @4patientrights so join my following and put in a word for this blog.
This blog you have accessed is about BIOETHICS and it is oriented with regard to issues of how bioethics is applied to many aspects of the profession of medicine.
But bioethical decision making with regard to clinical dilemmas in the practice of medicine has limitations.
Here is a great article in the Atlantic which clearly demonstrates the uncertainties, limitations and clinical frustrations which is associated with the clinical ethicist attempting to make decisions for patients and their attending physicians. The COVID-19 pandemic providing its early clinical issues and continuing on is an example but is not the only example of limitations facing clinical ethics decision-making.
Take the time to read the Atlantic article regarding how the entry of bioethics and its consultation potential to make clinical decisions easier is not fully working out. ..Maurice.
That is a great article Dr. Bernstein. Medical ethics can be incredibly difficult under circumstances where there is more need than resources. Certainly the need to provide direction last spring outpaced the ability of medical ethicists to guide practitioners, hospital administrations and politicians. I don't envy the position they were in.
Sadly, like with everything else about this pandemic many of the issues they were dealing with could have been anticipated had there been some pandemic planning on the part of govt. and hospital systems.
Biker, you have hit the issue precisely when you wrote "there is more need than resources. Certainly the need to provide direction last spring outpaced the ability of medical ethicists to guide practitioners, hospital administrations and politicians." But there was no listening to the facts provided by the epidemiologists by those who could organize an early effective plan for control of the virus infection. And, it is true, ethicists, who were called upon can spout ethical principles but in the COVID case there was only confusion and perhaps self-interests generated by various sources. Hopefully, the near future will bring more thoughtful and less self-interests by all in critical decision-making. ..Maurice.
I have another ethics and legal issue with regard to the preservation of patient dignity which I don't think I brought up as yet on this blog thread but is worthy of discussion here as it has been in both the ethics and legal communities.
Are we defacing patient dignity when physicians and nurses AGREE that further life sustaining treatment such as continuing ventilator support as primary tool to continue an unconscious patient's lung function and should be permanently stopped since the patient's clinical findings indicates the patient appears to be in a terminal condition of the underlying illness and never to recover from the underlying illness or regain consciousness....AND THE PATIENT'S FAMILY DISAGREES AND INSISTS THAT THE PATIENT REMAIN ON THE VENTILATOR AWAITING AND AWAITING RETURN TO SELF-RESPIRATION, CONSCIOUNESS AND RECOVERY. THEIR EXPRESSION IS THAT IT IS TOO SOON TO GIVE UP HOPE OF RETURN TO CONSCIOUSNESS AND RECOVERY. Should the ethics and law lead to the conclusion that the conflict is a matter of law and should be up to the court syst4em to make this important clinical decision? Or does the patient (patient's family) or does the physicians and hospital have the legal right to make such decisions? Is there or should there be an method of compromise? Well, there has been some answers to this dilemma in some states but
let's see what are my visitors opinions on this clinical-ethical-legal dilemma. Remember, the goal is to try to preserve patient dignity but are there limits? ..Maurice.
Consistent with how I have been answering these ethics scenarios, I do not see any dignity in keeping an unconscious person who is not going to recover alive by mechanical or other artificial means. I get it that loved ones don't want to let go and that they will pray for a miracle, but if I were the patient I want them to let me go. Keeping my body alive in such circumstances when for all intents and purposes I am already gone reduces me to an object. It is not respecting my dignity.
The hard part of this is what the medical criteria is to determine that the person has no hope of recovery. This should not be a decision made by a single doctor but rather there should be a consensus amongst a group qualified to make the decision.
Hello Dr. Bernstein,
Please read of Melissa Hickson's "nightmare" in Jul 20.
https://www.npr.org/2020/07/31/896882268/one-mans-covid-19-death-raises-the-worst-fears-of-many-people-with-disabilities
Reginald
Dr B. I have a problem with the expression " should be dead "
Doctors make educated GUESSES and sometimes they're wrong. My aunt's husband was given up for dead 6 times. When he ( and my aunt ) died, it was because of a traffic accident. I know other people who were predicted to die but ended up living far past what the doctors thought they would. I would be one of those family members holding out hope. My mom lived for 11 more years when she had a heart attack and appeared to be dying.
I want to thank Banterings again for motivating us to change the title of this blog thread to "Preserving Patient Dignity".
It expands the needs for concern far beyond simple or not-so-simple "modesty".
I know earlier today I put up a new subject regarding patient dignity which there can be even further discussed beyond the worthy responses Biker, Reginald and JF. However, this even I came up with another: the role of the ministry when the patient finds themselves in a religious organized hospital.
I found a posting on a clinical ethics listserv, to which I subscribe, a response by a listserv member of a hospital who presented his Director of Spiritual Care response "in support of substituted judgment".
The following is from a Director of Spiritual Care of such a religious hospital.
"I find the possibility of this practice deeply troubling. In my work, teaching, and guidance to staff, we do not perform religious sacraments or rituals for patients that would not cohere with their lived practice or identification with a particular spirituality or religion. Just as we would not allow a spouse, parent, or child ask a surgeon to give a patient a brow lift while they're under sedation, we as chaplains hold sacred the autonomy of the patient's meaning making system in how we intervene. If it is unclear due to incapacity that prevents communication, we err on the side of caution rather than responding to the anxiety of the family member. Instead, I ask my chaplains to offer spiritual and emotional support to the person making the request as they are usually the ones in need of significant support. We would be glad to offer a blessing for health when it's unclear, but the prospect of violating a patient by baptizing them without expressed desire or offering religious rituals that could be perceived as against their belief system would not be appropriate from a spiritual care perspective."
Any personal experience with regard to this issue by our commenters here? ..Maurice.
The example Reginald posted is a good one. The doctor seems to have made a decision unilaterally rather than going through a designated group to review the case such as I indicated needed to be part of the process. Even more important, Mr. Hickson was not in a "no hope of recovery" status but rather the doctor didn't think he had a life worth saving. Big big difference.
Maurice,
I am humbled by your thanks. Coming from you, a person that I hold in high esteem means so much to me and validates my work.
As to religion, that is the ethical basis for our laws and Constitution.
Being a person of faith, I have seen the power of praying for someone. People of all faiths tend to be appreciative when someone says "I will say a prayer for you." At the very least, people not of faith take it as "good wishes."
As to the case of Mr. Hickson, this is another example of why absolute power must rest with the patients.
-- Banterings
As Banterings suggests the "power of prayer" can have value even for individuals not of the same religion as the one who prays for the other. Religion and how it is treated as a patient is being clinically managed should not be ignored. This is emphasized in a detailed article "Cultural Religious Competence in Clinical Practice" starting off with the following Introduction but moving on to the detailing multiple religions around the world and their relationship to culturally competent medical care.
The diversity of religion around the world creates challenges for health care providers and systems to provide culturally competent medical care. Cultural competence is the ability of health providers and organizations to deliver health care services that meet the cultural, social, and religious needs of patients and their families. Culturally competent care can improve patient quality and care outcomes. Strategies to move health professionals and systems towards these goals include providing cultural competence training and developing policies and procedures that decrease barriers to providing culturally competent patient care
But how is the medical profession doing with regard to education of students and active physicians, nurses, techs and clinic and hospital administrators with the goal of achieving true religious cultural competence for their patients?
Whatever religion the patient holds, even those who hold "none" represents part of patient dignity that cannot be ignored. ..Maurice.
From a 2005 thread here:
Writing in “A Piece of My Mind” section of the Journal of the American Medical Association JAMA. 2001;286:1291-1292. Bruce D. Feldstein, MD told about his experience, while covering for a another doctor, with a patient Mrs. Martinez, who had metastatic lung cancer, previously treated, whom he now had to tell that a current CT scan showed metastases to the brain. She was overwhelmed by the news and described the information “a death sentence.” When it appeared that his statements of reassurance did not help, on seeing a crucifix around her neck, he considered that praying together would be best he could do for her at the time. When asked, the patient agreed. This was the first time in his career that he had considered praying with his patient. He was Jewish, she Catholic. He had concern what the words of the prayer should say. He finally led the simple prayer:
"Oh, God, You Who are the Great Healer."
"Who guides us through life,"
"In your wisdom . . . "
". . . may you guide [patient’s oncologist] and all the other doctors and nurses to provide the best care."
"Provide us all with Your comfort and guidance . . . "
"Thank you for hearing our prayer."
Amen."
and it ended with her tearful “thank you.” Later, out of concern about the ethics of what he had done, Dr. Feldstein discussed his action with an ethicist and Dr. Feldstein writes:
[The ethicist] and I looked at it in terms of core ethical principles: to do good (beneficence), to do no harm (nonmaleficence), and to respect a patient's autonomy. We examined it in terms of the duties of truth telling (veracity), loyalty and putting the patient first (fidelity), of confidentiality and privacy. We contemplated the virtues of compassion and professionalism. We reflected on the goals of a physician to relieve pain and suffering and to provide comfort, as well as the value of the Golden Rule: "Do unto others as you would have them do unto you." A prayer that is supportive and comforting for the patient, that has his or her permission, and is mutually respectful is ethical. One that is proselytizing, coercive, and unrealistic is not.
As [the ethicist] discussed, the prayer was appropriate on all counts. "Your intentions were ethical," he said, "to tell the truth and to provide comfort, what physicians pledge to do. Mrs Martinez asked you specifically for the test results. You answered truthfully. You were aware how your pronouncement could provide harm and suffering and you followed the Hippocratic principle First, do no harm. Conventional medical, psychological, or philosophical explanations were insufficient or problematic, so you considered a spiritual approach. Prayer is a tremendous source of comfort for people who are prayerful. Although new for you, in the world of spiritual care, offering a prayer is as straightforward as recommending an antibiotic.
"A physician praying with a patient may not be standard practice," he went on, "but this does not make it unethical unless you do not have the permission of the patient or if you conducted your prayer in an unethical way. You identified a cue—the cross—that it would be appropriate to offer a prayer and trusted your deep intuition and judgment. You could have called a cleric if one was available, but then there is the question of timing, to make the right intervention in the right moment. You asked her first if she was a prayerful person. She said yes. Only then did you ask her if she wanted to have a prayer together. She could have said no. You found a common language. You did not tell her what faith to have and did not pray for a miracle."
I was satisfied that that as a physician, praying with Mrs Martinez was right.
Note: The above link to the full text may be available only to subscribers or those linking via a library computer. ..Maurice.
Being someone who "holds" no religion beliefs, I can speak from experience abt how heinous it was to be forced by a religious hospital to have a chaplain present even though that chaplain was told to leave 3 or more times and refused. It was also heinous to read in the medical records the outright lies of said chaplain writing I was "grateful" for him being there. Although medical records are supposed to be legal documents, it is perfectly acceptable for them to be full of outrights so having confidence in anything written in them is questionable.
It just proved what I thought about religion and more enforced my belief that to all in the medical community, personal dignity does not matter. It is also is heinous to know these so-called invaders of personal privacy can and are present during times of patient nudity as if it is no big deal. While some may want religious direction present, others may not. They need to be absolutely certain before forcing upon someone the religious presence. While in the past, I have not been offended by other religious presence because of what happened, I am now offended. However, when the common person says they are praying, I take that in the manner in which it is meant just as I say they are in my thoughts. Having come face to face once again of a man of supposed faith just being as corrupt as a common criminal, I absolutely want nothing to do with organized religion nor does my husband because he was also their victim. They did not ask him that night but rather forced the man upon him and us. There was no comfort but rather a long-lasting resentment of our belief system not being respected but just is par for the course in medical encounters.
JR, I agree, patients enter any hospital primarily for diagnosis and treatment of a medical/surgical condition which cannot be managed as an out-patient. Their motivation and I am sure it is the admitting physician's motivation that the admission is not for religious palliative treatment. The presence of an unrequested and unwanted chaplain is a potential for psychic harm to an already sick patient and only adds to the trauma to the patient's personal dignity.
Especially in these days of COVID limitation of hospital bed space, entry of patients into religious operated hospital institutions may be unavoidable for the sick patient.
Some patients may find therapeutic and emotional solace by the entry of a chaplain into the clinical situation but others may not and should be given the opportunity to reject this particular hospital's policy and action.
My view is that unwanted religious "therapy" should be prevented by patient decision-making as decision-making is part of the ethical autonomy which should be part of every clinical decision-making.
Rather than the unexpected and unwanted intrusion of formal religious entry into therapy, as with clinical forms of decision-making, it should be the patient or, if needed surrogate family to provide the religious request. And that is why I appreciate the story I presented above of the therapeutic role of the patient's physician to evaluate the need for religious support, by communicating with the patient, as part of the search for specific clinical therapy benefit.
So, JR, if your story is valid and I assume it is, I clearly see and agree with your example of "heinous" interference by religion into your husband's clinical situation. Can anyone present an argument to the contrary? ..Maurice.
JR. I'm so sorry that that chaplain forced his presence on your husband. True Christianity doesn't treat people that way and true Christianity does exist. Our Ellen White ( that our church has been accused of making into our god ) said that false Christianity is more harmful to our cause than open sinners are. They are who confuse people and misrepresent Gods character.
The doctor in the example Dr. Bernstein posted handled it beautifully. The minister that JR had to deal with is was totally inappropriate. Beyond not respecting JR's "no", I am appalled that a hospital would allow clergy to be present for any intimate exposure w/o the patient's express request. Being a "person of the cloth" so to speak does not change the fact that he/she is a non-medical observer who simply should not be there.
When my wife was in the hospital earlier this year, a very pleasant elderly woman from the local Episcopal church called on her. My wife must have said she was an Episcopalian on a registration form at some point. The woman did not force herself on my wife nor did she preach or try to recruit my wife to join that parish. I think she came by simply to be there in case my wife had wanted to talk to someone from the church. Her stopping in to call on someone not from the parish wouldn't be odd at all as sometimes patients at the local hospital are tourists who had an accident at the local ski resort for example or took ill while visiting the area.
Does anyone here think that the entry of a hospital religious figure, by whatever title, into the patient's room without the patient's specific request is acceptable? The question becomes definitely more complex in the case, which of course still exists (though limited now related to COVID safety) of single rooms containing two patients. I wonder if the issue of verbal religious support to one patient in a two patient room is any administrative consideration.
What I am getting at is whether even the entry of a hospital's religious representative, without patient request, is morally and ethically appropriate practice.
And what would be your solution to the situation where, in a two patient room, one patient requests that representative. Or is this just an example of isolating clinical or even family communication in two-patient rooms with the physician or nurse attending one of the two patients. Can anyone here tell us about their experience in this regard?
Oh my! Do you realize what I have done.. entering a new twist to the issue of "preserving patient dignity" .. the matter of loss of privacy and dignity in two patient hospital rooms or even hospital wards that still exist. Any thoughts? ..Maurice.
Dr. Bernstein, as I described in my last post, the elderly woman from the local Episcopal church simply walked into my wife's room (a single) and introduced herself, asking if it is OK to visit. Had my wife objected I am sure she'd of gracefully exited. We are not especially religious, nor is the general culture in this State, but neither of us saw the woman just walking as a problem. Instead we saw it as a very nice gesture, and the woman very pleasant. To us it was no different than the volunteer coming around asking if she wanted a book or magazine or needed any toiletries. That volunteer would test the waters seeing if my wife was looking for some conversation. Bear in mind there are patients who don't get visitors and no doubt that volunteer helps fills a void for those patients. These things are culturally appropriate here.
