Bioethics Discussion Blog

A Doctor's Decision: Whether or Not to "Call the Cops"

2012-01-19T21:47:00.000-08:00

A most interesting scenario was posted on Medpedia by Scott M. Dyck which I am, in part, reproducing here but you might want to go there to review the responses there but also feel free to make your comments here. If you were the doctor in this case, what would you do? ..Maurice.

You are a general practitioner and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "cao gio," which is also known as "coining." The procedure involves rubbing warm oils or gels on a person's skin with a coin or other flat metal object. The mother explains that cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy's back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protective Services and report the mother.

Doctor vs Computer: Can a Computer Make a Better Diagnosis?

2012-01-14T11:36:00.000-08:00

I found this visitor question on a discussion forum:" i was debating this with some doctors who say that it would be impossible to program a computer to make diagnoses as well as they can. i find this pretty ridiculous. whatever thought process/string of questions they would use to analyze the situation are the same that the computer would be programmed to use. the compute:r would then analyze all available information, ask questions, analyze the answers and assign probabilities. in fact, it seems like this would be way simpler than some of the things computers have already been programmed for. what do u think?"

So what do I think?

My opinion, as a doctor, is that what is input into a computer for calculation is the most important part of the process of making a diagnosis and deciding on a treatment program to benefit the patient. No amount of computer power or access to data storage will substitute for the physician's input of the history and the physical findings of the patient. A computer posing questions to a patient and the patient responding will never substitute for a direct doctor-patient communication. There are many subtleties, nuances of a history which can never be accessed by a computer, such as body language and verbal expressions and there is no way for a computer to perform a complete and worthy physical examination. A robot used in surgery still requires a doctor behind it and no robot will attain the skills to inspect, auscultate, palpate and percuss and then interpret the findings. To me, how complete and understood is the input of data both from a patient telling a history and the doctor performing a physical is the basis for the diagnosis. Poor input will always lead to poor output. And, finally, it will always take a doctor to analyze the results of the computer to confirm its diagnosis. I would agree that the doctor with knowledge and with experience and then working together with the computer can be most productive of the correct diagnosis.

So.. what do you think?

..Maurice.

Patient Modesty: Volume 47

2012-01-11T17:46:00.000-08:00

We continue here the discussion regarding how the concerns about healthcare provider gender selection by patients and ways for the patient to be more comfortable with those who attend them can be brought to the attention of all those who provide service and maintain the status quo in the healthcare system. ..Maurice.

ADDENDUM (1-16-2012) On this date, PT, a long-time writer to this thread on Patient Modesty, wrote the following comment which includes a potentially valuable suggestion for a method for those who want to change the current medical system regarding patient modesty and caregiver gender selection. This is what he wrote:
Alan said

" Rosa parks was a single woman who started
a movement with a single act of resistance,Malcolm X
took another path and my style is more like Rosa parks
than Malcolm."

My style is more like Genghis Khan until I
realized that the pen is mightier than the sword. My idea
to solve this issue is a 40 step process, meaning I have
put together 40 different avenues of approach over a
period of about 10 months.

Here is the first avenue, visit www.change.org
to start a petition. Now I suggest you start perhaps at a
hospital or clinic that you in the past had concerns with.
Others around the world will join the petition
and to be effective use multiple facilities in each city. Keep
in mind this is a medium to bring our concerns forward. The
first of many mediums we will use as I suggested in volume
46 of Dr. B's blog.

PT

Graphic: From Google image resource modified by me with Picasa3.

Do Oaths and Rules Make a "Good" Doctor?

2011-12-31T15:04:00.000-08:00

Do oaths and rules make an ethical and caring physician?

In the realistic and present day world of medical practice, the way medicine is practiced both in terms of emphasis or de-emphasis of oaths, medical school teachings and established legal and professional requirements are going to be different between one physician and another. There are going to be shortcuts and at times excesses depending on the situation and even the mood of the physician. Doctors are going to take chances or they will strictly follow what they believe are standard operating procedures ("standards of practice"). Yes, the Oaths are there, the laws and professional requirements and all the tools for professional behavior as provided by the medical schools are there but in the end, each doctor in their own professional environment will obey them as they see fit at the time. And it is up to their patients and their colleagues to finally grade the doctor.

Do oaths and rules make an ethical and caring physician? My conclusion is "probably not". I think it takes more than that. And, if you agree, what "more" is necessary? Let's read your thoughts on the subject. .Maurice.

Should Doctors be Allowed to Strike?

2011-12-25T21:46:00.000-08:00

Currently, there is a strike by 10,000 physicians at public hospitals in a state of India in an attempt to get better salaries and work opportunities similar to those in other federal hospitals in India. The government has suspended 40 doctors, and 390 others have been arrested for failing to perform their duties.

Over the years there have been physician strikes elsewhere in the world and in the United States for various reasons including the high cost of malpractice insurance. A 2004 article in the American Journal of Bioethics by Autumn Fiester argues the ethics against walkouts by physicians, in this case the issue has been the increasing malpractice insurance cost rates not keeping pace with physician reimbursements.

My question to the visitors to my blog is whether physicians have a right to strike and if so for what reasons and if they do, is such individual physician termination of services, without any replacement provided ethical? ..Maurice.

Patient Modesty: Volume 46

2011-12-20T10:08:00.000-08:00

Continuing on with the discussion regarding issues of physical modesty in the context of medical care, there continues to be debate throughout these Volumes as to who is responsible for the contested inequalities in attention to these issues and what is necessary for the resolution of these issues. Is there a conflict between the male and female gender, working apart, in attaining their own individual modesty goals or should both genders look to each other's physical modesty needs and desires and stand and work together to change the medical care system to meet all their goals? I suspect the latter is the wisest. Perhaps the best suggestion for both genders to become active to the same cause and to get together on a website to develop tools for advocacy. I would suggest checking in at Suzy's site where the goal is to do just that. Here is her description of the Mission Statement and Goals:

MISSION STATEMENT:
We believe that each patient is an individual and as such has specific preferences and needs including what accommodations they require to maximize comfort when their modesty must be compromised in the medical experience. Our mission it to act as a liaison between patients and providers in establishing, understanding, and executing the policies and procedures essential to that end. When appropriate we will act as advocates for patients to achieve that goal through interaction, education, and referrals to both patients and providers.

GOALS: Our goal is to help patients achieve dignified and respectful healthcare through education and information. Everyone has different needs and expectations of their healthcare providers, and we provide choices and options in obtaining those needs. We understand that modesty, privacy, and respect are primary needs when facing procedures and we promote educating providers in the sensitivity of those needs.

ADDENDUM (12-23-2011)

On 12-23-2011, Belinda wrote the following comment : Going back the the "Naked" article, it would seem that now is the time to write protocols for exams with dignity at the forefront with equal accessibility as needed for any kind of exam making draping practices uniform. It would give patients and idea of what to expect and do as much to relieve the awkwardness of such an exam. Any thoughts on this?

I responded with the following:

Belinda, an EXCELLENT suggestion! In fact, to make the suggestion even more productive.. how about the visitors here (even you PT) together create a final consensus list, a series of suggested protocols for attending to all the patient modesty issues experienced in medical care. The development of the list can written to this blog or Dr. Sherman/Doug Capra's or on Suzy's blog.

But not just writing this protocol list to our blogs.. the final consensus list should be sent to Dr. Atui Gawande who wrote the article "Naked" in the New England Journal of Medicine and which was the basis for our entire series of Volumes on patient modesty. As some of you may know, Dr.Gawande is now a very well respected individual for his analysis and writings about a host of important medical issues that need fixing or change. By this project on our part, this may be the most direct way, through Dr.Gawande, to get something moving rather than repeated moaning and yearning on our blogs. How is that for an idea? Again, thanks Belinda for a suggestion to get us all "off our butts" (so to speak).

..Maurice.
Graphic: "Man and Woman Apart and Together"-Classic icons modified by me with ArtRage.

NOTICE: AS OF TODAY JANUARY 11, 2012 "PATIENT MODESTY: VOLUME 46" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 47

Should Patients Have Online Access to Their Medical Records?