When she was in a two person room she was too out of it for visitors but I doubt religious or other volunteers would behave any differently in two person rooms.
The arguments regarding the patient value between one patient vs two patient hospital rooms have been going on for a number of years and currently with the need for hospital space available for clinical use in view of the COVID-19 pandemic does require a re-consideration of perhaps a general patient and family request for privacy.
This issue one patient vs two patients in a single room has been going on for years.. and believe it or not there are reasonable arguments on both sides, by patients and by the healthcare providers.
Here is the results of a study of the views of both patients and healthcare staff published in the British Medical Journal
in the British Medical Journal published
2016.
Abstract
Background and objectives There is little strong evidence relating to the impact of single-room accommodation on healthcare quality and safety. We explore the impact of all single rooms on staff and patient experience; safety outcomes; and costs.
Methods Mixed methods pre/post ‘move’ comparison within four nested case study wards in a single acute hospital with 100% single rooms; quasi-experimental before-and-after study with two control hospitals; analysis of capital and operational costs associated with single rooms.
Results Two-thirds of patients expressed a preference for single rooms with comfort and control outweighing any disadvantages (sense of isolation) felt by some. Patients appreciated privacy, confidentiality and flexibility for visitors afforded by single rooms. Staff perceived improvements (patient comfort and confidentiality), but single rooms were worse for visibility, surveillance, teamwork, monitoring and keeping patients safe. Staff walking distances increased significantly post move. A temporary increase of falls and medication errors in one ward was likely to be associated with the need to adjust work patterns rather than associated with single rooms per se. We found no evidence that single rooms reduced infection rates. Building an all single-room hospital can cost 5% more with higher housekeeping and cleaning costs but the difference is marginal over time.
Conclusions Staff needed to adapt their working practices significantly and felt unprepared for new ways of working with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms.. ..Maurice.
Although I believe that for some people/patients, religious comfort is important to their well-being, I don't believe that bc you go to a religious affiliated hosp they automatically have the right to impose religion on you. As with schools, hospitals receive public funding and schools must follow certain guidelines pertaining to religion. If it is requested, then religion can be administered. In our case, it was not requested nor was it wanted. It was a violation of our civil rights for him to be forced upon us and to refuse to leave when told/asked. Also, as Biker stated, they are not medical and should not be privy to patient nudity unless specific permission has been granted by patient or patient's reps. Hospitals seem to think patient's body can be put on display for any and everyone during a medical encounter. And yes, Dr. B., my story is valid. The AG thinks so as that is the route we went as we weren't seeking $$$ but rather justice. Money is paid by their impersonal insurance carrier whereas justice will be personally paid by them by either their license or jail time. We prefer it to be both as the ones involved in the torture of my husband and me have no place dealing with ill and vulnerable people. Am I just special or what as I have never seen you question the validity of anyone else's story?
As far as patients sharing a room, there is no question privacy being preserved especially for the bed in the first position as everyone passes by there. Curtains do not provide complete privacy. Certainly everything said can be heard. Again, hospitals seem to operate on the concept that patients have no right to expect bodily privacy.
In nursing homes, residents who share a bed in a room have absolutely no privacy. Bathroom doors are left open. Visitors see everything. There is nothing abt what happens that is private. My sister while rehabbing in a facility was told by a male CNA to leave shower room door open so he could make sure she was okay. He was just a creep. For male residents, they mostly get only female care and most I saw there were in their 20's and the talk and actions coming from these young women blew my mind.
Let's dissect the concept of patient dignity.
Is it some concept attached to all living patient? But what about dying patients? Can one argue that patient or personal dignity and its attributes is an intrinsic reflection of a patient who is expected to use those attributes in further relationships with others in the patient's life? But what if life is ending and soon those living relationships are gone, gone permanently?
This subject has been discussed and is especially pertinent in relation to hospice care. Here is a worthy article published in 2016 in Ulster Medical Journal titled "The Importance of Patient Dignity in Care at End of Life"
This discussion is especially timely when we consider the decisions which have to be made by those physicians and nurses attending sick COVID patients who are not able even to be transferred into hospice care. ..Maurice.
I want to add the following to my last posting: A cardinal principle of medical ethics that we shouldn't compromise one person's health for the benefit of another person, even if the benefit would be great and the risk small.
Are you comfortable with the above cardinal principle? Would you feel comfortable if you were that "other person" who desperately needed the "benefit" at the "expense" of the patient already being attended?
Feel free to express your opinions. These issues I have been posing are not "made up stories" but are, unfortunately, ever present in today's life. ..Maurice.
In response to Biker on Dec 12 comment, I don't think stopping nutrition and hydration in a dementia patient really qualifies as euthanasia. It seems more in line with "Allow Natural Death" or following the patient's wishes. Injecting a person with a lethal cocktail of drugs seems more like euthanasia. It matters because euthanasia is such a loaded term, and evokes similarities to the eugenics of the early 20th century and the holocaust.
Carol, welcome to our blog thread on Preserving Patient Dignity. I hope for you to continue your participation. There are many interesting aspects to the "goal" of this blog thread and we have worthy contributors.
I would agree with your rejection of a concern that a medical decision to stopping clinically provided nutrition and hydration in a dementia patient who is refusing self-provision, truly represents proposing an act of euthanasia toward the patient.
\..Maurice.
I received the following, via e-mail, from Gerald S. Schatz, J.D. who identifies himself
as "a human rights lawyer and am retired faculty in bioethics law and clinical ethics"
He gave me permission to present his views here. ..Maurice.
Disregard or contempt for patients' individuality and inherent dignity is the sin that gave rise to 20th Century bioethics. Arrogance and abuse in health-care institutions and in biomedical and behavioral science have deeply offended medicine's inherent ethical norms then and now.
In bioethicists' comments on their experiences and challenges in the COVID-19 pandemic I see compassion and consensus that care-givers are working expertly and valiantly, themselves grieving for lost patients and colleagues and in distress for families torn apart. But I see also that some bioethicists seem preoccupied with influencing policy and treatment decisions while no longer focusing on how patients experience the system.
I have a personal followup on Gerald's description of "some bioethicists" and their seeming preoccupation "with influencing policy and treatment decisions while no longer focusing on how patients experience the system." I agree since clinical bioethics really deals with what is happening or about to happen with individual patients. Yes, the studies involve the future but they must start with what is happening now to that particular patient. ..Maurice.
Maurice,
In regards to your post:
"A cardinal principle of medical ethics that we shouldn't compromise one person's health for the benefit of another person, even if the benefit would be great and the risk small."
I will go back to a topic when I first started posting here (and one of the problems in medicine): the need to be thorough. Being thorough makes the physician feel good, it does NOT always make the patient feel better.
Case in point; my female friend has her hormones prescribed for her WITHOUT ANY blood work. Just about all providers would say that they need the blood work to be thorough. She had to push back and invoke the Americans with Disabilities Act (ADA).
This federal law would override state regulation of the profession of medicine and force the physician to acquiesce to her wishes and ACCOMMODATE her needs.
JR could argue that her husband and 58flyer did not want their providers to be so "thorough."
JR and 58flyer, please comment on my assertion.
We tried the carrot, now we have to use the stick (the ADA).
I have seen too many friends who have been abused by providers as myself. I am losing empathy for providers. I guess I am being conditioned the same way that I show the medical education kills empathy in the students.
-- Banterings
Banterings,
I definitely agree that "thoroughness" can be carried too far. What comes to mind most convincingly so was the nurse practitioner a few years ago who bullied me into allowing a hernia exam which was totally not indicated. I posted that here as I recall about her use of a female "chaperone" which further humiliated me.
58flyer
Not to derail the present conversation I want to give a report on my recent discussion with the hospital chief clinical officer about the issues I faced with my last hospitalization. I posted last about the female urologist from the practice I go to who brought the female high school student into my room when she did her rounds of the patients from the practice. I sent an email to the Chief Clinical Officer (CLO) and CC'd the Chief Quality Officer, both of them RNs. The secretary of the CLO called me to schedule a time for him to call me for a conference. That call came last Thursday.
We had a pleasant conversation and I sensed he was genuinely concerned about my experience. I recounted the 5 hour wait in 10/10 suprapubic pain and the urologist bringing the student into the room without asking for my permission. Those were the chief concerns. It wasn't all bad. I told him how well the prior visit went with the Greenlight therapy and how my concerns for gender concordant care were handled exceptionally well. I gave examples of how well the latest visit was handled. So, I spoke of both the good and the bad. I didn't want to come across as a bad customer.
He agreed that there were some things that could have been done better but he wanted to get information from me first before proceeding with questioning the staff. I told him of how easily my catheter clogging up could have been relieved with some low tech plunging of the Foley in a bay in the ER while awaiting further diagnosis involving my urologist. He agreed but he said he had to look further into that.
He was most perplexed by the conduct of the female urologist in bringing the female high school student in during rounds. There is a symbiotic relationship between doctors and the hospital. Doctors need the hospital privileges and the hospital needs the doctors to bring in the patients. One doesn't survive without the other. He said there is no hospital policy on who rounds with the doctors but good judgement is expected. Maybe a policy should be instituted. The CLO seemed more interested in this aspect than anything else.
So it seems like the CLO is interested in bringing about change to improve the patient experience at the hospital. He promised that he would investigate and let me know what he found out and what changes, if any, would be made. I also called the high school and spoke to the person in charge of the health sciences department and asked for a conference. That conference will take place after the New Year. I will report on it then .
58flyer
from the December 20 2020 Wall Street Journal:
Doctors are treating a new flood of critically ill coronavirus patients with treatments from before the pandemic, to keep more patients alive and send them home sooner.
Last spring, with less known about the disease, doctors often pre-emptively put patients on ventilators or gave powerful sedatives largely abandoned in recent years. The aim was to save the seriously ill and protect hospital staff from Covid-19.
Now hospital treatment for the most critically ill looks more like it did before the pandemic. Doctors hold off longer before placing patients on ventilators. Patients get less powerful sedatives, with doctors checking more frequently to see if they can halt the drugs entirely and dialing back how much air ventilators push into patients’ lungs with each breath.
So, at the beginning era in the treatment of seriously ill COVID patients the goal included, by early use of ventilators, other non-seriously ill patients and the staff would be "protected" by a patient placed on a ventilator. The approach to therapy of the individual patient now has become more oriented to the "true" patient requirement and not simply for hopeful "protection" of others.
But if this newspaper review is accurate as to clinical motivations early in this pandemic year, it would seem that the intrinsic protection of that patient who was put on the ventilator for hopeful protection of others took away that patient's dignity and with ventilator complications and inadequate other clinical approaches.
This history of the treatment programs in COVID management show a separation between the ethics of public health and the ethics of the health of the specific patient under treatment. What do you think? ..Maurice.
Thanks for the update 58flyer. I can't imagine any hospital, big or small, would be pleased to find out high school kids are wandering around their hospital pretending to be nursing students, even if accompanied by a doctor. Nor can I imagine any hospital, big or small, being pleased to hear that a doctor is employing (even if unpaid as was surely the case, a high school kid as a chaperone for an intimate patient exam. The doctor made the kid part of your care team the moment she said the word chaperone.
I look forward to your next update.
58flyer,
Thank you for responding on thoroughness and especially for the update.
My bread-and-butter involves dealing with insurance companies. I know the companies and the practice of insurance better than most people. If their malpractice carrier or any of their liability carriers ever got wind of this happening, they could actually issue a 31 day cancellation notice.
I often tell people who seek my advice to contact a provider's and facility's liability carriers to put them on notice of a claim. One of the first issues is why the provider/facility did not report a potential claim.
In the eyes of the carrier, this is the same as not reporting a claim. Next, the first thing that happens is the carrier sets a reserve; that is the expected amount the claim is going to cost. If there is a deductible (there always is), the provider/facility is immediately billed that deductible.
Even if self insured, that money is reserved for that specific claim. That means that the provider/facility must replenish that money. Even though that money is not spent, it is earmarked for that claim even though there is no claim filed. Standard practice is to hold that money 2-5v years after the claim is closed out.
Beyond that, carriers are so fickle, that one claim can get a policy cancelled or raise their rates. Insurance is the lifeblood of that business.
That is the reason that he is so interested in the student. This has created a liability (risk) that I am sure that the insurance carrier is unaware of and would be forced to cover any claims arising from the student's presence.
The carrier can also go back 2-5 years, audit the facility, and collect premium for the undisclosed liability (risk) of high school students. no surprises here.
-- Banterings
As a followup to my last posting:
Can you deliberately make one person worse off, in order to make many people better off?
Well, I would say YES when it comes to putting a criminal in jail.
How about the isolating a citizen from the community if the citizen has the possibility of having contracted a highly communicable disease?
Does it come from the U.S. Constitution? Well, apparently it does from the Commerce Clause. Here is a link from the Centers for Disease Control and Prevention that tells it all.
Banterings, I guess you are correct in stating the basis of the U.S. Constitution is "FREEDOM". in the current case, freedom from getting sick but it all starts with the Federal government and its leader. ..Maurice.
I am not an insurance expert like Banterings but in my former work life I had to approve the coverages the company bought and had many a risk discussion. The easily removed and/or unnecessary risks were simply removed or minimized.
It is thus so very easy to see a hospital administrator not wanting to incur any risk with high school kids masquerading as student nurses or staff chaperones. It is an unnecessary risk that can be easily managed with strict (and enforced) policies.
I want to state, as I may have in prior blog treads, that I am not ethically or morally happy with high school students or even junior high physically entering and observing a doctor-patient or nurse-patient interaction. Particularly disturbing would be if the patient is not fully informed about the status of the visitor and given full opportunity to deny the student's presence. One may argue that this is the only way for high school students to get a "close glimpse" of the work of the professional in medicine.
But, I disagree. A number of my first year medical students gave me their clinical exposure backgrounds as working in healthcare environments from hospital volunteer to volunteer work in specialty clinics associated with varying degrees of personal patient relationships and attention BUT taking place while during their college life. It is college age experiences which will finalize the professional goals of the student.
Never, never should a patient accept the presence of any other person in the diagnostic or treatment environment without knowledge and acceptance of their presence.
And I have applied this same dictum to the presence of a technical company employee presumably to demonstrate and carryout a new surgical tool without the specific knowledge and approval of the patient to be operated upon.
I may have mentioned this previously but in the past 17 years as a physician in a "free clinic" where I volunteered as the clinic physician, in the latter year or so, we had the participation of local hospital "interns" (first year hospital residents) to work with me.. but the patient had to be informed regarding the visitors status and accept their presence. Anyway, this has been my philosophy of "visitors" attending a clinical activity with a patient. ..Maurice.
Two patient rooms?? How is this news item published today by TV station KTLA about what happened in a two patient room going to affect your choices?
A patient accused of fatally beating his 82-year-old hospital roommate with an oxygen tank after the victim began praying has been arrested on suspicion of a hate crime murder, the Los Angeles County Sheriff’s Department said Wednesday.
The assault took place last Thursday morning at Antelope Valley Hospital in Lancaster, a sheriff’s news release stated.
The victim, who was diagnosed with COVID-19, and the suspect — identified as 37-year-old Jesse Martinez — were sharing a two-person room in the hospital and were both receiving treatment, according to the department.
Martinez “became upset when the victim started to pray. He then struck the victim with an oxygen tank,” the release said.
The victim succumbed to his injuries the following morning. He has not been identified.
Martinez was arrested on suspicion of murder with a hate crime enhancement, as well as elder abuse. He’s being held on $1 million and is scheduled to appear in court Monday.
No further details have been released amid the ongoing investigation.
Here is an example where a patient praying in a two patient hospital room can be lethal to the patient's expression of his religious dignity. Or is there another conclusion which can be drawn?? ..Maurice.
To my way of thinking the dignity aspect of single vs double occupancy hospital rooms comes down to the manner in which the patient's privacy is protected, both their physical privacy and the medical information privacy.
As with certain other things I come at the privacy matter partly in the context of a small setting where being anonymous is never assured. By that I mean my roommate's guest might be my neighbor's cousin or the person that I meet at cookout a week later.
Biker, on the other hand, the COVID load on hospitals in smaller communities has led to local patients being transferred to relatively distant larger institutions where your concern may be much less likely. ..Maurice.
My guess is that the guy who attacked and killed the elderly man for praying is a person who probably should have been in prison already. He'd been getting away with criminal behavior for awhile.
To engage a bit deeper into the title of this blog thread "Preserving Patient Dignity" it is worthy to review studies regarding the issue of patient dignity within a hospital setting. Here, for example, is a 2008 International Journal of Nursing Studies "Patient Dignity in an Acute Hospital Setting: A Case Study". I am sure additional studies are available, I selected this one from based on research within an acute hospital in England.
Actually, an issue for this blog thread is the question: does the necessity for medical care have the ethical and practical reality of the need to trump patient dignity? Is there any argument to support this view of medical care necessity?
One could argue that the immediate necessity to preserve good health and life is the main goal of the profession of medicine. ..Maurice.
Were I to be in a bad car accident the necessity of saving my life would trump my dignity as regards the need to cut away my clothing and have several people in the ER examining every part of me for signs of injury, or perhaps even the EMT's at the scene or in transit to the hospital.
That necessity does not mean they can allow unnecessary people to stand around and observe me naked on the table; police, the hospital registration clerk, reality show film crews, and/or other staff that are just curious and want to watch the goings on. That necessity also doesn't mean they can leave me exposed any longer than necessary.
Necessity to save my life might require surgery in which at a minimum I will be naked on the table during prep and then again during the post-op cleanup. That necessity does not mean I am exposed in extent or duration any more than absolutely necessary. It also doesn't mean non-consented (by the patient) students or other observers can stand there and watch while I am being prepped or otherwise.
The problem lies in what patients see as necessary doesn't necessarily jive with what hospitals see as necessary. How many people are catheterized because it is more convenient for the staff? How many women are still having non-consented pelvic exams by students during surgery? How many patients suffer the embarrassment of having their groin hair clipped for cardiac caths that will be done via the wrist simply because on the rare occasion the wrist won't work and the doctor will save a couple minutes switching over to do it via the groin?
So yes trump my dignity to save my life, but recognize the difference between necessity, convenience, and educating or entertaining others for their purposes as opposed to mine.
Maurice,
Perhaps a better question is can you prevent one harm by causing another?
Dignity issues lead to psychological trauma. Most in "physical healthcare" dismiss psychological trauma as minor or incidental. That trauma can linger for the rest of a person's life and keep them away from necessary healthcare.
As to your quarantine and the law; recent court decisions have struck down lockdown measures because they treat all people as if they are infected and part of the goal is keeping healthy people away from people.
Another issue is due process; so even if a quarantine is ordered, it must be able to be appealed.
The government also takes into account not to overuse this power, because the citizenry will vote to severely limit or remove these powers as they are doing to the governor's powers here in Pennsylvania.
-- Banterings
Banterings makes the key point. The doctors and other healthcare staff are focused on the physical trauma which is why patients initially seek them out. At the same time they are by and large either dismissive of or ignorant of psychological trauma. If they weren't they would not continue to inflict psychological trauma on patients.
I have no doubt the people who treated JR's husband took the attitude "what are they complaining about, he's alive isn't he". Their tools don't measure the piece of his soul that they killed.
And quite frankly, the followers and contributors to this blog have all suffered some degree of psychological trauma in the healthcare system. It is the common denominator.
I don't remember the names of some of the doctors I have had in my life, nor the names of any of the nurses or techs. I probably couldn't recall half the things I may have seen a doctor or tech for, including complete physicals where my privacy was protected and I was treated with dignity. I've similarly forgotten the names of some of the teachers I had growing up. Yet I remember all too well how that woman bathed me as an 11 year old in the hospital and I remember all too well the public physical I had in 6th grade.
As Banterings said, trauma lingers, and subsequent events where more of the same occurs only serve to reinforce it.
If all of these descriptions of the ideation and goals of workers within the medical system is true, widespread and "the usual" and my early ideation that our "reporters" coming to and expressing their experiences with the medical system and consequences were in fact "statistical outliers" really represents a terrible insult if not injury to all patients. And so what is the solution?
Education? Perhaps as we follow through on 4 years of medical school education, the process of medical care for patients is described to the students as only a major humanitarian process and there is no behavioral or ethical malignancy hiding within the medical provider-patient relationships.
Similar to the pathophysiology of diseases themselves, there usually is a course (whether hours, days or longer) period of time for the diseases development and expression. Clinical detection, management and treatment during this interval may beneficially modify or even prevent the clinical effect of the disease or even the disease itself. Perhaps this analogy could be applied to medical school and later education of doctor (and all healthcare providers) regarding potential individual behavioral or systemic disorders. All of this representing another "disease" to be considered, prevented or treated for the benefit of their patients. ..Maurice.
I want to temper what I wrote above with an acknowledgment of the behavior and risks the physicians, nurses and techs who are actively engaged in the management and treatment of more and more COVID patients and the personal emotional stress and injuries they are experiencing day after day. Is what we read and watch on TV about all this "fake news" or does this show some intrinsic goodness and care for their patients and does this exposure of personal stress and behavior tell us something worthy of the medical profession or can one use the expression "that they are not true examples of the medical profession but simply 'statistical outliers'? ..Maurice.
Dr. Bernstein, hospital staff giving it their all for covid and other patients is real and is very much appreciated. It is a major failing of the system that hospital administrators and public health officials chose to not be prepared for pandemic conditions. It has been known with 100% certainty that a pandemic would roll through at some point, just not known when or with what severity. That they chose to not take even the most basic precautions of stockpiling PPE makes the efforts of the staff all the more heroic.
The issue of respecting patient privacy and dignity is a separate issue which at its core speaks to patients and staff not sharing the same definition of what respecting privacy and dignity means. It is like ships passing in the night. The dermatologist thinks he is respecting patient privacy and dignity of his male patient if the female LPN, or Medical Asst, or Scribe is polite while staring at the patient and doesn't violate HIPAA afterwards. The female CNA thinks she is respecting the male patient's privacy & dignity by sharing her "you don't have anything I haven't seen" credentials. She somehow thinks he will take comfort being bullied by someone who has done it many times before. Staff and patients are often just not on the same page when it comes to what privacy and dignity mean.
Biker,
I take the opposite approach: Do NOT trump my dignity.
Even in what may be deemed an emergency situation, that does NOT mean that my life is in peril, so my choices are ignore my dignity and I absolutely suffer severe psychological trauma OR respect my dignity and there is a POSSIBILITY that I may be facing a life threatening situation.
Even if facing a life threatening situation, that does NOT mean that my dignity can NOT be preserved, it just may be inconvenient.
Does inconvenience justify disregard of my dignity?
I know 3 of the 4 people in the situations that disregarded my dignity. The 4th, my mind has blocked and I don't want to know. The reason for this is because for almost all of my life I have avoided all preventative healthcare; so nobody else has had the opportunity to abuse me.
And quite frankly, the followers and contributors to this blog have all suffered some degree of psychological trauma in the healthcare system. It is the common denominator.
I would love to see medical students practicing intimate exams on each other and licensed healthcare professionals having to participate in the training of med students in intimate procedures as a means of showing their competency in training med students.
I also imagine that many more medical professionals would suffer the same psychological traumas, they would find this blog (and other places on the web), participate in these conversations, AND push for change to preserve patient dignity.
Maurice,
As for the providers experiencing stress and trauma, I believe that they are experiencing psychological trauma. What they are missing is the suffering of the rest of the population during this pandemic. At the very least, they are still receiving a paycheck with lots of overtime.
I saw a news story about the sacrifices healthcare workers are making being away from their families. This year, me and my wife did not have our Christmas Eve dinner. That means I was away from my 22+ children, grandchildren, and great grandchildren. This was psychologically traumatic for my WHOLE family.
All the providers interviewed say this is part of the job, then complain about those who don't follow the "science." I have NEVER seen any provider acknowledge the sacrifices that everyone else is making. It is a slap in the face.
-- Banterings
Maurice,
You stated:
If all of these descriptions of the ideation and goals of workers within the medical system is true, widespread and "the usual" and my early ideation that our "reporters" coming to and expressing their experiences with the medical system and consequences were in fact "statistical outliers" really represents a terrible insult if not injury to all patients. And so what is the solution?
The solution perhaps can be found in the 12 Steps of Alcoholics Anonymous.
Most importantly, step 5 of admitting that the profession was wrong about these assumptions (being outliers), step 8, make amends, and so on...
I can NOT see how you can say If all of these descriptions of the ideation and goals of workers within the medical system is true, widespread and "the usual"...
There is no "IF."Just read A Pot Ignored Boils On: Sustained Calls for Explicit Consent of Intimate Medical Exams OR Doctors & Sex Abuse: Still forgiven - Atlanta Journal-Constitution.
I would argue that over 90% of physicians are guilty of doing at least one intimate exam on an anesthetized patient without consent. Yes, it is a terrible insult and injury to all patients.
Also think how unintelligent and untrustworthy providers look when they deny this is business as usual when the patients know the truth. This is why nobody cares about providers (as medical professionals) and burnout and the hardships they face during the pandemic. The outpouring of gestures (singing, delivering food, creating PPE, etc.) is for the suffering of them as human beings.
Just look at Dr. Deborah Birx, coordinator of the White House Coronavirus Task Force, said she plans to retire from civil service, citing attacks on her and her family after the Associated Press revealed she traveled out of state for Thanksgiving, in contravention of CDC advice.
People are smart, they ask if you can do this, why can't we? She ignored the existence human dignity (human nature) in being a social animal and needing connections with other human beings; YET, we all know that we are social animals despite their ignoring the subject.
I have had contributors to this blog tell me off blog that they have felt insulted and further injured by your assertions of being outliers. Note: it is not my place to disclose who they are or their feelings, that would be hearsay and up to those who stated their feelings. I only bring it up in this context where this has been brought up by you first. The dismissive nature of labeling them as outliers makes them feel like they are being gaslighted because these experiences were traumatic or that they were being NOT believed.
Finally, my friend the transwoman has approached me to publish her story on my blog. We are in the rough draft stages, but this is another story of business as usual in healthcare, AND it is NOT because she transgender either. I will post on here when I publish her story on my blog.
-- Banterings
Banterings, my use of the expression "statistical outliers" begun near the onset of the "modesty" tread topic was based on my many years of office and clinic personal experience with my patients and my reading of the literature and the issues brought up over 30 years engaged in hospital clinical ethics.
I took care of my patients in the hospital environment before the era of hospitalists and saw what was going on and was able to hear complaints raised by my patients there.
So, I thought "statistical outliers" was a reasonable assumption based on my experience. But I never thought that the conclusion was more than a "personal assumption". As time has gone on, I have admitted I may have been overreaching in my "outlier" assumption.
But I never have considered the symptomatology up to PTSD of the individuals writing here were "made up" for the narratives they presented here and have not ignored the visitor narratives as Moderator. Why is it that there is no national or international "speaking up" by patients regarding the need for medical system attention to patient dignity and patient modesty? Or am I just missing their voices? ..Maurice.
Let's dissect "patient dignity" An element of patient dignity is the patient's preservation of a good health, both physical and emotional and certainly this should be the responsibility of not only by the patient but also the medical community and our government in the form of public health both, as noted, physical and emotional.
Do you see this happening these days with the effect of the COVID infection from the beginning to the present?
Is the preservation of the patient's dignity the primary responsibility of the patient him/herself or is it dependent primarily by the social system in which the patient lives? Relating to the issue of COVID, where do you see the responsibility lie? Is patient dignity a property which is to be guided and protected by the patient, him or herself or should it be the primary responsibility of the society in which the patient lives and participates? ..Maurice.
Following up on my last posting, I wonder if we can depend on smell or odor of the issue to draw a conclusion. On this topic, I posted a topic "Bed Smell vs Good Smell: Can the Smell of a Decision Determine Its Ethics?" June 2012 and got one wonderful and pertinent response--you must read. What follows is my
introductory text.
In life, most of us can smell and make some
interpretation of the source and significance
of the smell. The odor may often be the
first sign of something bad such as an un-
expected fire or something good such as
a favorite pie baking in the oven.
Can we carry the analogy of smell to the interpretation of our initial casual observations or by hearing the explanations by others for the basis of their decisions or actions and then go on to develop a firm conclusion as to whether what was decided or what was done was ethical? Can one "smell" the good and the bad of a decision? And with that smell can we accept that smell as a basis for a conclusion? Can we accept the smell as the basis for whether or not to further investigate the decisions or actions? A "bad smell" requires a thorough investigation of the facts, whereas a "good smell" is evidence enough of a "good". I would argue that it takes more than the presenting odor to establish any final conclusion. Whether a smell is good or bad, I think is in the nose and mind of the beholder and it takes an analysis of as much of the facts as available to reach a reasonable conclusion about the ethics. I bring this topic up because I think it is very easy and I think it often occurs that we "rush to judgment" about someone's behavior or someones decisions or actions. Criticism or ethical conclusions without all the facts is unwarranted. Or, perhaps..our lives are too busy with not enough time or interst to develop the facts and it is just easier to go by our noses. What do you think? In life, most of us can smell and make some
interpretation of the source and significance
of the smell. The odor may often be the
first sign of something bad such as an un-
expected fire or something good such as
a favorite pie baking in the oven.
Can we carry the analogy of smell to the interpretation of our initial casual observations or by hearing the explanations by others for the basis of their decisions or actions and then go on to develop a firm conclusion as to whether what was decided or what was done was ethical? Can one "smell" the good and the bad of a decision? And with that smell can we accept that smell as a basis for a conclusion? Can we accept the smell as the basis for whether or not to further investigate the decisions or actions? A "bad smell" requires a thorough investigation of the facts, whereas a "good smell" is evidence enough of a "good". I would argue that it takes more than the presenting odor to establish any final conclusion. Whether a smell is good or bad, I think is in the nose and mind of the beholder and it takes an analysis of as much of the facts as available to reach a reasonable conclusion about the ethics. I bring this topic up because I think it is very easy and I think it often occurs that we "rush to judgment" about someone's behavior or someones decisions or actions. Criticism or ethical conclusions without all the facts is unwarranted. Or, perhaps..our lives are too busy with not enough time or interest to develop the facts and it is just easier to go by our noses. What do you think? ..Maurice.
People in positions of authority sometimes silence voices if and when they can and desire to do so.
JF, you wrote an interesting statement. \
I would say though that people in positions of authority "sometimes silence voices",but one thing they can't silence to the community is the "odor" of their decisions. And whether the "odor" is acceptable or easily to readily reject is, I think, something no authority can silence except cutting off the noses of those "underlings". There is much to be proud of for all those with a functioning olfactory sense. Certainly, "where there is smoke to smell.. there is fire." More than that was part of this blog thread's discussion...Maurice.