2011-12-05T20:16:00.000-08:00

Should all patients be given online access to their medical records? The British healthcare system is currently considering such a possibility. With electronic medical records progressively becoming the norm throughout the medical world, this access would be feasible but would it be wise? Certainly, there would be advantages to the patient who would readily see the written result of the office visit and could then, if necessary, confront the physician with corrections, additions and questions and in a timely fashion. But what are the negatives to such an idea beyond potential loss of patient privacy due to inappropriate or illegal computer access? For example, would this mean that the medical record would have to be written in words understandable by any patient rather than in more concise and professionally understandable terminology and thus perhaps degrade professional communication? Would such access more easily give rise to patients starting malpractice actions due to misunderstandings of what was written to the record? Could patient's be pressured by others (insurance companies or employers as examples) into providing access to the electronic records since they would be more readily available? What do you think? ..Maurice.

Do We Own Our Own Germs?: Ethics and Law in Research

2011-12-04T19:09:00.000-08:00

From the current New York Times Sunday Review: IMAGINE a scientist gently swabs your left nostril with a Q-tip and finds that your nose contains hundreds of species of bacteria. That in itself is no surprise; each of us is home to some 100 trillion microbes. But then she makes an interesting discovery: in your nose is a previously unknown species that produces a powerful new antibiotic . Her university licenses it to a pharmaceutical company; it hits the market and earns hundreds of millions of dollars. Do you deserve a cut of the profits?
In on ongoing legal challenge to the patent law which allows isolated human genes to be patented and which was previously overturned, the Court of Appeals for the Federal Circuit of the United States returned a ruling earlier this year that these genes were not simply a product of nature, which would not be eligible for a patent, but indeed could be patented. So..who has the legal rights to that rare and valuable germ growing in your nose or that gene which was part of your body but the one that was recovered and used for, as an example, a genetic test for cancer? And beyond the law.. what are the ethics? What is the good vs bad, what is the right vs the wrong?

..Maurice.

When is Privileged Communication Not Privileged? The Law and Ethics.

2011-11-25T15:58:00.000-08:00

Privileged communication is "an exchange of information between two individuals in a confidential relationship."

I present now three scenarios and look toward some wise visitors to this blog to provide me with some answers from the legal point of view but also a view of the ethics. ..Maurice.

Suppose a patient admits to his physician that he is emotionally upset and is having gastro-intestinal symptoms because he killed his wife and buried her body in the back yard and told others that she was on a vacation. Suppose a client who is about to be questioned by the police, admits to his lawyer that he killed his wife and buried her body in the back yard. Would the professional standard in each case see the admission as privileged communication and allow the professional to withhold the information to the police or courts that the patient or client admitted? Suppose the patient with symptoms and that same story went to his physician who was both a physician and a lawyer licensed to practice and revealed the killing but desired the professional as a lawyer to provide professional legal advice and, if necessary, defend his case. Could privileged communication still be preserved?

Patient Modesty: Volume 45

2011-11-08T14:00:00.000-08:00

Doug Capra, a regular contributor to this thread, wrote a comment on November 1 2011 which I inadvertently didn't publish but which I think is valuable for our consideration of two issues related to the patient modesty discussions here. Read it and then read my analysis below. ..Maurice.

Relative to the current discussions -- In past posts, I've referenced an articled called "Not Just Bodies" which is based upon a study of the strategies and/or defense mechanisms doctors use to deal with body issues == which include not just nakedness and modesty, but also horrible accidents and diseases. The profession knows well about these issues and addresses them. A major problem, as I see it, is this: Some of the strategies they use protect them psychologically but do little for or actually psychologically harm the patient. Some doctors never really "get over" this issue but just put up fences to protect themselves. There are also studies out there using medical students showing how they deal with this issue. There are some related studies about nurses. I think a myth within the profession is that these issues can easily be hidden from the patient by covering up using these strategies. I question that. I think many patients pick up on this and it may affect their healing and/or psychological health. Most of us, medical professional or not, are often unaware of the face we are actually "showing" to others. It takes quite a bit of self-reflection and knowledge to be aware of this. My other concern is what I've started to call the "deprofessionalization" of medical care in this country -- for cost saving reasons. I'm not so concerned with what are called mid-levels (PA's and NP's) But the use of all kinds of various initialed (cna, cma, pt's, ma, etc.) nurse assistants, some with little maturity and/or training, in this country is frightening. Some have no actual scope of practice, work under the doctor's license, and can do whatever the doctor is willing to risk. It's this trend that bothers me most and IF, and I emphasize the IF, there's a tendency for people with sexual perversions (or other psychological defects) to enter the medical field, it would be in this area. And these are the people these days doing most of the bedside care and, more and more, even some invasive procedures.By Doug Capra

First, I agree that physicians, in order to emotionally not react or show to the patient that they are not unprofessionally reacting to the patient's nudity, may take on a bland, emotionally neutral affect which demonstrates to the patient a sexually inert physician. And since the physician is sexually inert, he or she expects the patient to be likewise. And particularly, if the patient doesn't verbally complain, the physician thinks that the current behavior is fully acceptable.

I also agree with Doug regarding a certain degree of inadequate screening of the motivations of those entering the medical field and particularly those whose time and money and life investments are truly minimal and perhaps sexual interest values may play a role beyond the desire to be a care provider for the sick.

So who can be called a "peeping Tom", the title of this Volume's graphic, is a matter open to discussion. Perhaps we all are "peeping Toms" or "Little Bo Peeps" at one time or another, but it never should be at the physical or emotional expense of any patient. And that is why I think that discussion and dissemination of the issues of patient physical modesty is so important in the consideration of the best patient care. ..Maurice.

NOTICE: AS OF TODAY DECEMBER 20, 2011 "PATIENT MODESTY: VOLUME 45" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 46

Does the Fertilized Egg Equals Legal Person?

2011-10-26T20:34:00.000-07:00

From today's New York Times:

"A constitutional amendment facing voters in Mississippi on Nov. 8, and similar initiatives brewing in half a dozen other states including Florida and Ohio, would declare a fertilized human egg to be a legal person, effectively branding abortion and some forms of birth control as murder. With this far-reaching anti-abortion strategy, the proponents of what they call personhood amendments hope to reshape the national debate."

By the time most of my visitors will have read this thread, the voters in Mississippi will have voted and the constitutional amendment will have passed with all its potential consequences or simply defeated and with some folks in Mississippi unsatisfied. Read the article describing the significance of this vote and return and discuss here what you think would be the consequences of such an amendment passing in other states or even become part of the United States Constitution. Should a fertilized human egg be a legal person and the intentional destruction of that person be consider a crime such as a homicide (murder)? ..Maurice.

Medical Bloopers 3: A Medical Communications Defect

2011-10-25T19:37:00.000-07:00

The following medical charting errors may appear funny to the casual reader but if they or their cousins are written in medical charts, they not only appear ambiguous but may in some cases be harmful for the safe and effective medical management of patients. These "bloopers" are the results of rushed notations with no rereading by the writer of what was actually written.

This is actually the third in a series of such charting errors (the second in this series was an addition of 6 "bloopers" added to the original 19 and may be found at this link). There may be a few repeated from that second listing in this current presentation. Enjoy. ..Maurice.

Note: These "bloopers" come from a variety of sources and I don't know who to acknowledge for them.

By the time he was admitted, his rapid heart had stopped, and he was feeling better.

Patient has chest pain if she lies on her left side for over a year.

On the second day the knee was better and on the third day it had completely disappeared.

She has had no rigors or shaking chills, but her husband said she was very hot in bed last night.

The patient has been depressed ever since she began seeing me in 1986.

Patient was released to outpatient department without dressing.I have suggested that he loosen his pants before standing, and then when he stands with the help of his wife, they should fall to the floor.

The patient is tearful and crying constantly. She also appears to be depressed.

Discharge status: Alive but without permission.

The patient will need disposition, and therefore we will get Dr. Shapiro to dispose of him.

Healthy appearing decrepit 67 year old male, mentally alert, but forgetful.

The patient refused an autopsy.

The patient has no past history of suicides.

The patient expired on the floor uneventfully.

Patient has left his white blood cells at another hospital.

The patient's past medical history has been remarkably insignificant with only a 45 pound weight gain in the past three days.