Dr. Bernstein, they can't silence the perception of the community but they can ignore the perception of the community. With some limited criminal law exceptions, Boards of Medicine and Boards of Nursing get to decide right from wrong and what standards or protocols they want to impose on patients w/o input or concern for what the patient's perceptions might be.
My guess is most patients think non-consented pelvic exams is wrong, yet Medical Boards still condone it. State prohibitions have come from legislatures, not from the self-policing Boards of Medicine. Most patients would think what Dr. Sparks was doing was wrong, yet her employer and the Board of Medicine didn't see it that way. Most patients would think the "Denver 5" of body bag voyeurism fame were wrong, yet their employer and the Board of Nursing didn't see it that way. Patient perceptions don't matter to the governing boards.
Banterings said:
"I would love to see medical students practicing intimate exams on each other and licensed healthcare professionals having to participate in the training of med students in intimate procedures as a means of showing their competency in training med students."
I would add nursing & CNA students, tech students that will be doing intimate procedures on patients (sonography, urodynamics etc), and scribes or Medical Assts that will be observing intimate exams or procedures.
I would vary from Banterings in one key regard though. I wouldn't make it students w/each other given most patients don't have such exams by people they know. Instead I would make these exams be by regular staff of the opposite gender.
It is all too easy for students to be told to respect patient privacy and dignity when they are the one that is fully clothed. Only by pretending to be the patient themselves will they ever understand how the patient feels. That might teach them some empathy and to take patient privacy seriously.
Moving a bit back to "good smell vs bad smell" if used in ethical or other decision-making, here is what I wrote to the medical ethics listserv, continuing with the topic.
Hasn't there been use of "smell" in the rushed, unprepared and complex medical decision-making
in the early months of the COVID-19 infection and perhaps to degrees has continued to the present?
In fact, {remember?} perhaps there was "smell" involved in expressions about responses to COVID even
in the governmental "political" sphere. I remember about how the pandemic and possible "treatments"
were presented to the public.-- Created on the basis of what would "smell" best?
Oh.. and another appropriate question regarding "smell". What is the ethical significance of a resultant
"sneeze"?? ..Maurice.
Biker you wrote: " I wouldn't make it students w/each other given most patients don't have such exams by people they know. Instead I would make these exams be by regular staff of the opposite gender."
To make this teaching procedure part of student medical education is to subject the male and female student to clinically (and I mean clinically) unnecessary genital exposure which is part of the rejection based on personal experiences revealed here. And it is unnecessary here with the students also. The students are well aware of their patients' need for modesty without having themselves "tested" for this awareness. For other areas of the body, my medical students examined themselves in one room with all present and me supervising as I have described in past Volumes. It is necessary, if capable, for the patient to reject to the physician or other medical folks present what the patient finds as unnecessary or improper examinations. Medical staff look and touch your clothing uncovered body only with your approval. There is nothing in medical education which states otherwise unless the patient is unconscious or otherwise unable to understand and make decisions and there is no patient surrogate available at the moment to give permission for an urgent examination. This is what I did and what I taught the students. ..Maurice.
Maurice,
I am not saying that you dismiss the fallout of dignity violations, my point was that if medical students do intimate exams as "business as usual," that alone is multiple dignity violations by every medical student and supervising physician.
How many more dignity violations are there of patients who don't remember.
Going back to when I first started posting here (and well before that), you dismissed our views on dignity violations as anecdotal, yet you say "statistical outliers" was a reasonable assumption based on my experience...
The absolute definition of anecdotal.
What you should have been asked is for data showing that dignity was protected (which you would have been unable to produce).
Absence of evidence is not evidence of absence.
I am not trying to "beat you up" over this, I am simply trying to understand how you could not know how rampant dignity violations were in medicine. This is the problem with medicine (and most likely why medical professionals do not post here); they do NOT believe that this occurs and at the high percentages that it does.
I would compare it to the phenomenon of people who do not believe the Holocaust occurred or that COVID is real.
-- Banterings
Dr. B. wrote, "Medical staff look and touch your clothing uncovered body only with your approval...." I have to disagree with that as my husband was a victim of inappropriate medical action. He did not give permission and yet they did it. Another aspect I disagree with is assuming because they are taught differently, they will adhere to what they have been taught. In elementary, I taught students to dissect reading passages for comprehension but later in high school when I came across those same students, I would find them struggling with reading comprehension. Come to find out what how I taught them earlier was disregarded so I would reteach them and for the most part--problem solved if they were still open to learning and growing. In plain words, what I am saying is just because a student is taught the correct method does not mean they will continue to use the correct method. Medical students may be taught about patient dignity but somehow somewhere along the way discard their recognition of the right to every human to dignity in care. Seems to me that in the medical community, patient dignity (and it encompasses many issues besides being exposed) is an area that many in the medical community are willing to disregard as being unimportant in the delivering of healthcare. There seems to come a time and point where far too many are unwilling to be "open to learning and growing" especially in the area of patient dignity. Many see patient dignity as an inconvenience and the patient will be fine if their dignity is disregarded and disrespected. Somewhere after learning the correct methods, they have willingly chosen to disregard and disrespect the basic human right of dignity. Another area I disagree is saying the teaching exercises would subject students to unnecessary genital exposure. How could this be classified as unnecessary as it would be a teaching exercise and not exposure just to expose like in the cases involving actual medical care? The teaching exercise would allow them to experience what they potentially could make a patient experience and that is a valuable lesson. Unnecessary exposure is occurs when a medical provider strips a patient entirely naked when they only needed access to their knee for a procedure. Unnecessary exposure is like the lady 58flyer mentioned in the ER hallway with her breasts exposed for everyone to see. Big difference so maybe part of the problem is the medical community itself does not know the meaning of unnecessary exposure as they are so used to being able to expose patients without need, they believe they have the right or ownership of a patient's body to do so and it does not matter. Part of the problem is they know the patient will be unlikely to remember bc drugs are given to make those memories of inappropriate behavior disappear from the patient's memory. Fact is whether the patient remembers or not, they did experience the sexual abuse in real time. Just like the date rape victim, just because they do not remember the rape bc of the drug, does not mean it was less wrong or did not happen. According to Plaintiff Magazine, sexual abuse of a patient is more likely to occur if any type of sedation has occurred. This is very troubling indeed and not just because this is when my husband suffered his sexual abuse. Clearly, it is recognized for medical students the need for genital privacy during their in class exams of each other but medical students and medical providers do not carry this over for the ordinary patient or such criminal activities such as unconsented for pelvic/rectal exams would not still be happening. So the better question is what is going on during the teaching phrase that tell them they are entitled to genital privacy but in practice, patients are not? I have read accounts from med students that take part in these gang rapes of sedated patients that it becomes easier to do after the initial rape. So maybe it is taught on paper to respect patient dignity but in practice there seems to be a contradiction.
Dr. Bernstein, I agree that it would be unnecessary exposure for students to be subjected to intimate exams, but they are not learning empathy or respect for patient privacy & dignity. I know you emphasize in it in your classes. I applaud you for doing so, and maybe your students take it to heart, but if they do they are the exception rather than the rule.
How in the world did that female urologist that 58flyer dealt with come to think it was appropriate to bring a high school girl in to observe an intimate exam of a male patient? And to lie to the patient in doing so? Dr. Sparks was an anomaly with her behavior, but how did the rest of the staff in the OR and the administrators at the hospital who apparently were aware of what was going on, think this was somehow OK? Were they not taught differently? Did the nursing schools that the Denver 5 went to teach them that voyeurism was OK?
Do the students you have taught think twice about bringing female staff in to observe intimate exams or procedures of their male patients? Odds are they see nothing wrong with it because those minimally trained women are all "professionals" that don't mind seeing intimately exposed males. If any of your students went on to become urologists or dermatologists, what are the odds they have hired any males for their nursing and ancillary staff?
How did the "you don't have anything I haven't seen" and similar phrases come about if nursing, CNA, and other students were taught empathy & respect as concerns patient intimate exposure? Medical, nursing, & ancillary staff training does not recognize that sometimes gender and needless observers(from the patient's perspective) matters.
Banterings, JR, Biker: After 30 years of teaching first and second year medical students, I and my teaching colleagues get to understand by listening and observing our assigned students their motivations for entering the medical profession to become "hand on skin" physicians. It is the personal benefit (performing a "good" for another human in need for that "good" while working in a "respected and needy profession"--yes, respective and needy. And hopefully, in addition, a worthy salary.
For the instructor to observe these students in action (their direct communication and "laying on of hands" on the patient's body) provides insight to the instructor regarding student motivations. It is rare but not impossible to discover a student starting out their intended profession with some malicious motivations and there are mechanisms to deal with such students. Rarely some have serious ideologic or behavioral abnormalities which was not apparent on admission to school but that is what, as instructors with close observations, are present to identify and notify student and Administration.
Remember, these students are in medical school and not yet engulfed within the full healthcare system and the system's administration and practice.
By the way and I know I have written here long ago.. the most effective way to "teach and experience" clinical residents the "life and experience" of a hospitalized patient is to require as part of their education "a few days or so" stay in a hospital bed and room and treated as a true patient.
[I recall this was a practice within a hospital in Long Beach California].
My conclusion to all your concerns, is to attack the clinic and hospital administrators and the governmental medical oversight boards. They are the ones who need to see that all patients are treated with the dignity they deserve. ..Maurice.
JR, Biker, et al,
Biker asked: How did the "you don't have anything I haven't seen" and similar phrases come about if nursing...
Phrases like that are not designed to open up discussion, in fact just the opposite; to shut it down. That very topic was written about back in the 70's volumes of this discussion. I have written extensively about this on my blog as well.
As to where medical students learn this behavior despite Maurice's teachings, again back in the 70's volumes and I have also written about this: the hidden curriculum.
This is where the students learn efficiency, how to abuse, and the way we have always done things... Perhaps Maurice can link his hidden curriculum discussion.
There is also another answer to both of these issues:
Power corrupts, absolute power corrupts absolutely.
The paternalistic model of medicine allowed for any answer the physician felt like giving (or not giving). Most common was ...because I am a doctor and I say so; are you a doctor?
-- Banterings
If you don't know your rights... you don't have any!
JF,
We knew his right to choose his treatment and his right to refuse certain drugs. We knew his right to tell his medical history but what we didn't know was how corrupt/criminal-like those particular medical providers were. In fact, we believe that because he asserted/advocated in a polite manner his rights is why he suffered such heinous medical retribution ie. to teach him a lesson of only the doctor knows best or can decide what happens to your body. Just because you know your rights doesn't mean your rights will be respected. No patient I know had asked to be medically harmed.
Dr. B.,
I have known some of the future medical workers around here from a very young age where their reasons for becoming a medical provider were much more unfiltered than when they were in the presence of someone who could actually make or break their career choice. Of course, by the time you see them, they know how to be guarded. I am not saying all are bad but the psychos know how to act and what to say. If anyone had bothered to read the social media site of the offending nurse, maybe she would have never been allowed to be around defenseless patients.
Don't worry I have more than enough criticism to go around and I am spending much time of medical boards and govt lack of oversight. However, it is also the case that some people within the system are bad and that is a huge problem because even one bad apple can rot the whole basket. So let's be clear--the whole system from beginning to end needs a major revamp. No part has escaped my scrutiny.
Banterings is very correct in most of their conversation is geared towards shutting the patient down and not opening up lines of communication. To confirm that just take a quick look at consent forms. They tell you what they are expecting you to accept and give no where you can say "NO" to anything except the whole thing by walking out. Even the new forms in Florida for pelvic exams for as it is termed both females and males just defined what an exam consists of and you may be there. There is no where on the form for a patient to say I don't want this or that. It is more you agree or you get no treatment.
When I needed to change a male patient who was wet and couldn't change himself I told him I wouldn't be looking at him and that I understand about modesty because I have it also.
Do you want to see the etiology of the beginning of what you are all writing about as it
develops during the "Hidden Curriculum" of the 3rd and 4th medical school
years? Just click on the link below and take a look at the brief videos extracted from the book "Professionalism in Medicine". This may provide you with an idea of etiology of what you have been discussing here. ..Maurice.
One additional Comment to my above posting.
Take a look at the very brief but worthy to watch and understand videos "additional videos" section besides the "Videos (from the book)". Each tells a separate and important example story about the behavior within our medical system. You will not be disappointed in the value of these short stories. ..Maurice.
JR,
Here is how the patient gets to pick and choose:
1.) Just ask for a paper copy of the consent form so that you can read it with glasses. Unser the Americans with Disabilities Act (ADA), places of business must make different media available for the visually impaired.
2.) Cross out the sections that you don't want, initial and date the section.
3.) On ALL pages, initial and date on the bottom of the page.
4.)This way they can not slip in original pages.
JF,
God bless you for your compassion. I also hope that you say that to your female patients as well.
-- Banterings
Banterings,
Yes, that is what we have always done except when my husband was medically assaulted as there was no consent form ever presented to him or to me. @MedicalCorrupt did the crossing off and yet she still was surgically assaulted by a totally different procedure than she agreed to and one that wasn't even a procedure at all. Also, hospitals around here have gone to an electronic form on a tablet where the crossing off cannot be done easily. What we have done is in the signature area wrote what we didn't agree to & other instructions we had. We just crammed it in. The big problem comes as in talking with others is finding out they are having one last consent form signed while they are in pre-op. This is where the hospital is able to bully patients into compliance ie. signing another form without all the stipulations the patient previously wrote on it. The bigger issue is the corruption of the medical boards not recognizing this is coercion. Okay, I know they recognize it as coercion but they side with the evil medical provider. Medical boards sole purpose is to find as many medical providers innocent as they possibly can get away with doing. In talking with Michelle who has Jessie's Story, her research has shown over 93% are ruled in favor of the medical provider. Michelle has written a book about the loss of her daughter from medical harm and is working on a 2nd one. @MedicalCorrupt and I are planning our own book of different types of medical harm and what needs to be done. We have contacted media and I have even had dialogue with a fairly well-known journalist. From what I have seen, this is especially true when it has to do with consent. The medical boards are there to make sure patient autonomy is not recognized. You asked me what #MedicalRape is and I defined it as having something done to your body without your permission/consent by a medical provider. A rapist is defined as someone in power/control which perfectly describes a medical provider. Also, patients who are sedated and/or elderly are prime victims.
JF,
I too commend you for your compassion. All healthcare needs to take a lesson from you.
For anyone who wants to see our story, it is on https://medicalerrorinterviews.podbean.com/e/larry-jane-part-1-profit-and-punishment-profiteering-hospitals-intersect-with-religious-bigotry/ There is 2nd part but I don't have the address handy but you will be able to find it once you go to this. My husband did the interview last spring. It is one of the rare times he talked in public about it. Scott did a wonderful job and on his site there are many stories of medical harm. Please visit it and see for yourself that medical harm is a real pandemic.
JR,
If you request a paper copy due to ADA issue of visual impairment, by FEDERAL LAW, they must provide a paper form. You only have to sign the paper form because since you (*technically*) can't see the tablet, you can not ascertain if the words are the same.
-- Banterings
Here is a "solution" for the medical school to gain a perspective of what is going on in the mind of their students. Why not, medical school instructors, staff and in the latter years, attending physicians and residents monitor their medical students and what the student writes on social media from their first to the final years in medical school. Do you think that monitoring the social media would catch the student that later would be one of the "baddy" doctors described here..and do it also for nursing student? ..Maurice.
my predictions are coming true, healthcare providers are squandering the goodwill they earned during the pandemic by trying to tell people how to live their lives.
Society expects our providers to diagnose and treat injury and illness, NOT tell us how to live our lives. Read: Toxic Individualism: Pandemic Politics Driving Health Care Workers From Small Towns.
I disagree with the description of "toxic individualism;" it is individual liberty, freedom, and human dignity.
The reckoning has come for the abuses of organized religion, we are in the midst of the reckoning of the police (wait until the new administration takes over), and the profession of medicine is next.
People are already standing up to providers and those in public health (thegovernors).
-- Banterings
I really hope everyone here takes the time to open the link "Professionalism in Medicine" and watch the minute and half acted out videos from the book at the additional brief videos which cover many of the arguments presented on our blog thread. Here is one brief video of the ignoring the promise a surgical patient's attending agreed to do all the surgery but ended up a faked promise including the medical student closing the surgical wound.
Try to look at all the videos both "from the book" and "additional videos". They are all pertinent to what has been discussed here all these years. ..Maurice.
Also click and read the brief Medical Student's Perspective and the brief Faculty Perspective associated with each video... and then, of course, return here and provide us with YOUR perspective. This is a very worth while reference production covering the concerns regarding "professional" behavior or in fact misbehavior in the medical system. ..Maurice.
Hello,
Relative to Electronic Informed Consent Forms, I tried to amend one but, was informed that I could not be admitted to the hospital for surgery, unless I signed it "as is". I was not admitted until I did so. Nevertheless, the signing in Pre-Op is another story. Everyone is there ready to work on you. If you have someone with you before the procedure, you both can line-out anything, or add anything. The staff will either object and tell you to leave; OR, the surgeon, etc. will quickly arrive to "negotiate". (With everything in place and everyone present, do you really think anyone wants to cancel?) This is the time to "try" to have the procedure the way you'd like it. Of course, what happens in the OR, against your wishes, is anyone's guess. Notwithstanding all of the above, the BEST WAY is to work everything out with the surgeon BEFORE the big day (especially a written agreement by the surgeon). On the day of the procedure, remind the surgeon of his agreement. Maybe, just maybe, if the surgeon is ethical, you may be treated with respect and dignity.
Reginald
Reginald's description of his personal experience is a great example of the behavior of "urgency" within the medical system and lack of full attention to the "needs" of the patient. With that "urgency" what is missing is the "working with the patient" to reach a needed goal. Assumptions are made that what is requested has a standard response to all patients. And to me, this represents providers maintaining a "clinical distance" from the requests and immediate needs of the patient.
Going back to September 16 2012 on this blog, I put a question to my readers as the title of a topic "Maintaining Clinical Distance: A Patient Value or None"
The doctor looks at the patient who
Sits restlessly, coughs and is not smiling
The doctor's first thought
"Why is this patient coughing?"
Instead of
"This patient appears uncomfortable,
What can I do or say to relieve the discomfort?"
+++
What I have just described is a simple example of the professional behavior or perhaps misbehavior of maintaining "clinical distance". It is the mindset of a technician to immediately look at the anatomy and pathology of the patient's symptoms rather than to look at the patient. Shouldn't the doctor's first interest be the observation and consideration of the patient as a whole human person who comes for consultation because of a personal problem and attempt to understand how the patient is feeling? But the fear of being contaminated by the patient's "feeling" may be more in the mind of the doctor than being exposed to whatever bacteria or viruses the patient is bearing and has become the basis for maintaining "clinical distance"; not measured in meters but in pain, in sorrow, in anxiety and fear.
But, shouldn't, at first, the doctor be more than a technician in the diagnosis and treatment of illness? Shouldn't the doctor at first find and express some signs and acts of partnership with the patient's worries with responses of sympathy ("I care") and/or empathy ("I understand")?
In the current rush of medical practice where time is limited to attend to each patient and the fear by doctors of "becoming too emotionally involved" (contaminated), it is considered a wise practice to maintain that "clinical distance". But is "clinical distance" really what makes a good medical professional? Does it provide a way to maintain physicians in less emotional distress, fatigue and more time to diagnose and treat and thus is of benefit and value to the patient?
On the other hand, maybe it is the basis of why some patients are dissatisfied with their doctors in many ways. Perhaps, we medical school teachers should more strongly emphasize to the students something more than the creation of a differential diagnosis list as the doctor-patient relationship begins and strive to shorten that "clinical distance".
What is your opinion about maintaining vs shortening "clinical distance"? Should the following be the doctor's first thought?
+++
The doctor looks at the patient who
Sits restlessly, coughs and is not smiling
The doctor's first thought
"This patient appears uncomfortable,
What can I do or say to relieve the discomfort?"
One of the responses was from Ed who wrote:
It takes a huge leap of faith to bare our body and soul to a complete stranger. If the physician (any provider for that matter) does not sincerely convey sympathy and empathy, he/she will not participate in my care. I'm a human being and expect to be treated as such. "Clinical distance" is nothing more than a fancy way to rationalize treating patients as a disease or piece of meat.
Ed Reginald, did you feel like a "piece of meat" to be operated upon? ..Maurice.
Reginald,
Here in the US any person at any time can exercise their rights under the ADA.
-- Banterings
Read the text of an interview (or listen) with a physician but who is also administrator of a hospital system and covers the subjects which deal with exactly what is being discussed on this blog thread. Here is the address:
https://freakonomics.com/podcast/compassionomics/
I thank my daughter who provided me with the reference.
Let us know what you all think about the interview with a physician with mixed responsibilities. ..Maurice.
Maurice,
The freakonomics podcast only validates my research and should further strengthen the assertion that the incidents reported here are not the exception, but the norm. If there is such a universal deficit of compassion and empathy, how can patients being treated with dignity be the norm?
As many of us stated here, that it is when this behavior starts costing money that things will change.
-- Banterings
As I look back at the titles of my blog topics over the years, I find some which really fit with what we are discussing here on this Volume 115 and previous Volumes. This shows the extent of the this blog title's potential for discussion. In the past, I have repeatedly referred our readers here to previous title subjects presented on this blog. Well, here is another one which makes us want to separate humanistic behavior of the professional vs unprofessional acts, perhaps of non-medical self-interest.
From November 9 2007 is the blog posting topic _ "Being Hugged by Your Doctor: Invasion of Privacy vs Sign of Compassion".
Of course, in these days, months or more of COVID communicability concern, this topic might be mute (or is it?) but yet, for later, another professional behavior or misbehavior to consider.
Here is my introduction to the topic which was followed by 50 responses.
According to the article in Fox News "Affectionate students are feeling the squeeze around the country as their displays of affection land them in trouble with school administrators." Even if the intent is to express, though the act of a hug, a social connection with their peers on the school grounds, this behavior may be considered sexual harassment. I find this news story has directed me to consider something some of us doctors do as part of being a humanistic human being beyond simply a doctor of medicine. Some of us actually hug our patients or patients' family members. We hug, not out of sexual excitement or anticipation, but out of a sense of the need to express directly compassion and support at the time of a patient crisis. Is hugging a patient professional? Does it exceed boundaries of professional behavior? Does it invade the patient's privacy? Should doctors first ask the patient "may I hug you?" and wait for permission? When you are upset and in distress and need the attention and compassion of someone who shows that he or she cares about your feeling, should you or would you accept a hug from your doctor even without them asking?
..Maurice.
Dr. Bernstein, I looked at those short videos and the comments. Very interesting and well done. They nicely demonstrate how the real world is always more complicated than most of us would like to be the case.
It does not come as a surprise but the manner in which healthcare staffing hierarchy (physician vs resident vs student) and the need for students and residents to learn can preclude patient interests coming first is an ethical dilemma for sure.
On the hugging matter, the huggers of the world might like hugs from their doctors and nurses but non-huggers like me do not want to be hugged by caregivers. That is not how I want them to show that they care. That said, I would not raise a fuss if one of them did hug me. I would instead just accept it in the spirit in which it was intended. If it makes them feel better, I'm good. It is just something I would never initiate or expect.
Biker, I agree with your evaluation of the videos involving the exchange of 3rd and 4th year medical students and their "higher ups" within their school and affiliated hospital staff.
With regard to "hugging" the patient, we do not teach this behavior to first and second year medical students. There is one more "benign" way of making "even emotional disclosure" contact with the patient that we do teach our students from the onset of their education. That act is the very initial contact with the patient-- the student offering (with the student's extended hand) for a handshake. It will be either accepted or non-response by the patient but the student can learn many clinical factors by this initial handshake and the patient can find some initial comfort or insight. Clinically, the patient's hand movement to meet the hand of the student can demonstrate right from the beginning of the clinical experience strength, tremor not seen at rest, degree of warmth, sweating etc, etc. This initial offering attempt or completion of handshake tells even more and begins the "doctor-patient" relationship and even can provide a tentative diagnosis.
So, yes, the offering of a handshake is taught but "hugging", that is not taught the students and this behavior and sign of personal feelings, understanding and support is left to the patient or the physician to expressively apply and all that is what was discussed in my previous posting here. But the handshake with the patient remains diagnostic and expression that the handshake shows the patient is not an "object" but is the subject of the possible developing relationship. ..Maurice.
Maurice,
As to the videos, I have seen too many comments from ned students that they feel that the patient is obligated to allow them to do whatever and they are willing to overlook these things in the name of gaining experience.
I have seen too many articles written that push patient participation because of the good it will do. I hardly see any mention of how such things damage the trust of the profession.
As to hugging, a hug from a provider and acknowledgement of the abuse that I suffered by providers would go a long way with me in building trust with a provider.
Earlier this year, I visited friends. I gave my friend a hug when she answered the door. As I was hugging her, she said "you don't know how good it feels to hug another human being."
We are starving our souls with these measures. We have past the point where the psychological harms are now greater than the physical harms.
One other point that the profession of medicine is missing is that is teaching patients that all those screenings are NOT necessary and NOT to let other people touch them. I am fine with that.
This will change the screening conversation for ever; if screening is so critical, why was it cancelled for a year? It can't be that important...
-- Banterings
Yes, handshakes are fine, but I'm not going to be upset if a doctor doesn't offer to shake my hand. For me, just maintaining eye contact while they introduce themselves (or greet me if they already know me) is sufficient.
Biker, if what we teach our first year medical students is clinically beyond socially important, all physicians should make use of an introductory handshake.
To All: These are difficult times for everyone and a "happy new year" may sound a bit not realistic, nevertheless, I think that it is important to retain and speak out that greeting nevertheless. So, particularly for the year 2021..to all my blog visitors--my best wishes for a happy and healthy year ahead. ..Maurice.
I want to give my visitors here a delayed "Christmas Present" to provide a bit of end-of-year humor in these difficult days. First is an excerpt from the May 18 2006 blog topic "The Meticulous Doctor: An Ideal Doctor?"
From the “THE BOSCOMBE VALLEY MYSTERY” in the classic "The Adventures of Sherlock Holmes" by Arthur Conan Doyle, Sherlock Holmes. after inspecting the grounds of where a murder had taken place responds to his friend and colleague Dr. Watson’s questions:
…"And the murderer?"
"Is a tall man, left-handed, limps with the right leg, wears
thick-soled shooting-boots and a gray cloak, smokes Indian
cigars, uses a cigar-holder, and carries a blunt pen-knife in his
pocket.
By an examination of the
ground I gained the trifling details which I gave to that
imbecile Lestrade, as to the personality of the criminal."
"But how did you gain them?"
"You know my method. It is founded upon the observation of
trifles."
"His height I know that you might roughly judge from the length
of his stride. His boots, too, might be told from their traces."
"Yes, they were peculiar boots."
"But his lameness?"
"The impression of his right foot was always less distinct than
his left. He put less weight upon it. Why? Because he limped--he
was lame."
"But his left-handedness."
"You were yourself struck by the nature of the injury as recorded
by the surgeon at the inquest. The blow was struck from
immediately behind, and yet was upon the left side. Now, how can
that be unless it were by a left-handed man? He had stood behind
that tree during the interview between the father and son. He had
even smoked there. I found the ash of a cigar, which my special
knowledge of tobacco ashes enables me to pronounce as an Indian
cigar. I have, as you know, devoted some attention to this, and
written a little monograph on the ashes of 140 different
varieties of pipe, cigar, and cigarette tobacco. Having found the
ash, I then looked round and discovered the stump among the moss
where he had tossed it. It was an Indian cigar, of the variety
which are rolled in Rotterdam."
"And the cigar-holder?"
"I could see that the end had not been in his mouth. Therefore he
used a holder. The tip had been cut off, not bitten off, but the
cut was not a clean one, so I deduced a blunt pen-knife."
Is this example of meticulous inspection and interpretation what you would be satisfied from your personal physician or is there something else or more that you would expect?
More to follow which continues to humorously praises the physician in a lyric. ..Maurice.
And now, here is the work of Steven Miles MD, the longtime physician ethicist who had given me permission in 2004 to publish his satirical takeoff from "My Fair Lady" lyric.
I posted it on a blog thread titled "Why Can't a Patient Be More Like a Doc?" Humorous but may anger some of you and you may ask just the opposite. ..Maurice.
A HYMN TO HIM
Why can't a patient be more like a doc?
Docs are so honest, so thoroughly square;
Eternally noble, historic'ly fair;
Who, when you win, will always give your back a pat.
Well, why can't a patient be like that?
Why does ev'ryone do what the others do?
Can't a patient learn to use her head?
Why do they do ev'rything other patients do?
Why don't they grow up- well, like their doctor instead?
Why can't a patient take after a doc?
Docs are so pleasant, so easy to please;
Whenever you are with them, you're always at ease.
One doc in a million may shout a bit.
Now and then there's one with slight defects;
One, perhaps, whose truthfulness you doubt a bit.
But by and large we are a marvelous lot!
Why can't a patient take after a doc?
Cause docs are so friendly, good natured and kind.
A better companion you never will find.
Why can't a patient be more like a doc?
Docs are so decent, such regular chaps.
Ready to help you through any mishaps.
Ready to buck you up whenever you are glum.
Why can't a patient be a chum?
Why is thinking something patients never do?
Why is logic never even tried?
Questioning me is all that they do.
Why don't they straighten up the mess that's inside?
Why can't a patient behave like a doc?
If I was a patient who'd been offered a cure,
Hailed as a miracle by one and by all;
Would I start weeping like a bathtub overflowing?
And carry on as if my home were in a tree?
Would I run off and never tell where I'm going?
Why can't a patient be like me?
We are now into the new year and I want to wish the best of health and comfort to all despite the burdens which we all will face.
I want to express my views of the two literary presentations I published here as the year 2020 ended.
I presented them for my visitors to look at and consider on their own and now I want to express my concern about the stories they are attempting to express about the medical profession.
The first, an excerpt from a Sherlock Holmes story actually worries me from the methodology used in clinical situations.
The dynamics of what is written and assumed is that a conclusion is derived from making perhaps logical and thought to be valid guesses but is freely open to heuristic errors as it is in medical diagnosis. The elements presented by Mr. Holmes to his physician friend while some may be valid or seem valid and reasonable they may be assumptive errors and that is exactly what can happen in medical diagnosis of a symptom and disease. Caution has to be taken when adding up a series of findings and assumptions to make a final diagnosis. It is these assumptions that can create what seems "logical" conclusions. So, the assumptions made by Holmes may sound valid as presented, they may identify the wrong conclusion ..a heuristic error. So it is reasonable for a patient to always be a bit suspicious since heuristic errors can easily occur in medical diagnosis and treatment.