She slipped on the ice and apparently her legs went in separate directions in early January.

The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.

The patient had waffles for breakfast and anorexia for lunch.

Between you and me, we ought to be able to get this lady pregnant.

The patient was in his usual state of good health until his airplane ran out of gas and crashed.

Since she can't get pregnant with her husband, I thought you would like to work her up.

She is numb from her toes down.

While in the ER, she was examined, X-rated and sent home.

The skin was moist and dry.

Occasional, constant, infrequent headaches.

Coming from New York, this man has no children.

Patient was alert and unresponsive.

When she fainted, her eyes rolled around the room.

Malpractice vs Involuntary Manslaughter: What is the Distinction?

2011-10-13T21:16:00.000-07:00

The current legal case being tried in court regarding the death of Michael Jackson by the alleged acts of Dr. Conrad Murray as involuntary manslaughter in contrast to the death being an act of malpractice brings up the question: what is the difference in legal terms between medical malpractice and involuntary manslaughter. And, perhaps, what is the difference in ethical terms? If the physician is found guilty, the physician is punished financially in the first case but by prison time in the second. An excellent article written by Eisenberg and Berlin in the American Journal of Radiology in August 2002 gives case examples and may tend to answer to the question posed in the title of my thread. An excerpt from the article follows:

The circumstances under which a physician's error of medical judgment triggers criminal prosecution are not totally clear. An English court of appeals ruled that to justify a criminal conviction, it must be proven that a physician acted with “gross negligence,” which is characterized by any or all of the following elements: indifference to an obvious risk of injury to health; actual foresight of the risk coupled with the determination nevertheless to run it; an appreciation of the risk coupled with a high degree of negligence in the attempt to avoid it; and inattention or failure to avert a serious risk.

A person whose behavior is “grossly negligent” may be liable for involuntary manslaughter if his or her conduct results in the accidental death of another person. Most jurisdictions hold that something more than ordinary negligence must be proven before the defendant can be found guilty of involuntary manslaughter. This usually requires that there be a substantial danger not only of bodily harm, but also of “serious bodily harm or death.” The defendant must have acted “recklessly,” a term defined as a “gross deviation from the standard of conduct that a law-abiding person would observe” in the same situation The court must consider all the circumstances surrounding the incident, including the social utility of any objective the defendant is trying to fulfill.

What, in my opinion, seems to be missing in the accusation of a physician with a crime of involuntary manslaughter rather than a professional error of malpractice is whether the physician's intent in diagnosis and management was to ignore any attempt toward the professional goal of beneficence (doing a "good" ) to his or her patient. If one could prove that such was not the intent and goal, shouldn't that be the overriding criteria to define a death as professional malpractice and not a crime? On the other hand, I look forward toward what how others to my blog thread look at this distinction. ..Maurice.

Another Look at Medical Futility

2011-10-09T16:15:00.000-07:00

What is medical futility? What does it mean to stop or not start some procedure or treatment because such action is futile? And what does futile mean in this context? Over the past 7 years on this blog, I have started a few threads which included this issue. Once, I presented the definition of futility as described by physician-ethicst Dr. Steven Miles in his humorous "A Thai Dictionary of Medical Ethics" in which he described an example of the use of the term "futility"as "a siphon for removing puddles of water that form far ahead on highways on hot summer days." Medical futility is a bit more complicated than that. Recently, for me, a concise description of medical futility was made by an ethicist and teacher Laurence B. McCullough, Ph.D. on a bioethics listserv and with his permission, I present his words below. But also what I would like to read from my visitors is how they look at the term "futile" or "futility" in relation to its use by doctors and whether it represents to them as patients or family members of patients a term which has meaning and should be used. ..Maurice.

In its general clinical meaning, 'futile' means that in evidence-based reasoning there is no reasonable expectation that the usually intended outcomes of a clinical intervention will occur. The roots of the concept can be found in the admonition in the Hippocratic text, The Art, against the madness of thinking that clinical intervention has unlimited power to alter the course of disease or injury. (Blackhall in "Must we always use CPR?" suggested 100% failure rate or 97-99% failure rate with high and unacceptable morbidity.)

Providing futile clinical management is not consistent with professional integrity. (See Brett AS, McCullough LB. When patients request specific interventions: defining the limits of the physician's obligation. N Engl J Med 1986; 315: 1347-1351.) Professional integrity has been a consistent, core consideration of common law on end of life care, starting with Quinlan in 1976.

This general meaning of 'futility' must be specified, to be clinically applicable. (See Jones JW, McCullough LB. Postoperative futility: a clinical algorithm for setting limits. Br J Surg 2001; 88: 1153-1154; Rabeneck L, McCullough LB, Wray NP. Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 1997; 349: 496-498.)

Physiologic futility: no reasonable expectation that physiologic outcome will be achieved (e.g., antibiotics for viral infection, CPR on totally decapitated human being [from international resuscitation guidelines and my favorite], artificial administration of nutrition to a patient with cancer cachexia). Physiologic futility is not discredited by a transient physiologic effect, such an occasional heartbeat during CPR.

Imminent demise futility: clinical management is expected to be physiologically effective but the patient is expected to die during current admission with no expectation of recovery of interactive capacity. (Medicine is not vitalist in any global tradition of medical ethics. See Baker RB, McCullough LB. The Cambridge World History of Medical Ethics 2009, in which'vitalism' does not appear in the index.)

Clinical or overall futility: clinical management is expected to be physiologically effective and prevent imminent death but the patient is not expected to recover interactive capacity, as in permanent vegetative state diagnosed by American Academy of Neurology guidelines. (Again, medicine is not vitalist.)

Quality of life futility: clinical management is expected to be physiologically effective, prevent imminent death, and preserve interactive capacity but the resulting functional status is not acceptable to the patient from the patient's perspective. (Quality of life is engaging in life tasks and deriving satisfaction from doing so. This concept does not apply to infants or to patients about whom too little is known to reliably identify the life tasks in which they engaged and the values by which they would make judgments about whether engaging in those life tasks with projected functional status will result in sufficient satisfaction.)

The first three specifications fall within clinical expertise; the fourth depends on clinical expertise (prognosis of functional status) but is also a function of the patient's values and beliefs.

These specifications often cannot be invoked a priori. Instead, they become the basis for stopping rules for critical care (initiated by CPR, high-risk surgery) as a trial of intervention. Explaining this concept in advance is a powerful preventive ethics response to requests to "do everything," by focusing on everything that is consistent with excellent medical care.

Race, ethnicity, and money (source of payment) are irrelevant to the conceptualization and clinical application of these specifications, which, when explained, can help address the distrust problem. If someone wants to make discussions of futility toxic, just introduce money, especially with folks of modest economic means or people of color. (Against stupidity, though, even the gods themselves rage in vain. See I Asimov, The Gods Themselves 1972.)

Some surrogate decision makers are not willing or are not able to engage in evidence-based, deliberative discourse. This is a rare but real phenomenon. Education and persuasion end in failure. The remedy becomes the exercise of professional and organizational power, which, in Texas, is sanctioned by our advance directives act. Elsewhere, local healthcare organizations need to agree on a futility policy, so that, when it is enforced by one organization, the others will be in support. (See Halevy A, Brody BA. A multi-institution collaborative policy on medical futility. JAMA 1996; 275: 571-574.)

Laurence B. McCullough, Ph.D.

 Dalton Tomlin Chair in Medical Ethics and Health Policy

 Center for Medical Ethics and Health Policy

 Baylor College of Medicine

 Houston, Texas

Contemporary Art and Education of Medical Students: Beauty and Truth

2011-10-04T14:43:00.000-07:00

Diagnosing and treating a patient's illness is many times a challenge which is not easily solved with a snap judgment but requires the doctor's attention to a sequence of important considerations and actions. There is importantly the observation followed by the interpretation of what has been collected in terms of the patient's history, the physical examination of the patient and the diagnostic tests performed. Sometimes, this collection of data is complex, intertwined and frankly ambiguous and confusing. But there may appear after further contemplation and perhaps after consulting with other professionals a pattern which will direct the doctor to make the correct diagnosis and follow with the appropriate treatment. But how is the detection of patterns taught to medical students and physicians?

What is going on in a number of medical schools including the school at which I teach is to give the students an opportunity to look at and think about and discuss among themselves and their instructors contemporary art. Yes, like many illnesses themselves, the art work at first glance may appear wildly confusing but with attention to details, contemplation and discussion with others, the meaning of the painting to the student and perhaps also the meaning of the painting which the painter was attempting to express becomes more clear and definitive.

Schaff, Iskin and Tager writing in the October 2011 issue of Academic Medicine describe that teaching technique using contemporary art. The following is an Abstract of that article.

Many medical schools have incorporated experiences with representational or figurative art into the curriculum in an effort to improve learners' powers of observation, visual diagnostic skills, and pattern recognition skills or to enhance communication skills, foster teamwork, and/or improve empathy. The Keck School of Medicine of the University of Southern California has partnered with Los Angeles' Museum of Contemporary Art to design an educational experience with the goal of honing students' abilities to observe, describe, and interpret complex information. The authors discovered that through a constructivist approach to viewing and discussing nonrepresentational, contemporary art, students were able not only to apply their observational and interpretive skills in a safe, nonclinical setting but also to accept the facts that ambiguity is inherent to art, life, and clinical experience and that there can be more than one answer to many questions. This intervention, entailing extensive guided inquiry, collaborative thinking, and process work, has allowed students and faculty to reflect on the parallel processes at work in clinical practice and art interpretation. In patient encounters, physicians (and physicians-in-training) begin with attention and observation, continue with multiple interpretations of that which they observe, move to sorting through often ambiguous evidence, proceed to collaboration within a community of observers, and finally move to consensus and direction for action. In the worlds of both art and medicine, individuals imagine experiences beyond their own and test hypotheses by integrating their own prior knowledge and intuition and by comparing their evidence with that of others

Another way of looking at the value of such teaching is from the philosophical point of view and consider aesthetics, the beauty of a painting as a reflection of some truth. By analyzing the painting and exploring its beauty, the truth will most likely be apparent. When treating a patient, the doctor should always look for the truth. Isn't that a truism? ..Maurice.

Graphic: "Astigmatism" created by me using ArtRage 10-4-2011.

"I am a nurse but I am also a doctor": Conflicting Identities to the Patient?

2011-10-02T10:05:00.000-07:00

Should a nurse with a doctorate degree in nursing identify herself as a doctor to a patient? Here are excerpts from the current New York Times article on this question:

"Doctorates are popping up all over the health professions, and the result is a quiet battle over not only the title “doctor,” but also the money, power and prestige that often comes with it. ...

As more nurses, pharmacists and physical therapists claim this honorific, physicians are fighting back. For nurses, getting doctorates can help them land a top administrative job at a hospital, improve their standing at a university and win them more respect from colleagues and patients. ...

So physicians and their allies are pushing legislative efforts to restrict who gets to use the title of doctor. A bill proposed in the New York State Senate would bar nurses from advertising themselves as doctors, no matter their degree. A law proposed in Congress would bar people from misrepresenting their education or license to practice. And laws already in effect in Arizona, Delaware and other states forbid nurses, pharmacists and others to use the title “doctor” unless they immediately identify their profession."

What do you think? Should M.D.s be identified to the patients as "doctors" and nurses with a doctorate degree be indentified as "nurses"? ..Maurice.

What to do about "Mixed Messages" in Medicine

2011-09-27T22:08:00.000-07:00

What do you know about the sending of "mixed messages" to the public and patients by the medical profession either from the government, institutions or from individual physicians? I might define a "mixed message" as virtually advice or education based on one view and at the same time presenting advice or demonstrating behavior of an opposing view. Such "mixed messages" can range from issues such as over-weight physicians advising weight control to their patients, medical institutions advising influenza immunizations to patients but a large proportion of the institution's staff rejecting immunization, a governmental medical agency advising against routine mammograms before age 50 and in contrast to other cancer specialty groups advising mammograms at an earlier age. Even in the critical care unit, the attending physician may recommend to family the reduction of energetic supportive treatment in a end-stage ill patient whereas specialists on the case may encourage further supportive treatments.

As patients, families of patients or just plain citizens who want to stay healthy and need to be educated about matters medical, how should we handle the issue of receiving "mixed messages" from those who we look to for clear information to make our decisions? Or should we just resign ourselves that this is only part of the human condition, a fact of life and we should simply live with it. (..or occasionally die with it.) ..Maurice.

Should children be told that they were "donor conceived"? Would it ever be ethical not to tell them?

2011-09-07T12:29:00.000-07:00

Should children be told that they were "donor conceived"? Would it ever be ethical not to tell them?

If they are to be told, at what age should that be? Should an attempt be made to identify the donor? Should the donor be allowed or encouraged to visit the children? When?

If the donor is a woman donating eggs and not a man donating sperm would there be a difference in answers to the above questions?

How would the questions be answered if the questions applied to a surrogate "mother" who only carried the pregnancy to delivery resulting from implantation of the fertilized eggs of a husband and wife? ..Maurice.

Note: I also posted these questions on Medpedia. You can read responses there by clicking on this link.

How Would You Like to be Told that You Have Cancer?

2011-08-28T14:10:00.000-07:00

I would like to start a followup conversation on a thread that I began September 25, 2005 titled "Telling 'Bad News': But There is More to Tell" The question is how can a doctor tell a patient that he or she has cancer without the patient "freaking out" at that moment and not being able to be educated by the doctor about the nature of the cancer, the various approaches to treatment and the outcomes. What suggestions would you give regarding how the doctor can meet the emotional needs of such a patient as well as to provide necessary education that will be needed for future decision-making? How would you like to be told that you have cancer? If this has happened to you in the past, it would be worthy for me and other physicians to listen to your story about how you were told and how you dealt with the information and education... and, of course, your suggestions. ..Maurice.

Graphic: Painting John the Baptist by Guido Reni (1575-1642)

Patient Modesty: Volume 44

2011-08-27T10:11:00.000-07:00

It has become clear from reading all the responses to this thread "Patient Modesty" that the issue of physical modesty in the context of medical care is not gender specific. Patients of both genders need attention by the healthcare providers to their modesty concerns. And yet, it appears in many situations, this attention is not being applied to that patient and because of resource differences, particularly with regard to the male patient. In addition, perhaps unrecognized to many of us, and as brought to our attention by the "stressed student" (SS) in the previous 2 Volumes even medical students may be aware or personally concerned about how and what they are being taught regarding sensitive genital and rectal examinations. Now.. continuing on with the discussion we will begin Volume 44. ..Maurice.

Graphic: Photograph of bronze Auguste Rodin's "Burghers of Calais-Pierre de Wissant" taken by your moderator 8-13-2011 at the Norton Simon Museum, Pasadena, CA

NOTICE: AS OF TODAY NOVEMBER 8, 2011 "PATIENT MODESTY: VOLUME 44" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 45

The Price of Precaution and the Ethics of Risk

2011-08-20T18:06:00.000-07:00

I am borrowing the title of a book by Christian Munthe published by Springer for this thread. I will not be using the title, perhaps, in the same general context as Munthe but using the words as I imagine their meaning when applied to medical care.

One will find many examples of precaution and their corresponding examples of risk in how medical care is provided by physicians and accepted by patients. In fact, not only do these two elements correspond but at times the price, itself, of precaution becomes the risk. Risk is everywhere in medical practice. Risk is present when a patient is selecting a physician. The risk is becoming the patient of a doctor whose professional behavior does not meet the goals of a "good doctor" set by the patient. It is often that the patient really has no chance to predict how the doctor-patient relationship will turn out since the patient is often immersed in the relationship already by the time the uncertainty about that doctor begins to develop. Ideally, the patient should be cautious of all physicians from the onset as to how that relationship will turn out unless the patient doesn't care. Recommendations by neighbors, family or even other physicians may be helpful but are only the views of others regarding what is strictly a personal relationship. Precaution in the making of a selection of a physician is not often fully available due to time and medical urgency and inadequate communication between patient and doctor. The price of precaution in this example can be what turns out to be unnecessary and harmful delay in diagnosis and treatment in the attempt to find a satisfactory medical provider. On the other hand, not accepting a physician for personal consultation without an introductory "get to know you" appointment, if accepted by the physician, would be of great benefit for the patient's comfort with subsequent medical consultations.