Next, is the wonderful poetic narrative regarding "your doctor" by Dr. Miles. But its main point "why can't a patient be more like a doc?" is really a "tongue in cheek" question exposed by Miles. Do we all really want the patient to have taken on the clinical and personal behavior of their physician? From what has been written here on this blog thread, it would seem that patients would want physicians and nurses to provide more attention to the needs and requests of their patients. And finally with regard to patients being "offered a cure, hailed as a miracle by one and by all", it is very reasonable that a thoughtful patient to bear suspicion and demonstrate their ethical autonomy regarding their care.
I hope all my readers here had taken this view of the two presentations. That is why this blog thread is moving into this "next year" since neither Sherlock Holmes nor "patients more like a doc", as I explained, provide cures for the obvious problems within the medical system, described here and the news media. Anyway, that is my opinion. ..Maurice.
Maurice,
Why can't a patient be more like a doc?
Let the patient drug the doc and sneak a bunch of other patients into the room to intimately violate the doc.
Let the patient make the doc wear a skimpy, open back gown and say that is how we have always done it.
Allow other patients to abuse the doc and look the other way.
Dictate how the doc is going to dispense care and withhold something of value if the doc does not comply.
Blacklist the doc if they do not comply.
Let the patient be looking at their phone when they are with the doc.
Let the patient(s) come into the doc's bedroom to watch (and learn) when the doc is having an intimate moment with their partner.
Let the patient talk gossip about the doc to everyone they are friends with and post pics of the doc that the patient took on social media.
Let the patient dictate how the docs should live their lives.
Answer "...because it is my body and I know what is best for it; are you in this body?"
Yes, I agree, why can't a patient be more like a doc?
-- Banterings
Dr. Bernstein, what I see in the Sherlock Holmes story is the risk of ego (always having to be right) potentially blinding a doctor from seeing something really important. Sherlock Holmes of course is always right but in real life such people don't exist but rather just the ones that think they are always right.
On the poem, its cute but harks back to the paternalistic approach that has fallen out of favor with many patients.
Thanks for the pertinent reviews by Biker and
Banterings. They appear to agree with me that there is an "other side" to the story and the lyric. ..Maurice.
I would like to add a bit of support to my distinction between Sherlock Holmes and his ability; and skills to "diagnose a crime" and physician's responsibility to diagnose an illness. Here is a 2001 writing in the 2001 Journal of Medical Ethics "A Medical Perspective on the Adventures of Sherlock Holmes" https://mh.bmj.com/content/medhum/27/2/76.full.pdf
Of particular interest for me is the section of the writing which deals specifically with "Holmesian deduction and modern medicine"
I like this part of the section:
Deductive reasoning as employed by Sherlock
Holmes undoubtedly forms an important part of
the modern medical diagnostic process. The real
skill of the doctor lies, however, in operating simultaneously on a variety of levels, pulling together
straightforward factual knowledge with more abstract impressions and experiences to produce an
appropriate response. This response may not
necessarily lead to the solving of the “mystery” (the
cause of the patient’s illness), but it should lead to
the solving of the “problem”(helping a sick
patient). The problem may not necessarily be
resolved as a direct result of the medical interventions, but simply as result of an effort being made
(for example, supportive care following GuillainBarré syndrome paralysis).
And this conclusion: It has been said that
Sherlock Holmes would have made a superb diagnostic physician, but is this really the case? It seems
more likely that he would have been severely
frustrated by the lack of logic in medicine, and by
the number of occasions on which his carefully reasoned conclusions would be either proved incorrect
by mere chance, or never proved at all. Medicine
would offer little to keep him from returning to the
familiar world of chemical bottles, magnifying
glasses and fine tobacco.
Are there any behavioral elements based on your reading of Sherlock Holmes that you could consider which could help a physician or nurse in preserving the dignity of their assigned patient? ..Maurice.
Concerning doctors & nurses emulating Sherlock Holmes, one aspect of his character that might better preserve patient dignity is tending the details. Doctors, nurses, techs etc often seem oblivious to patient distress over the exams or procedures they are undergoing; a detail anyone observant shouldn't miss. When they bring the female chaperone in for a male genital exam, were they like Sherlock and noticed the distress her presence is causing, the doctor or nurse might realize they are violating the "do no harm" premise of healthcare. But they generally don't notice, or they don't care.
Another aspect of tending the details is knowing when intimate exposure isn't necessary. Lift the gown from under a sheet to expose the abdomen for example rather than exposing the patient and then covering the genitals.
The reality however is Sherlock Holmes is fiction as is the mantra that the people who work in healthcare care about patient dignity. Of course some care, but any given patient on any given day can't assume their caregivers that day will pay attention to the details that support respecting patient dignity. Patient dignity gets in the way of staff convenience on a regular basis and on occasion (Mr. Kirschner, Dr. Sparks, Denver 5 etc) it gets in the way of staff entertainment.
Biker, I think you "hit the nail on its head"--a very realistic answer to my question when you wrote "Concerning doctors & nurses emulating Sherlock Holmes, one aspect of his character that might better preserve patient dignity is tending the details." Could one argue that Sherlock dealt apparently with one case at a time and most doctors and nurses are driven in their actions and its behavior by the fact that other patients and diagnosis and treatments are awaiting. And it is possible that medical details, in a rush, are overlooked or erroneously ignored and that would include awaiting for the autonomous directions or complaints coming from their patient. I am sure Sherlock Holmes, based on the narration, had the time to create a "diagnosis" regarding the "case".
Maybe, what we need to improve the medical profession and its behavior toward patients is MORE doctors and nurses to provide each with more time to listen to their patient and and think about not only a more accurate diagnosis and treatment but also time for more insight into the dignity issues appropriate for each separate patient. It just seems to me that Sherlock took the time to "think things out". Not all doctors and nurses are pathologic creatures so perhaps the "hurtful behavior" toward their patients is lack of time to listen, think or to do and to me it seems that Sherlock Holmes had that time and ended up doing a "good job". ..Maurice.
Maurice,
Biker so eloquently expressed something that I have said repeatedly when he referred to patient distress about exposure; rationally there are only 2 answers as to the "why. Either they don't know that the patient is in distress, uncomfortable, etc., OR they do NOT care.
Perhaps it is both: The profession of medicine does NOT CARE, so it does not train providers and they do NOT RECOGNIZE (KNOW) the patient is in distress.
As to your Sherlock Holmes reference, the best analogy that I can give is the 2004-2012 TV series, House M.D..
References to the famous fictional detective Sherlock Holmes created by Sir Arthur Conan Doyle appear throughout the series. Shore explained that he was always a Holmes fan and found the character's indifference to his clients unique. The resemblance is evident in House's reliance on deductive reasoning and psychology, even where it might not seem obviously applicable, and his reluctance to accept cases he finds uninteresting. The name "Holmes" is a homophone of the word "homes", and the words "home" and "house" have a similar meaning. House's investigatory method is to eliminate diagnoses logically as they are proved impossible; Holmes uses a similar method...
I have explained to many that Dr. House is an extremely rare occurrence. 99.999% of what physicians do is repetition. They recognize cellulitis, labs point to diabetes, etc. Real life "House M.D." situations make for interesting TV. The series Mystery Diagnosis is such a show. It is interesting to note that the reoccurring theme is that the patient visits many doctors before getting an answer.
There are the Dr. Gregory House's out there, but they are far and few between. Many are found at such places like the Mayo Clinic or become experts in a specific illness or disease from a learn-as-you-go curve such as Joseph Sonnabend, MD with HIV.
Whether Dr. House or Dr. Sonnabend, I wonder how many dignity violations patients are willing to overlook to save their lives or make the pain go away. That being said, at some point that trauma will rear its ugly head and "they saved my life" turns in to "they violated me."
Just look at PTSD after ICU stays.
-- Banterings
Banterings, I can second that PTSD after ICU Stays article. As in the article, my wife's septic shock (& month long hospitalization) earlier this year profoundly affected her. Though mostly physically recovered at this point, she clearly has lingering PTSD effects. She keeps bringing herself back to the fact that she might have died or suffered permanent physical disability, and she is very fearful of it happening again. That in turn has made her terrified of covid-19 beyond what the remote odds of acquiring it are where we live.
Maurice,
Why is this happening in 2021?
Still happening: Pelvic exams on anesthetized patients. Why?
Is this NOT evidence enough of the corruption of the profession of medicine?
The profession has lost any moral authority that is ever had.
Society is changing the profession. The witch hunt is coming...
-- Banterings
It's still happening. But why? Here is a December 8 2020 article in Medscape titled "Still Happening: Pelvic Exams on Anesthetized Patients. Why" There is much up to date information on this subject. In states where such exams are still used aa a student teaching resource, a female Florida state senator states "At best, these exams have been learning experiences for medical students or at worst equivalent of sexual assault."
Also read some of the 101 Comments posted at this time. ..Maurice.
With regard to the article above, here is the Comment from a female pediatrician:
"I recently had extensive gynecologic surgery at a teaching hospital where I am retired staff. Part of my consent clearly stated that I would have a gyn exam under anesthesia and who would be doing it. If I found out that had been done without my consent by anyone other than my surgeon, believe me, I would be suing for assault, and whatever else my lawyer decided."
What this teaches me (though I am not totally surprised) is that there are physicians out there who would take legal action on their own physicians as has been stated by our non-physician patients. writing here. ..Maurice.
Dr. B.,
I posted that MedPage article previously to my Twitter but I went ahead and posted the link here and your comments.
I will say here like I have said on Twitter, that pelvic/rectal exams on sedated female/male patients without expressed consent is much like date rape. The only difference is patients go into a medical procedure having trust/faith in the medical provider doing "no harm" to them whereas the date rape scenario is different. However, both use drugs to achieve their goal of getting something needed for the offender--power, control, satisfaction, and nothing for the victim except extreme harm. Just like the date rapist, medical providers insist it is harmless since many cannot remember the "rape" and if they would have asked, the answer might have been "no'. Using power and control to do something to someone without consent is the very definition of assault. Medical treatment with a twist--assault and battery.
My husband never thought much abt what medical providers did. He assumed they would trustworthy and wouldn't intentionally harm him until they did. With that, came the medical PTSD. It can be triggered by little things. It has been a real experience trying to identify and control the triggers but those triggers are everywhere in their scrubs. They even come into our home--our safety net. Again, on Twitter I post articles about medical PTSD and how very little the medical community recognizes it can be caused by medical horror encounters like my husband experienced.
One follower tweeted an article by CBS news of people that did an investigation into how corrupt medical review boards are especially Indiana's panel. Quite enlightening. It is no wonder some medical provider feel entitled to commit what are criminal acts in other parts of life. We know for many procedures, patients are exposed unnecessarily which makes it a criminal act. Why has this not been addressed and fixed?
As I have tweeted on Twitter, the unconsented for pelvic/rectal exams are just a stepping stone for other acts of hostility to be committed against patients because it erodes in the medical provider the need to accept/acknowledge the patient has rights to dignity and autonomy.
Maurice Bernstein says,
"It's still happening. But why?"
Having read the link Dr. Bernstein I am astonished when I read the comments section. Many supposed nurses said that if it was rectal or prostate exams on males the practice would end immediately. I find that disingenuous, if anyone can make a contrast between the care of men and the care of women, it has to be nurses. They are right in the middle of it. I am quite certain that if nonconsensual pelvic exams are being performed on women, most certainly nonconsensual prostate exams are being conducted on men.
58flyer
In my last posting I discussed my phone call to the Chief Clinical Officer at the hospital where I had the experience with the issue of the female urologist bringing a female student with her on rounds.
Between Christmas and New Years, my wife and I along with our son made a trip to Houston and many stops along the way, the occasion being the 4th 29th birthday for my wife (do the math). We stopped at the WW2 Museum in New Orleans, visited relatives in Houston, visited the Space Center, spent a couple of days in Galveston, made a stop at Beauvoir in Biloxi, MS, stayed at the inlaws in Pensacola, then got home on the 3rd of January. We managed to pull it off without contracting COVID. I think.
Upon inspecting the mail when we got home I found a letter from the Chief Clinical Officer. Short and sweet, only 3 paragraphs. I didn't expect much more than that as they are not going to admit liability. In part it said, " As a team, we have identified a few opportunities and have since taken the necessary steps to improve our processes. In regards to waiting, I understand how frustrating waiting can be, not to mention being in the pain described. Patient flow remains a top priority and I continue to work with the department leaders to optimize patient throughput especially in these challenging times. We have identified an opportunity to be even more vigilant during the intake process, increase purposeful rounding and decrease the time between updates to our patients." He thanked me for bringing up the issue and giving them an opportunity to "enhance the patient/family experience." He gave a phone number to call him back if I had additional questions. No mention was made of the juvenile female brought in by the urologist. I put a call through to the number provided and had to leave a message. I am awaiting a response.
58flyer
58flyer, while I was hoping you'd get a real response that spoke to the issue of a high school kid masquerading as a nursing student and a doctor deploying a high school kid as a chaperone, I am not surprised that you got a stock non-answer answer. Your complaint had nothing to do with throughput nor does the current covid-19 situation have anything to do with what happened.
Hopefully you'll get a response to your follow-up.
My interpretation is that the hospital doesn't care that the student and doctor lied to you and that they had an under-aged non-licensed non-employee being deemed part of your care team.
As I noted previously, there are alternate ways for "pre-med" college students to demonstrate to the medical school admission committee their interest and understanding of the medical profession WITHOUT having to present to the committee that the student participated in "shadowing a physician".
Here is how it can be accomplished American Association of Medical Colleges:
"Five Ways to Gain Experience Without Shadowing"
As a physician and medical school instructor and writer of ethics documents, I totally dislike the word "shadowing".
There should be no "hiding" the role of some observer (student or otherwise) or standing in the shadow of the doctor in a doctor-patient relationship.
However, thinking about another clinical issue of "shadowing" which you might discuss and possibly distinguished from the student-doctor "shadowing". Has JR also been "shadowing" and who: the doctors and nurses or her husband? Maybe the word "shadowing" is a bit ambiguous word in terms of student-physician or family member-physician/nurse relationship. I say let's toss "shadowing" out. ..Maurice.
Dr. b.,
Please be more explicit in exactly what you are accusing me of being guilty of so I may answer your charges.
JF, I have been wondering, as an elderly-care worker, whether you finally accepted an offered COVID vaccine dose injected into your arm. And if you did, how you tolerated the dose. ..Maurice.
Maurice,
In your link to Five Ways to Gain Experience Without Shadowing, one suggestion is to be a scribe. We have discussed how scribes are a "shady practice" just as physician shadowing is a shady practice.
-- Banterings
JR, no guilt. The issue is whether, beyond students shadowing physicians (and observing and contemplating the physician's motivations and behavior) whether in your role as a wife of your husband, you could classify your activity and contemplation in observing and considering the actions of the doctors, nurses and others in healthcare as "shadowing": observing and evaluating their behavior before finally communicating with them about what you observed.
Finally, in a way, would you also consider that you were "shadowing" your husband and observing and considering the direct behavior of the medical others on him, how he was able or not able to react to gain insight into what he might be experiencing and perhaps not immediately telling him or his doctors and nurses what you were at the time observing.
As I already mentioned, "shadowing" may not be the proper word to use with regard to these relationships noted above. ..Maurice.
OOPS! THE LAST ATTEMPTED POSTING WAS DELETED BY ERROR. IF YOU WROTE AND DO NOT SEE YOUR POSTING, PLEASE SUBMIT IT AGAIN! ..Maurice.