On another thread on this blog, it appears that patient physical modesty issues become a risk. The visitors write about the emotional risk of examinations and procedures in terms of their emotions associated with that modesty. It is related to the presence of those attending or looking on being of the opposite gender than the patient. The inability to obtain an environment free of those of opposite gender including the physician, nurses and technicians may lead to a decision by the patient to avoid the exams or procedures even if their life was at stake. Such is the price of their caution.

Yet, even absent the context of physical modesty, precaution may be elicited in a patient's decision whether or not to accept a necessary medical or surgical procedure in face of the risks of that procedure. Presumably, that decision is based on information regarding the statistical value of the procedure vs the side-effects and life risks of the procedure. A patient's precaution decision against the procedure may have a price of further sickness or death.

Risk may often be warranted and thus beneficent to the patient. It may turn out, in medical practice that the price of precaution is not worth the benefit permitting a risk. The physician the patient received before searching for others may be the one who could diagnose promptly and correctly and cure the patient. It could be that the risk of emotional upset related to the physical modesty issue, concerning opposite gender presence is not worth the outcome of avoiding the examination or procedure. And finally, the price of precaution leading to the rejection of a procedure based on statistics instead of "taking a chance" on being the statistical outlier who would benefit despite the risk would be to the detriment or even the death of the patient.

What is your philosophy regarding balancing precaution and the apparent risk in medicine? ..Maurice.

Graphic: "Better Safe than Sorry" text image created by your moderator 8-20-2011.

Extra-Marital Sex: Spouse of the Demented Marital Partner

2011-08-08T14:41:00.000-07:00

Without additional discussion by me, I would like to pose a question to my visitors. There is a husband or wife of a severely demented (institutionalized Alzheimer's) patient who asks the doctor whether it would be the ethically right thing to do to engage now in extra-marital sex. What should be the doctor's response? Or what should the doctor find out before responding? ..Maurice.

Making Clinical Ethical Decisions: Common Fallacies: 5. Argumentum ex Silentio

2011-07-28T21:37:00.000-07:00

argumentum ex silentio is a fallacy appealing to ignorance as evidence to argue that something exists or doesn't exist. For example, the argument goes:" since we have no evidence that God doesn't exist, therefore he must exist". Or "because we have no knowledge of alien visitors to our earth from other planets, that would mean that alien visitors don't exist."

The state law allows the CEO of a hospital to permit organ donation of a patient was without friends who know him or family and who died without any sign that the patient had previously stated whether or not to allow his organs donated at death. An ethics committee met to decide the ethics of whether it was appropriate ethically for the hospital CEO to give permission for organ retrival on this patient. The ethical principle of beneficence would suggest that procurement of a vital organ from this deceased patient and transfer to a needy patient would be an ethical decision to consider. There are no other facts for the ethics committee to consider.

Yet, a troublesome factor can be introduced if the fallacy argumentum ex silentio is not rejected but used to make a decision. One can say, that even in death, patient autonomy while alive should be respected and since there is no information that the patient had accepted organ donation therefore one could argue that organ donation was unwanted. Or.. since there is no information that the patient rejected organ donation therefore one could argue that organ donation would have been acceptable to the patient. One could also argue one way or the other with regard to whether the patient had religious restrictions to transplant.

Avoiding the fallacy would have allowed the following logic: "we are ignorant regarding whether or not the patient had made any decision about organ donation, therefore there are no other facts for us to use to make a decision about whether or not it would be unethical for the CEO to decide to authorize organ procurement except the fact that donation would be considered as beneficence toward the recipient and thus on that basis the CEO's approval would be considered ethical."

Can you think of some other examples of use of this fallacy in making an argument? ..Maurice.

Making Clinical Ethical Decisions: Common Fallacies: 4. Argumentum ad Verecundiam

2011-07-24T11:17:00.001-07:00

Argumentum ad verecundiam literally meaning "argument from authority" may be an easy way to get a point across in the process of discussion or debate regarding an ethical decision of a medical situation but alone it is incomplete. Simply saying that "Professor Jones has concluded that such an approach is ethical" or "Doctor Smith says that this will be the clinical outcome" without Professor Jones or Doctor Smith presenting the factual basis and logic for each to arrive at their conclusions is inadequate. It is essential that in a clinical ethics consultative meeting, both the ethics committee members and the stakeholders of the case are made aware of all the facts and how the doctor interpreted the facts to come to his or her conclusion. The academic degree of the individual is of value to be aware of the individual's area of training but tells nothing about how some conclusion expressed by that individual was reached.

Looking at these professional resources as an "authority" is misleading with regard to any specific case. Authority may mean that the individual has the training, has the experience, may have done research and may have published articles or books and may be recognized by others for all this and for their value as a resource for others but realistically that is still not enough to accept an authority's conclusion without having been presented and understanding the basis for that conclusion. That is why when a case is being discussed in ethics consultation, it is important that the professor or doctor are present either better in person or, if unable, by phone communication rather than by a view presented by another person "second handed". The authority must be able to hear the active discussion and reply to direct questions.

Authorities are of value for their general knowledge and specific knowledge and relationship of facts regarding which neither the members of the ethics committee or stakeholders of the case may be so educated. Everyone should be dealing with the one specific medical case at hand and not generalized scenarios and that is why frank and unquestioned acceptance of an argument from authority is unacceptable. ..Maurice.

Patient Modesty: Volume 43

2011-07-23T08:32:00.000-07:00

Continuing on with the concerns of a former medical student as begun in Volume 42:

THE CONCERNS AND EXPERIENCE OF A FORMER MEDICAL STUDENT

July 11,2011

I was a [Moderator: school name deleted] medical student. Like many teenagers and young adults, I had never visited a gynecologist or proctologist. I did not come from a medical family either. And because pelvic and prostate exams are not mentioned in the premedical curriculum nor explained to medical school applicants and incoming [My Medical School] students, I did not know about these exams when I first moved to [Moderator: city name deleted] to begin my medical education.

My faculty did not bother to explain what bimanual exams were my entire first year of medical school. I only learned about them from classmates cracking jokes, and from receiving e-mails from students selling T-shirts that compared the exams to sexual activities, making light of the way we must complete the exam once on an actor as part of our Essentials in Clinical Medicine (ECM) course in our second year [Moderator: Link is in error and cannot be completed]. You can see from the link how insensitive and immature my classmates are to sell such T-shirts.

I immediately had problems with pelvic and rectal exams. I found them violating in concept. I believed it had to be wrong for my school not to explain to applicants beforehand that there was more to examining men than testicular exams and more to examining women than breast exams and catching babies. I thought that training students to lubricate and insert their fingers into male and female sexual organs was much more taboo than what many young students would creatively imagine on their own before matriculating. I thought it was not right to assume that every student must agree with digitally penetrative exams just because they are widely accepted as valid medical procedures, at least in this country. After describing these exams to my younger sister and a few friends from college, I was confident I was not the only human being who viewed these exams as more than just a little uncomfortable, but also violating.

There was ample support at my school for students with academic problems regarding written exams. But there was nobody to speak with for students who had personal, cultural, or ethical conflicts regarding clinical procedures. I did speak with a school psychologist who specialized in stress management because she gave students her contact information during orientation week, but all she did was invalidate my perspective by repeating "There is nothing sexual or violating about these exams." Realizing that a broken-record psychologist could not alleviate my stress, I decided to complete the first year curriculum and resolve my issues directly with faculty over the summertime.

I started reading Dr. Bernstein's Blog as a medical student, and contacted him back when I was trying to resolve my concerns with faculty. He bought to my awareness today that the essay I wrote for the Blog does not mention my personal career aspirations, which is something I told him about last summer. I realize this is a pertinent detail that several readers have asked about in their responses.

I entered the program at my school to prepare for a career in translational services between medicine and investigational science. I wanted to focus on pathologies of the brain and nervous system. So I was looking to develop into the capacity of a pathologist or maybe a neurologist who conducted translational research on that organ system. I was not aspiring for a career in a field like family medicine, emergency medicine, internal medicine, and obviously gynecology.

When I learned about these invasive genital exams, I found them violating enough to refuse when unnecessary. Realizing they were not part of my future responsibilities, I thought the most professional and honest approach would be to discuss all of this with faculty

Over the summer, I confided in faculty that even though I understood many people saw these exams as being just another part of the physical exam, I saw pelvic and rectal exams as being violating procedures, and that unless I went through some psychological change where I could perform them without feeling violated, I would decline to perform them, especially in non-emergency scenarios such as practicing on an actor in an artificial environment, and especially since it was not listed as a graduation competency to students beforehand (or even at all anywhere). What happened when I said this is they withdrew my scholarship, and shunned me for asking for "special privileges". I withstood so much abuse when I brought the topic up with faculty, ridiculing me with "What? We have to tell students that doctors touch people?", guilt-tripping me with "If you cared about patients, you would do the exam", and victim-blaming me with "You knew all about these exams before you got here, you just repressed it."

********************

Over the summer, the first person I contacted was the head instructor of ECM (the physical exam class where we must complete these exams). I vaguely told him I had "concerns" about the ECM course for second-year students. He offered to meet with me, but said most students speak with other instructors of the course first, and then with him if things are not resolved. So I spoke with all the other course instructors, and by then he knew what my issues were, and was no longer interested in meeting with me. I did learn a lot of unacceptable facts about the ECM class from the other course instructors though.

I was appalled and frustrated to realize my school has watched students suffer personal conflicts like me for decades:

1) Every single year, the instructors watch a "few" students resist these exams. One instructor told me these students say "I just can't do this" and "I don't want to do this". Some students abruptly walk out of the exam room, and some postpone their dates, all the way until summertime when they must complete it once to advance to third year.

2) Students have fainted during the exams.

3) Students have cried during the exams. The worst was a recent student who said she was a rape-survivor and had problems with the male rectal exam. My instructors still forced her to do it, and she left the room sobbing in front of the actor and instructors.

4) The instructors have a rule that one female must be in the room for the male rectal exam. The rule was established to mitigate any "homophobia" among male students, and apparently my school thinks the presence of a female neutralizes any viewpoints students might possess that the exam is a "gay thing". I thought this "rule" reeked with discrimination and hypocrisy. It seemed to me this "rule" was conjured up decades ago by the primarily male heterosexual faculty who empathized with problems male heterosexual students as a selective group would face, and made it easier for them to at least graduate, when many male students never even asked for it. The most disturbing part about this "rule" though is that the faculty EXPECT a few young students to be unable to desexualize the prostate exam when it is introduced to them. To then force students to complete the exam, knowing that some cannot desexualize it, must be sexual abuse. But not wanting to "scare students away", these instructors deliberately keep students in the dark until they have invested too much time and money into school. Because at that point, students who find these exams unacceptable must choose between getting sexually abused or crawling away with a mountain of debt as a medical school dropout. The instructor who told me about this "rule" said it was handed down to her when she took the position in 1982. In other words, this "rule" is over three decades old!

What do you think of these four points? I think they unfold like rape scenes. A self-proclaimed rape-survivor leaving the exam room sobbing? Students crying and fainting while doing "intimate exams" that were not explicitly explained beforehand? Students "resisting" and "postponing" the exams for months? One instructor assured me that I was not out of place, and said he always sees students "make horrified faces". Unfortunately, his comments did not make me feel better, they made me feel angry that my school failed to question why this is the case. It disgusted me that nobody advocated for the rape-survivor. I believe they raped a rape-survivor. And it outraged me that this student cried in front of her peers, and then felt she needed to reveal personal information about herself too. There is no justification for the fact that they did absolutely nothing after that for future students.

I was sickened by the degree instructors deny they are hurting a few students each year. They assured me "I always ask those kids who keep postponing the exam how it turned out, and they say it was not as bad as they thought." What else can these students say when their own abusers fish for an agreeable response like that? The instructors even told me matter-of-factly "Students faint during the pelvic exam because they did not eat a big breakfast." They cannot possibly be keeping tabs on 200 students breakfast schedules. It irritated me they never considered why nobody fainted during the ear exam. As of now, their "solution" to the fainting episodes is to remind students earlier in the week when they explain the pelvic exam workshop to eat a big breakfast on the morning of the workshop.

********************

I read a book "Public Privates" by Terri Kapsalis. When I learned halfway through the book the author was a pelvic exam actor at [My Medical School], I was shocked to discover she wrote an entire chapter about [My Medical School] students having problems with pelvic exams. This book was published 20 years ago, and nothing at my school has changed. Here are some quotes from her book about my school:

1) [The author discusses a paper by a physician named Buchwald] "Students seem to find it very difficult to consider female genital display and manipulation in the medical context as entirely separate from sexual acts and their accompanying fears. Buchwald's lists of fears makes explicit the perceived connection between a pelvic examination and a sexual act. "A fear of the inability to recognize pathology" also reflects a fear of contracting a sexually transmitted disease, an actual worry expressed by some of Buchwald's student doctors. Likewise, "a fear of sexual arousal" makes explicit the connection between the pelvic exam and various sexual acts. Buchwald notes that both men and women are subject to this fear of sexual arousal. "A fear of being judged inept" signals a kind of "performance anxiety," a feeling common in both inexperienced and experienced clinical and sexual performers. "A fear of disturbance of the doctor-patient relationship" recognized the existence of a type of "incest taboo" within the pelvic exam scenario."

... "Buchwald's work deviates from most publications dealing with the topic of medical students and pelvic exams. Largely, any acknowledgment of the precarious relationship between pelvic exams and sex acts is relatively private and informal, taking place in conversations between students, residents, and doctors, sometimes leaking into private patient interactions. For example, as a student in the 1960s, a male physician was told by the male OB/GYN resident in charge, 'During your first 70 pelvic exams, the only anatomy you'll feel is your own." Cultural attitudes about women and their bodies are not checked at the hospital door."

... "In his article about medical students' six fears of pelvic exams, Buchwald accepted student fear without either questioning why young physicians-to-be would have such fears or searching for the cultural attitudes underlying them."

2) [The author discusses that schools hired prostitutes to teach the exam] "In a sense, the patriarchal medical establishment took the position of a rich uncle, paying for his nephew, the medical student, to have his first sexual experience with a prostitute. This gendered suggestion assumes that female medical students are structurally positioned as masculinized "nephew" subjects as well."

3) [The author quotes a fellow pelvic exam actor] "I think the students are afraid it's sexual. They're afraid about how they're going to react, whether they're going to be aroused, but it's so clinical."

4) "Only with the use of GTAs [pelvic exam actors] have medical schools attempted to incorporate women patients' thoughts, feelings, and ideas into pelvic exam teaching. And yet, as these feminist teachers pointed out decades ago and as my experiences have occasionally confirmed, it may be impossible to educate students properly within the medical institution given unacknowledged cultural attitudes about female bodies and female sexuality."

The author of this book is correct: There is no validation from faculty at [My Medical School] that some students suffer problems regarding these exams, and there is no effort to investigate why this is the case. I also agree there is no search for "cultural attitudes" that could underlie students perceiving these exams differently. In fact, although I have American citizenship, I was raised overseas from age four and returned to America for college at age nineteen. I retrospectively learned that in many developed nations, the thought of asymptomatic women paying strangers in white-coats to routinely penetrate their vaginas is the exception rather than the norm. In Korea, for instance, some women use vaginal swabs in the privacy of their homes. In Japan, screening for cervical cancer at all is not commonplace. In other developed countries, there are self-pap tests that some women use because they find the traditional gynecological exam to be inappropriate in the absence of symptoms. In addition, the developers of the CSA blood test cite "cultural taboos" as being a primary motivation for them inventing a non-invasive alternative to check for cervical cancer. So I think my school is very ethnocentric to believe all incoming students automatically agree not only with these exams, but also with practicing them on asymptomatic actors. It is undeniable some students discover personal clashes that might derive from cultural upbringings while learning about the most taboo aspects of physical exam for both sexes, and I find it unethical that schools would not inform students about these potential problems before they move to new cities and matriculate.