We haven't been offered the vaccine yet. But we have to get tested every week now. My niece who is a Physical Therapist in a nursing home in Georgia just got vaccinated. She just posted about it on Facebook yesterday and was excited.
Dr. Bernstein, that was probably a post from me. I was just commenting that the "Five Ways..." article offered good alternatives to shadowing, though I generally object to the presence of scribes for anything where patients are undressed or conveying personal information.
On the matter of shadows, I would love to see the term student doctor banned. There is no such thing. There are Residents (who are doctors), medical students, college students, and high school students. Those are the descriptors that need to be used, not student doctor. That said, high school students should not be allowed to shadow doctors at all. Children have no place observing or being part of patient care.
Maurice,
JR is NOT shadowing. She is a caregiver, a spouse/partner/family, and protector. There is history with the patient where any provider is basically meeting the patient for the first time, they are strangers.
As to Biker's comment, we have discussed the use of appropriate terms used by these alleged, self-proclaimed scientists; most recently in the modesty vs. dignity discussion.
As biker puts it, there is no such thing as a student doctor. This is semantics, this is to intentionally deceive the patience and force compliance with the provider's wishes. The use of the term student doctor is well documented and should not be in question, neither should the proliferation of its use. Most notably is the website Student Doctor Network.
On this blog, the moral turpitude of the profession of medicine has ben demonstrated ad nausium, yet members of the profession still have their heads in the sand and excuse the behaviors. In the most recent article that you and I both referenced, well over 90% of all practicing physicians and a majority portion of other providers, have participated in the practice.
That means that the majority of the profession has committed (systematic) crimes against humanity. (This is one of many practices that intentionally deceive patients.)
As I have said, the day of reckoning is coming for the profession of medicine. It has already started in the this time of the pandemic. BLM and the recent melee at the Capital show that society has finally had enough of institutions not meeting the expectations of society. The beginnings of this movement against medicine started in the #MeToo movement.It has been trying to take a hold. Eventually, the arrogance of the profession will do something that will trigger the change.
Unlike the other institutions, (almost) the entire profession is guilty of having participated in this practice in their education.
-- Banterings
Biker, here is my Introduction to blog thread titled "What Should Medical Students be Called--Revisited" posted December 8 2004.
This posting is a revisiting as an ethical issue of a situation in medical education which was first considered here on August 7, 2004 (scroll down this page if you want to read it.) The view today is written by a medical student herself for a class discussing ethical issues. Jennifer Piel is a second year medical student at the University of Southern California Keck School of Medicine. Jennifer will have any comments on her essay by visitors to this blog accessible to her. Thanks Jennifer for allowing me to post your words here. ..Maurice.
A problem that I have seen repeatedly at the hospital and in situations in community practice is the scenario in which a practicing physician introduces a medical student as a “doctor.” Addressed here are some of the ethical issues presented by the scenario.
Students Placed in Awkward Position
When a supervising physician introduces a medical student as a “doctor,” it places the student in an awkward position. Most likely, a physician makes these introductions to encourage trust between the student and patient. Nevertheless, it places the student in an uncomfortable position to correct the physician and inform the patient of the mistake.
Although the student should take responsibility to correct the statement of mistaken identity, it may be difficult for the student to confront his/her supervisor, particularly when the physician would feel that the student is undermining his/her authority or intentionally being confrontational. The student may be correct in recognizing an ethical conflict, but feel prevented from addressing the issue out of fear of reprisals from the physician.
Similarly, the student is placed in the difficult position of addressing the issue with the patient. Some students may fear that correcting the issue of mistaken identity will result with the patient refusing care by the student. However, even if some subset does refuse student care, many patients will likely be quite willing to allow appropriate student involvement in their care, In my opinion, the fact that some patients decline student care is no justification for deliberately misleading them.
Moreover, clarifying the mistake with the patient will likely preserve trust between patient and student, if the patient realizes that the student is trying to be honest and straight-forward.
Continued:
Effect on Patient Decisions
When a medical student is introduced as a doctor, particularly when the student is going to be involved in the patient’s care, it prevents the patient from making informed health care decisions. Not only does this scenario present ethical concerns, but legal concerns as well.
The first issue here involves the student holding himself/herself out as a physician. To respect patient decision-making autonomy, there should be a free exchange of material information between the patient and student. Autonomy is a key ethical consideration, focusing on the right of self-determination. It is grounded in the idea that patients should have control over their personal decisions. Accordingly, it is appropriate to disclose to the patient that the physician-in-training is, in fact, a student.
It may be argued that the principle of beneficence should be the key ethical consideration in situations involving medical care. The principle of beneficence commands that benefits to individuals and society be maximized and that harms be minimized. Under this principle, one could argue that it is in the patient’s best interest to identify the student as a physician because, then, the patient is not burdened with potentially troubling information. Some patients are likely to consent to student care, but subsequently feel uncomfortable with the student’s level of knowledge or skill. This argument begs the conclusion that, because the patient would have consented to the student care, the patient is subject to less harm when the student’s true identity is withheld.
A number of flaws exist with this latter line of reasoning. To begin with, it is naïve to suggest that we could benefit a patient by withholding relevant information. Patients would likely prefer that their health care professionals are honest with them. As mentioned above, the patient may justifiably feel disrespected. This could cause the patient to mistrust other members of the hospital’s staff. Additionally, to even minimally respect a patient’s autonomy, health care providers should give the patient the option to refuse care. Even patients that would consent to student care should be asked.
In situations where a student is held out as a doctor, a second issue concerning the patient’s decision-making is brought into question. In this situation, the patient will not know to ask, nor be informed, whether the procedure or care in question is ordinarily provided by a student. Like the failure to disclose the student’s true identity, failure to adequately provide the patient with this information inhibits the patient from making a fully-reasoned decision. It could be that the patient would have agreed to the student performing the procedure, subject to certain conditions, such as an experienced physician being present or that the procedure be conducted in a particular manner. Alternatively, the patient might have agreed to student participation, but, upon hearing that a particular procedure is not a routine responsibility of medical students, decide that he rather have a physician perform the procedure after all. This illustrates the situation where the patient is unaware that the student’s competency is even a question to consider.
In terms of the law surrounding informed consent, physicians have a duty to disclose and ensure that patients understand all information material to the patient’s decision to undergo or deny particular medical attention. A physician who fails to fulfill these requirements may face liability under a simple negligence theory. Further, medical personnel who perform medical procedures without gaining proper consent may be liable for civil battery. Although courts disagree as to whether informed consent cases should be evaluated from a patient-oriented or physician-oriented approach, it is risky in either case to mislead a patient about the identity and skill-level of an individual treating the patient. This information is likely material.
Facilitating the Unauthorized Practice of Medicine
As a society, we have established regulations to prohibit non-physicians from practicing as doctors. We do this to protect the public from incompetent or unethical performance of medical services. It further serves to protect the integrity of the medical profession. Because patients often cannot distinguish between their doctors, medical students, and other health care personnel, it seems imperative that providers make specific efforts to minimize any confusion.
Although students practicing under the supervision of a licensed physician are generally protected from claims of unauthorized practice of medicine, this may not hold true where a student holds himself/herself out as a physician and/or the student is not adequately supervised. A physician may not delegate ultimate responsibility for providing medical care to an assistant. Such delegation is appropriate only when it is consistent with the assistant’s training and education.
The legal case of Oliver v. Sadler (Jury Verdicts Weekly, Oct. 7, 1994) involves a similar situation to the illustration presented here. In that case, a patient was seen by a physician assistant. When the treatment proved harmful, the patient sued Dr. Sadler, in part, because he misrepresented his physician assistant as a physician. It was argued that the patient assumed the physician assistant was a doctor because he wore a white coat and had a stethoscope. This presents the very picture of medical student and underscores the need to accurately identify for the patient the individuals who are involved in the patient’s care. Isn’t it unethical to foster patient confusion?
This essay highlights some of the ethical issues faced when a student is introduced to a patient as a “doctor.” It is unrealistic to expect that this situation will never again occur. Accordingly, it is advised that students and their supervising physicians speak openly about the student’s status, role, and responsibilities before being introduced to a patient.
I hope you all found the above student Essay in keeping with what has been described here by our contributors as a need for openness and honesty in the doctor-patient relationship and premature identification of students as "doctors". ..Maurice.
And now, if you want some worthy reading and maybe extrapolation to issues of the taking away of patient dignity which have been a mainstay of the comments on this long running thread topic..well, just go to the following link from the AMA Journal of Ethics and the articles about the Holocaust:
https://journalofethics.ama-assn.org/issue/legacies-holocaust-health-care
and a modern-day version of holocaust-like behavior, physicians balancing patient autonomy against "protection of public safety": https://journalofethics.ama-assn.org/article/how-should-clinicians-involvement-holocaust-inform-contemporary-responsibilities-protect-public/2021-01
Sometimes these are challenging decisions, whether to follow the requests of the patient or the requirements of governmental agencies. Let me know what you think after reading these brief articles. ..Maurice.
I skimmed through the "holocaust" material Dr. Bernstein, and it is sobering to be reminded of that sad history as well as some of our own sad history of forced sterilizations and the like. I will venture to guess that ethicists a generation or two from now will be shaking their head at the practice of non-consented vaginal exams and wondering how could medical educators & trainers have allowed that to happen. Assuming of course that it has stopped by then.
Part of the past practices imposed on the poor and those who had no power stemmed from racism and other prejudices as noted in the articles, but part of it was also rooted in paternalism. I think I had shared this before but my own mother was involuntarily sterilized by our family physician. In conjunction with a cesarean birth he took the liberty of doing a tubal ligation to prevent another pregnancy. It was her 7th child (6th boy) and each baby was larger than the last. #7 was 10.5 pounds which was a lot for a 5'3" woman, and too big to get through the birth canal, forcing an emergency C section. This was in 1968 and she just accepted it at face value because her generation automatically deferred to authority, and the doctor was authority. She was 36 and as a Catholic would have continued having kids until Mother nature stopped her, but never would she question the doctor as to what was right for her. Nor did he think it necessary to consult her. Paternalism.
Yes, Biker, the ethical issue involved in the actions of the medical profession attending to their patients is defining with each decision-making event whether the action is based on patient autonomy or instead on physician-medical profession-society paternalism. And the third ethical principle to consider is justice, which includes who deserves, under the existing circumstances, the ethical right to make the final decision (the patient or the physician who may be speaking in essence for betterment of the patient but also betterment of society). Quite a responsibility of those decision providers in the medical profession. ..Maurice.
JR, you wrote 2 days ago "Dr. b.,Please be more explicit in exactly what you are accusing me of being guilty of so I may answer your charges." Actually, I was trying to make the point that "shadowing" was an ambiguous description and could involve others beyond students and finished the posting with "I say let's toss 'shadowing' out". ..Maurice.
Maurice,
In your last posts, I see the same that I always see from the profession of medicine: Lip service and double speak. It sounds like they are for patient autonomy but they justify deceiving the patient: ...could cause the patient to mistrust other members of the hospital’s staff...
You can NEVER justify deception.
You also mention; ...third ethical principle to consider is justice, which includes who deserves, under the existing circumstances, the ethical right to make the final decision (the patient or the physician who may be speaking in essence for betterment of the patient but also betterment of society)...
This is exactly the justification and defense of the physicians for the Holocaust. This is the same justification of medical rape of patients by students to learn intimate exams.
Everybody in the profession condemns the the practice publicly, yet it continues?
Why, why, why???
The only answer that can be concluded from observations is the profession thinks that it is exempt from society's expectations. You talk about ethics, but the profession continually acts unethically.
Please, give me another possible reason why intimate exams on anesthetized patients is still happening?????
PLEASE ANSWER ME.
-- Banterings
Today when I went in to work we were told that now we have to be Covid tested TWICE every week, instead of once. It's hard for most staff to do that but a person without a vehicle will be paying Uber a lot. Occasionally we are tested at the facility and that's good because we don't have to schedule an appointment then. It's still an extra trip in though because it's done at 9 or 10 in the AM. And for a job that pays $10 an hour.
Banterings, physicians are the ones who set the final clinical decisions to present to the patient except as within many, many other professions and public work there are limits (or absence of limits) which are set by the local, state or national governmental bodies.
That means that decisions have to be guided by governing "others". And, in the case of physicians and nurses, there are immediate governing bodies, state boards for example, who are allegedly present to attend to the health and safety of the individual patient but also the community. Fortunately or unfortunately, physicians and nurses are NOT exempt from whatever has been legally decided is "society's expectations". But fortunately, most clinical decisions are set, in the current generations, by patient autonomous decisions. But, nevertheless, the medical profession cannot act independently of law and government.
Fortunately, in the state of California and some other states, pelvic exams, under anesthesia or other otherwise, by individuals (students) who have not been given permission by the patient cannot be permitted by the patient's physician.
Unfortunately, in states which do not have such laws, I understand the "teaching tool" continues to be used. And, in a Democracy, which I hope USA continues to be (despite recent events), it is up to the citizens in their communities to "speak up" and legislate change and physicians and nurses will have to obey the new laws or face punishment. ..Maurice.
JF, I am sorry to hear about the disorganization of the testing process occurring in your working environment. The disorganization has been now shown to be part of the COVID immunization process. And it all has to do with central national governmental administrative dysfunction if not shifting of interest there to non-medical but political issues. Hopefully, shortly the orientation of our national government will be attentive to COVID control and a working and effective testing and immunization process and program instead of attention to other political gains. ..Maurice.
This past Friday I placed a call to the office of the Chief Clinical officer and spoke to his secretary. I asked her what would be the most preferable time to call him back that would assure that he would in his office. That time was right after lunch, or about 130. So, I called and he was in!
I started by thanking him for taking the time to investigate my report and respond with a letter. I then asked him why he did not address the most important concern, that being the presence of the juvenile female acting in a chaperone capacity. He said that was still under investigation and consideration with board members. I mentioned to him the many legal and ethical considerations that many of you expressed recently. He didn't disagree. We spoke for the better part of an hour. I am amazed he gave me that much time. His thoughts were that there has to be a balance of the interests of the patient, the hospital, and the doctor. I pressed hard on the need for honesty with the patient, and not to lie to get a patient to agree to the intrusion. He said that this is not the first time the subject has come up and they will have to come up with a policy for dealing with this issue in the future. He kept stressing to me that the needs of the patient come first. I asked him if there is any citizen involvement with the board so that they could hear things from a patient perspective. He said there was not but felt that it was a good point and he would bring it up in the future.
So, I came away with the impression that he was concerned and that there will be a policy decision made in the near future. He thanked me for being proactive. I guess time will tell if my efforts will be of gain for the dignity rights of patients at that hospital. He has promised to get back with me and keep me up to date with policy decisions. I offered to speak before the hospital board and provide patient input if needed. He thanked me for that and said he would keep that in mind.
This week I will get in contact with the local high school the student allegedly is attending and ask to discuss my experience with one of their students. I will ask for a face to face meeting with the program manager. Hopefully they will agree to meet with me.