At the same time, the author conveys similar beliefs as the instructors I met at [My Medical School], hastily diagnosing students as having "anxieties" and "fears" that they can "cure" us of via "education". I think the quote the author provided from a fellow pelvic exam instructor ("Students are afraid it's sexual") is nauseatingly narrow-minded. How does this woman believe she can tell all adults that an exam, mechanically the same as digital sex, is not sexual? Why does she think she can speak her mind for all adults about human sexuality in medicine by resorting to empty buzzwords like "professional" and "clinical" to do so? In fact, she cannot define what is and is not sexual (or sexually violating) for any other adult.

This reminds me of one instructor who concluded I had an "irrational phobia". Do you think it was fair for this instructor to tell me I had a "phobia" of being forced to have digital sex with an actor without my consent? Because you could easily make the reverse argument: Students who do not want to do these exams when introduced to them (as this apparently happens each year), but still complete them have "phobias" about disobeying orders from faculty, or have "phobias" about standing up for themselves, or have "phobias" about what instructors will think of them if they admit they see a medical exam as being sexual. The same with patients too: I have seen peer-reviewed papers written by gynecologists investigating why some women have "fears" about getting exams. But the counterargument here is that women who dread the thought of being humiliated and penetrated by strangers, but force themselves to suck it up, have hypochondriac "fears" about developing a rare cancer and benefiting from a notoriously inaccurate exam. Depending on their lifestyles, some women are more likely to be harmed than benefited from the outdated pap smear, and the World Health Organization does not recommend ovarian cancer screening via bimanual exams. For these reasons, I believe smart and responsible women can decide to never submit to these exams while asymptomatic, without being diagnosed by pushy and one-sided doctors as having "curable fears".

It is too easy for instructors to label and ostracize students as having "fears". These instructors told a rape-survivor she was being irrational to "fear" the prostate exam. What is particularly evil is they knew this teenage girl or young woman likely did not know about taboo old men healthcare to decide for herself before starting school whether or not she found completing a prostate exam to be acceptable. In any case, her "fear" turned out to be a rational one because the experience did cause pain, as she expected, seeing that she left the room crying. These instructors pride themselves on walking over students and their problems, and believe that with their supremely rational minds, they can triumph over anything, when in fact they have not proven any strength unless they have all been raped themselves. So who are they to judge a rape-survivor student with long-term effects of depression? And then to boast that they gave this student such a valuable educational experience, just because they cannot relate to her suffering from traumatic life events? I thought that was just plain childish.

I do not think my instructors are very intelligent. There is more to intelligence than exercising the rational mind. The author refers to these exams as being a "first sexual experience" for many students. If it is indeed true (that medical exams can be sexual experiences), then forcing teenagers and young adults to perform them without consent using shame and blackmail, when it causes problems for a few of them each year, is institutionally-sanctioned serial sexual abuse and rape. At least that is how my intellect - both rational and emotional - sees it.

************************

After I spoke with all physical exam instructors, they sent me to the "Associate Dean for Curriculum", who is also an OBGYN. I met with him twice, and our second conversation bothered me.

He told me he was "ignorant" medical students had problems. But really, he was anything but "ignorant" since he works with the same instructors who watch students cry and faint.

I asked him if I could bring in "evidence" that students have problems. So the second time we met, I brought detailed information about [My Medical School] students having problems, as well as news articles about students across the nation being "known to faint, cry, vomit, become hysterical and sweat" over these exams (http://www.nytimes.com/1998/06/02/science/teaching-doctors-sensitivity-on-the-most-sensitive-of-exams.html?pagewanted=all).

I also brought one article about teenagers and women getting unwanted pregnancies because they could not obtain birth control from gynecologists when they refused pelvic exams. I brought this last article because I empathized and related to the female patients, as I would also refuse the exam if I were in their positions. The article was pointing out that because the medical community does not respect and accommodate these women and their opposition to pelvic exams, it leads to bigger problems like unwanted pregnancies. And I felt that was a similar message to what I was trying to voice to my school: I think a small number of medical students can find out they disagree with exams, and they should no longer be marginalized and ignored for it because that only leads to bigger problems.

When I handed him the paper, his demeanor changed from the previous meeting, and he suddenly raised his voice at me (even though I never raised my voice at him). He actually balled up his fist like he was holding pills and growled at me "If I have something a patient needs, I withhold it until they get the exam!" He was steaming with anger, even though I never thought to question his practice at all. I had read about why it was unethical to require pelvic exams for birth control (http://www.law.harvard.edu/students/orgs/jlg/vol27/dixon.php), but I assumed the doctors who abused their power in this manner were working in private clinics out in the boonies. It never even crossed my mind that an OBYGN Dean of a medical school would fit that profile.

Shocked and creeped out, because I saw his true color, I asked "Shouldn't doctors at least tell patients they could go elsewhere and get birth control without a pelvic exam?" I thought it would be lacking informed consent not to do so. He just sneered at my comment. It was very clear to me this person went into gynecology for all the wrong reasons one might expect. It infuriated me he could not even pretend to empathize with the girls and women in the article who found pelvic exams to be intolerable, just as he could not empathize with his own students who have felt the same way for years. Any gynecologist, especially one who is training the next generation of gynecologists, should understand and respect how various patients feel about their reproductive rights and healthcare. Hurdles should never be imposed for women seeking contraception. In my opinion, this has nothing to do with health care, and everything to do with power, control, and making money.

His thinking and practice is outrageously sexist: When he was a teenager who needed a condom, he did not need to confront an old woman in a white coat who withheld what he needed until he had digital sex with her first. He presents himself as someone who cares so much for women, but then dupes them into accepting pelvic exams for birth control, even though the World Health Organization and numerous medical associations have consistently stated that the only recommendation is a blood pressure check, since hormonal contraceptives are as hazardous as Aspirin. Medically speaking, there is no greater logic to requiring pelvic exams for women who want birth control than there would be for requiring prostate exams for men who want Viagra.

You can only imagine some terrible scenarios he has exploited: An adolescent patient from a poor family shows up for birth control but does not want a pelvic exam, and does not know beforehand that she will be pressured to accept one. Once in the office, she might view doctors as authoritative figures whom she cannot question. She might be time-pressured for immediate access to birth control. She might be too scared to challenge a doctor. She might find it more embarrassing to try to resist the exam. She might be fooled that the pill will harm her body if she does not accept the exam. She might be intimidated by the medical setting, and maybe cannot speak fluent English. At that point, she can either run away from the exam room (and get undesirably pregnant), or reluctantly submit to the exam (and suffer rape-like symptoms). And I am not just speculating here, I have read about female patients who realize they were mistreated after being coerced into something they adamantly did not want but ultimately accepted because of false guidelines presented to them. I have also read about women feeling "raped" from this practice, and driving for miles to find a doctor who actually follows the law.

I wonder why no students speak up when they see him mistreat patients? Maybe their voices have no impact. Maybe they worry they are out of line to defend patients. It agitates me because I know his misogynistic attitudes have an exponentially poisonous impact, seeing that his peers actually respect his philosophies enough to bestow him the responsibility of training future gynecologists at the largest public medical school in the country.

When I was about to leave the room, I recalled a discussion I had with a kind-hearted classmate who recently drove me home. I told him I had problems with these exams, and he urged me to speak with faculty and resolve the issue. Then he told me although he did not have problems performing the exams, he did have problems the way some instructors handled them: He said he shadowed the head ECM instructor, and watched him reprimand each female patient who asked for a female to do her pelvic exam. Evidently, the instructor believes such requests are backwards and bigoted.

So when the "Associate Dean for Curriculum" asked me if I had anything else to add, I said I was concerned about the head ECM instructor teaching students to reprimand patients when they prefer one sex over another for intimate care. The Dean scolded me, and said he applauded the instructor. He believed it was sexist for me to assist these patients and their wishes. He asked me "Would you ask a black person to leave the room? Would you ask a Jewish person to leave the room? Would you ask a short person to leave the room? Probably. Because you would ask a man to leave the room!"

I thought his analogy here was meager and self-serving. Funny how he was offended by modesty in medicine to vilify it as condoning sexism, when he is the one who abuses his position of power to do such despicably sexist things as withholding birth control from girls and women who refuse pelvic exams.