58flyer
Dr. B.,
I am not shadowing my husband but providing to him a service for which he has asked for and that is to be there to protect him during the medical encounter. For victims of medical harm, medical encounters are terrifying as they never know if/when or could/will be harmed again. I am there to provide protection for him. This is the end result of what happened to him in the past. I do not remain in the shadows as he was verbally told them and supplied them with paperwork staying I am his health partner. I am not in there to decide to "finally" tell them what I have witnessed but rather to immediately stop them from again harming him. I would think as a student of medical ethics your question would be what would have prompted a patient to feel as if they need protection during medical encounters? Before the harm, I was there as a second pair of ears to remember the info but now my role is entirely different. Before I did not have to accompany him to all medical encounters or else he would not go. So the better question would be what would have happened that made a grown man completely feel unsafe during a medical encounter? Unlike those who "shadow" doctors or nurses, I clearly identify why I am there. There is no misrepresentation on my part. My husband has made it clear that due to his medical harm history, if I cannot be present, he will leave and seek no treatment. Is it acceptable for the delivering of medical treatment to cause so much harm to a patient that a patient would rather have no medical treatment than to be harmed again? I am afraid the next 4 years will increase the odds of patients being medically harmed as clearly there are two sets of standards. I believe will see differing opinions silenced. I believe it will once again become the land of medical harm going unchecked and politics ruling who becomes medically harmed.
Thanks for the update 58flyer. It sounds like the Chief Clinical Officer knows what happened is wrong but is getting (or has gotten in the past) push back from doctors who don't want to constrained by ethical conduct requirements in this regard. It could also be that the girl in question is the daughter or granddaughter of a VIP, a hospital exec or Board member perhaps, or maybe even a doctor critical to their operation. Whoever this girl is connected to may be of the mind that her desire to masquerade as a nursing student and chaperone outweighs the rights of patients.
Hopefully there will be some change as a result of your complaint.
JR, as I have previously stated I am against "shadowing", in the current discussed definition, literally means an individual attending a relationship between a professional at work with a patient as some observer whose presence and participation may not be fully identified and accepted by the subject. All individuals present in a doctor-patient interaction should be fully identified and their presence, role and responsibilities should be made known and clear to all and accepted by all. If a family member, that individual should make clear to all present doctors, nurses, technicians, identification and role in their presence.
To me "shadowing", when used in the current context, represents some behavior which can be unclear, unlimited and unfair to the patient. ..Maurice.
By the way, and I repeat it again and again, I think that all individuals in an operating room who are not the usual designated participants should be specifically informed to the patient prior accepting surgery and should be accepted to be present by the patient. Those "not usual" would include industrial technicians who demonstrate and supervise their surgical product and would include the presence of medical students at the operating table or within the room.
..Maurice.
Maurice,
You stated: ...he medical profession cannot act independently of law and government...
So why even bother with ethics if the only governing constraint is the law? By your very words, "first do no harm," ethics, etc. do NOT apply, only the limits of the law.
What happened during the Holocaust was legalized by the state. I guess then by your argument that was acceptable behavior by medical professionals.
As I have espoused all along, honesty, integrity, ethics mean NOTHING to the profession of medicine.
-- Banterings
Maurice,
Another prediction of mine has come true: Providers try to scare society by saying that if I can't do what I want, then I will quit and there will be no doctors or nurses. I don't feel that I need to reference this because numerous examples have been presented on this thread in the past.
My contention is that foreign doctors and nurses would be brought in to the US to replace them and I already know of companies making contingencies to do this, although it historically has been to break strikes.
In the face of the pandemic and a provider shortage, that is happening: Covid surge prompts NMC to fast-track more overseas nurses onto temp register
Granted this is the UK, but the United States has this as a fallback provision. Another option that I have espoused is also being used currently here in the US: National Guard Medical Corps.
So threats by providers amount to little more than idle annoyance.
-- Banterings
Banterings I wrote "But fortunately, most clinical decisions are set, in the current generations, by patient autonomous decisions. But, nevertheless, the medical profession cannot act independently of law and government." But, fortunately the diagnosis and treatment of a patient is not absolutely set by law or government since despite the fact every physician must be aware of "law and government", the final decision-making is truly set within the doctor-patient relationship. So, in the reality of medical practice, it is primarily the physician who understands any dilemmas conflicting with law and government, nevertheless it is only the patient's physician and patient who can settle any conflicts with the law since law and government themselves have not taken the history or performed the clinical examinations. And this reality therefore supports the ethical process of "mediation" between physician and patient which is how conflicts on the issue set by law and government can be resolved. Read the Case and Commentary covering this conflict in the AMA Journal of Ethics which I referred to previously which shows such an example of what I just wrote:
https://journalofethics.ama-assn.org/article/how-should-clinicians-involvement-holocaust-inform-contemporary-responsibilities-protect-public/2021-01
..Maurice.
If anyone thinks that the power of the government in the issue of doctor-patient relationship is focused on limiting the power of the patient, here is some news for all patients regarding the "21st Century Cures Act". I want to let you know that the government also has the power to take things away from the possession of the physician and place those things into the lap of the patient. Here is a
link to a current Medscape article which outlines the "?good news?" to all patients beginning April 5, 2021.
"The 21st Century Cures Act mandates that patients have fast, electronic access to the following types of notes: consultations, discharge summaries, history, physical examination findings, imaging narratives, laboratory and pathology report narratives, and procedure and progress notes." So patients "worry not" because as with the HIPAA patient information limiting legal regulations, this upcoming law presents power to the patient.
You must also read the Comments section of the article which contains some worthwhile issues to consider regarding ready access to the physician's written words. Here is one example: Yes, you are charting only what will be OK with the patients. In the process you are likely omitting a lot of details that may be important, e.g. "this patient often stops taking his/her medications on his/her own", or this patient was overtly hostile to the nurses and me in the office, screaming in the hallway, insulting everybody, demanding this or that, and insisting on having such and such medication prescribed although I did not think such an intervention was indicated, as explained", etc". "The patient was upset, got up and left the room, without letting me finish the conversation or the examination". You may omit all these things that may well become important later, for a lot of different reasons not the least of which being medico-legal.
My conclusion to this medical news is that patients and their concerns with the medical system are not fully being suppressed by the government. ..Maurice.
Dr. B.,
You were the one who brought me into the conversation suggesting I was "shadowing" before you disavowed shadowing. I merely was explaining my role as it is nowadays.
I do agree with you last post those "not usual" should have explicit patient consent in order to be there but often the blanket clauses on consent forms are deemed acceptable to the medical institution. It is not acceptable. I also think there needs to be uniformed procedures clearly stating how to guard patient dignity and not to expose patients unnecessarily. Every patient should know what is going to be exposed to whom, and why. It is our bodies, our choice. Information is the key to make many patients feel comfortable. Again, having a patient advocate of patient's choice is also doable. There are areas within an OR or procedure where the advocate could be and not interfere with the sterile field but could still be a witness for the patient's rights. This would help eliminate some of the patient dignity violations occurring that are either intentionally degrading or just careless on the part of the staff not to mention those which are criminal like pics on personal cameras.
You said that medical community cannot act independently of the law and government but they can and do. Even your liberal news channel, CBS, did an article about medical boards being biased and basically do nothing to protect harmed patients. They also focused on Indiana's medical board which is one of the worst for allowing crimes to happen. Remember Indiana licensed a doctor who was convicted of a felony kidnapping (burying a woman alive) who went on to sell drugs. Your CBS news reported on the corruption of the medical boards. Remember the Earl Bradley case where the President of the Medical Board's statement was to the effect of "oh, is he up to his old tricks again?" which represents all of what is wrong with having a system self-police itself.
Patients do have autonomy according to the law but in practice patient's autonomy is often ignored as in many of the cases of patient harm I have come across. It seems the medical system has become so arrogant and so greedy they do not feel patients have a say in what happens to their body. They are the experts so what they say will happen despite what the patient has dictated. Patients rarely win lack of consent cases in malpractice courts.
Sorry I have been giving the wrong handle of my main account on Twitter. Due to the censuring and denying the rights of free speech, I am considering terminating all my Twitter accounts. I have lost hundreds of followers as Twitter deems free speech unacceptable. I have always said the difference between an outright communist country and the US is the communist says no from the beginning but the US allows you to try and then shuts you down and punishes you. Looks like that is happening now. With most in the medical professional being "progressive" which defined means small/narrow/closed minded, it is only a matter of time before they come after accounts like mine which routinely call out medical harm. This has and will continue to become a country that shuts down differing opinions. Patient harm will continue to grow especially since many in the medical field will feel justify to punish patients for perceived political beliefs. I believe my husband was harmed because the MeToo movement gave those nurse that night the belief they had the right to "punish" an older male during the Kavanaugh hearing and more incidents like this will happen or otherwise defined as medical retribution. Biden is right--we are heading into a dark winter from which there will be no sunlight for a very long time. Buckle up, male patients, it is going to be a rougher ride from here on out.
JR, I encourage and have encouraged free speech (exception ad hominem remarks degrading a contributor as a person and not the content of the view.) I am confident that the "dark winter" is being referred to the COVID ongoing disaster and not frozen political discourse. JR, I suggest you read the link above to the description of the "21st Century Cures Act" which will actively permit a patient full exposure to the recorded views, constructive or "destructive" with regard to that patient. This Act will allow physician's "free speech" to be made available to the patient and via the patient to family and potentially to others. I am sure you will find the "Cures Act" with regard to the opening to the patient, the exposure of physician conclusions and motivations of value in preserving patient autonomy and dignity. ..Maurice.
Maurice,
You state: ...the final decision-making is truly set within the doctor-patient relationship...
Where is the patient when the medical students sneak into the procedure room to perform intimate exams the patient never consented to?
The original 21st Century Cures Act date was supposed to be November 2, 2020, but the healthcare industry lobbied to have it pushed back YEARS (supposedly due to COVID), thankfully it was only until April 5, 2021.
-- Banterings
Banterings, the medical students do not "sneak" into procedure rooms.. they are instructed by their teacher to enter and perform the examination. The actions are the responsibilities of the teacher, the medical school, the hospital administration and the state government. ..Maurice.
For a super-detailed description of a female second year medical student who was "forced" into performing male and female genital exams
just go to "Patient Modesty-Volume 43". Banterings, I don't remember if you were with us in July 2007. ..Maurice.
Dr. B.,
I understand that in theory the Cares Act is a good thing. As it is, patients do not see everything in their medical records. They do not see the videos most hospitals take as most everything in a happening in a hospital is being filmed. They do not see the private notes made by medical providers. The EHR systems may provide abbreviated versions of the records.
Currently, patients have the right to submit corrections to medical records BUT it is up to the "discretion" of the medical facility whether they will include the correction or make the correction. I know of a lady who was diagnosed with a ED. She submitted the correction and it was denied. I know of many more but used the most obvious as she does not have a penis and does not have ED. Many, many I have talked too including my husband have blatant errors/lies in their MRs. My husband has in his he is gay, married and had a baby during the hospital stay. No correction accepted there either. This law/regulation does not work.
Informed consent is another area that is govt mandated. However, over the years informed consent has been twisted into something that no longer protects the patient but rather is a built-in protection or line of defense for the medical provider. It is an either you accept it or don't have the procedure in many instances. I have seen one of the new forms for the Florida pelvic exam law and it merely defines what a pelvic exam is for a female and for a male. It also states basically that whoever they want can be present during your exam. There is no where to opt out and it says if you sign you accept all described above and all questions have been answered. This is a very dangerous to the patient as there aren't any options to opt out such as if you verbally agree no rectal exam or medical students, the paper you sign says you agreed to have them.
I realize you basically regard 99.99% of medical providers as being honest but it simply isn't so. They will still hide their personal observations of patients and still will not release films of patients. They will still operate in the underhanded manner in which they have done all these years except they will say they are being more open/transparent to lure many into a false sense of security. They have thus found a way around most regulations/laws to still protect their secret society of medical care.
Maurice,
It is a matter of perspective. When a student does such an exam without consent, the patient's view is the student sneaked in and committed medical rape. The student would say the attending told the student to come in to the procedure room to do an exam for learning purposes...
Part of the problem is the profession whitewashing these crimes against humanity.
-- Banterings
Concerning "hidden" records, I am convinced I am labeled at the hospital where I get all of my care (except of course should I need the local ER). In my specific case it is "prefers male staff" which is OK with me as it makes it easier when scheduling something and I ask for male staff.
My very first visit there was an intro visit with a urologist which then also included an exam with just the two of us in the room. Rather than make me do the long drive coming back for a 2nd visit he said if I was willing to go grab some lunch and then come back in an hour he'd squeeze me in for a cystoscopy that day. He gave me over to a nurse to make the arrangements and when she told me where to go for the cystoscopy and asked if I knew how to get there, I said no. She then walked me most of the way over to that part of the hospital and in doing so I asked her if it was possible to get a male nurse for the prep. She said no problem she'll take care of it, and she did. I suspect my request was noted in the hidden records.
When I had my 1st dermatology visit with a male Resident that went very badly (which I previously described back at the time it happened) and for which my complaint prompted some changes, I know I was labeled because they put it right in my public record "prefers male staff". They also put "No Residents" which was a misinterpretation of my complaint in that I didn't have a problem with Residents but rather just that one. I have since asked them to remove the "No Residents" but I suspect it was also in the hidden record because for two subsequent visits with the urologist, they initially scheduled me for a back to back appt. which I assumed meant maybe me seeing a Resident or medical student first. I assume that was just an automatic default setting as neither time was there a 2nd appt. My guess is the doctor saw the "No Residents" in the hidden records and told whoever else I was going to see to not come in.
Next month I plan to run an experiment. I have an annual full skim derm exam scheduled and rather than make a fuss upon arrival with my "LPN stays out of the room, scribe faces away or exits for the genital/rectal part of the exam", I don't plan on saying anything so as to see what they do. That'll confirm for me what is in the records. Of course if both women come into the room I will insist on privacy for the genital/rectal part, but I want to see whether they do anything without me asking.
Biker, hopefully by April 5 2021, you will have the opportunity and legal power under the 21st Century Cures Act to read and consider what was actually inscribed on your charts and be able to respond to your healthcare providers with any issues you find need to be corrected. ..Maurice.
Dr.Bernstein, it will be nice to know I have some additional rights, though I don't see myself using that new law except under extraordinary circumstances. I am actually a very compliant patient when it comes to following their instructions, deferring to their recommendations, being polite and friendly to all the staff, saying please and thank you, using proper titles etc. I as well don't make an issue of them using my 1st name instead of calling me Mr. Biker as I'd prefer. I dress appropriately for all appts, and am always on time (early actually. I graciously accept delays (usually telling them there's nothing to apologize for, I'm glad they spent the extra time with those that needed it as maybe someday I'll be the one that needs extra time), and I do my registration online ahead of time.
In return I just want to be treated in a respectful manner as if my privacy and dignity mattered to them. Minimize my exposure in terms of extent, duration, and audience. Make my privacy and dignity a higher priority than their convenience, especially when the difference between the two might only be a matter of a few seconds. I don't think it is too much to ask.
IT IS TIME TO MOVE ON TO VOLUME 116 https://bioethicsdiscussion.blogspot.com/2021/01/preserving-patient-dignity-formerly.html
OF OUR ONGOING BLOG THREAD. NO FURTHER COMMENTS WILL BE PUBLISHED ON VOLUME 115.
RUN THE YOUTUBE VIDEO WHICH HEADS THE NEW VOLUME.
I THANK ALL OUR USUAL POSTERS FOR THEIR CONTINUED PARTICIPATION IN VOLUME 115 AND PREVIOUSLY BUT I KNOW THERE ARE VISITORS HERE WHO HAVEN'T POSTED THEIR VIEWS. i DO ENCOURAGE THEM TO JOIN US AND READ WHAT THEY THINK ABOUT PRESERVING PATIENT DIGNITY. ..Maurice doktormo@aol.com
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