Patients requesting same-or-opposite-sex care for intimate exams was legalized under the Bona Fide Occupational Qualification (BFOQ) by humanitarians who advocated for patient rights to preserve cultural and personal beliefs about sexuality and bodily modesty. There are scenarios where patients know they will experience the exam as being less sexual because of their sexual history and preferences. For instance, a heterosexual man who has only had sex with women might prefer a male to do his exams because he might experience that as being less sexual. But another heterosexual man who has only had sex with women might prefer a female to do his exams because he might experience that as being more natural. And yet another might have no preference. So really, all individuals have unique sexualities both in and out of medicine. For these reasons, I believe my instructors are the ones who pass judgements on their patients and their sexual values and identities.

Some patients might find it more logical to speak with a provider who has experienced physical problems, like a female patient talking about cramps. And some patients might prefer same or opposite intimate care to protect the intimacy between their partners and spouses. How can a health provider admonish a patient and his or her relationship values?

In all honesty, I do not believe that a woman asking for another woman to do her pelvic exam is sexist. Many women perceive the act of getting naked and spreading into the lithotomy position as being sexually vulnerable and submissive. Even if a woman consciously believes that male and female doctors are equivalent caregivers, her natural instincts might strongly prefer a female examiner because she could not get impregnated by a strange female, as opposed to a strange male, between her naked legs strapped in stirrups. The consistent prevalence then of females requesting female intimate caregivers must have instinctive and deeply emotional roots, and must be accommodated by doctors without judgement or ridicule. Because when these women are demonized for making reasonable requests, doctors are punishing them for protecting themselves at a primitive and instinctual level. Hence, these doctors are docking points off patients for being human, known as dehumanization.

I have to say I find it troubling that these male providers harasses female patients for requesting same-sex care. The power differential is too unfair. Most (American) female patients are very young when they have their first pelvic exams and are too often pressured by biased propaganda and brainwashed mothers to get them without the opportunity to judge for themselves whether it is really necessary or whether they are candidates for less invasive alternatives routinely offered in other developed countries. The pelvic exam is also longer in duration and so much more visually exposing than the prostate exam. Women also face additional hurdles since our society is still a very patriarchal one, where women are sexually abused by men at much higher rates than any other combination of sexes. Even if a woman has not been directly sexually abused, she has certainly been emotionally abused from a very young age, knowing female friends who have been sexually abused (often by men), reading newspaper articles about women being raped (often by men), reading history books about villages of women being raped (often by men), receiving catcalls and verbal sexual abuses (often by men), and knowing about pornography and prostitution and late night clubs where women are sexually belittled (often by men). She has been surrounded with evidence her whole life that some men might view sexual parts of female bodies differently. Unfortunately, OBGYN is not much different than these phenomena anyway, as it is a field that has abused the sexual organs of women for decades and was created primarily by male minds. And so when a female patient requests same-sex care, it may be because she has read books such as "Women and Doctors" by John M. Smith, MD, which revealed frightening statistics such as how much more likely it is for male gynecologists to recommended unnecessary hysterectomies, and how much more prevalent it is for male gynecologists to be reported as sexually abusive.

So how can this Dean, who holds birth control hostage from girls and women until they submit to stirrups, relate to patients who ask for modesty accommodations anyway? Any physician or nurse, male or female, should be open-minded and accommodating with all patients and their valid and legal requests for same or opposite intimate health care, as well as their legal right to refuse degrading exams for contraception. Unfortunately, instead of accepting his patients as human beings with modesty concerns, he exploits their situations to elevate his own status as the heroic physician who is educating students to end what he conveniently believes to be sexual discrimination in medicine.

Even if these instructors are so black-and-white in their thinking to believe they are being discriminated against, they still hold responsibility to follow the law and teach students to do so as well. If they dislike the law, they can always orchestrate their own rallies to advocate for fewer patient rights. But I wonder how honest and humanistic they would feel about their pursuits. All they would be doing is transferring the alleged target of discrimination to the group of people who are in the much more vulnerable position, the patients.

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The OBGYN "Associate Dean for Curriculum" said he did not support my conflicts with the curriculum, and sent me to the "Senior Associate Dean for Educational Affairs". This Dean gave me an unhelpful psychotherapeutic session the moment I walked into his room. Before I could explain in my own words what I came to speak about, he asked me "Do you remember anything happening to you that would make you see an ear exam differently than a pelvic exam?"

I thought it was unprofessional for him to ask me personal details about my life, but I told him I have never been sexually abused. I told him some students might find the exam itself to be violating if they are not told about it beforehand. He shook his head like I was a child trying to convince him Santa Claus was real, and told me the only explanation for a person to feel angry over medical exams was if he or she had been abused. Even when I reiterated this was not my case, he told me to seek help from a psychiatrist and "connect the dots" to my abusive upbringing. He went so far to ask if I had siblings, and suggested they also seek help.

I did not think this Dean seemed like an intelligent person to preach about sexual abuse inside or outside of medicine, seeing that he gave no exemption to the student who did admit to an abusive past, and maybe even believed the prostate exam granted her the ability to stop overreacting to whatever caused her to cry.

When searching for criticism of modern gynecology, I came across a popular book "(Male)Practice" by Dr. Robert Mendehlson, who was a pediatrician at [My Medical School]. The author stated:

"I will never forget a student of mine who wanted to specialize in obstetrics but couldn't swallow all of the ridiculous obstetrical intervention that he was being taught. He began to ask questions of the obstetricians: Why were the mothers' feet up in stirrups? Why were they giving the women analgesia and anesthesia? Why were they inducing labor at such an early stage? Why were they performing Caesarean sections when there was no clear indication of need? Did he get answers? No, but he got action. He was referred by the chairman of the department for a psychiatric examination, because any student who asks a hostile question in medical school is presumed to be 'disturbed.'"

This book was written in 1982, and still thirty years later at the same school, when students disagree with sensitive medical procedures, the Deans immediately send them in for psychological evaluation. I whole-heartedly concur with the author: Instructors at [My Medical School] stubbornly maintain there is something wrong with individual students each year, and never with the system itself.

Even worse, this Dean promotes a philosophy to his students that as long as nudity, touching, and penetration occur in the medical setting, then no sane person could possibly feel violated. This is far from the truth, and patients are beginning to speak up about their rights to refuse, request accommodations, and seek alternatives for "intimate" procedures.

For instance, I read the term "birth rape" has been coined. While I understand the term may be legally problematic, I find it conceivable that some women can only describe it this way after what was done to their bodies without permission. And I do not think these women are upset having life-saving C-sections, instead of natural dreamy births. They are upset having unnecessary and aggressive interventions without consent. Can it really be true that so many women must have their labor induced (a known risk factor for pelvic floor damage, perineal tears, epidurals, and C-sections)? Do so many women need episiotomies, when there is no evidence that artificial tears are safer than natural tears, which are rare anyway? Large studies of home births with trained birth attendants show that the majority of women can give birth without interventions, with less injury to mothers and babies, and no increased risk of mortality to either.

There is an unfair rule from doctors that all women automatically accept fingers and instruments in their vaginas if they wish to deliver a baby, even when births are proceeding smoothly. Doctors have an obsession with "checking progress" and recording numbers, with no respect for women who feel the procedures are barbaric. Some insurance providers cash in $250 per bimanual exam, which generates big bucks when doctors perform multiple "cervical checks". There are less demeaning maneuvers that cause less vaginal infections, but these alternatives are never offered. Instead, women who decline pelvic exams and episiotomies receive them against their wills! The baby needs an emotionally healthy mother, and that does not happen when she leaves the experience with so much trauma to call it "birth rape".

As for cancer screening, women are kept in the dark about less intrusive methods to test for cervical cancer (CSA blood tests, urine tests, vaginal swabs, and self-pap tests). Unlike this Dean, I strongly believe patients could feel mistreated by undergoing traditional pap smears should they discover that alternatives, which could have preserved their dignities, were not fairly discussed with them, or should they discover they were not even candidates for cervical testing in the first place.

A report released by Dr. Angela Raffles (cervical cancer screening expert from the UK) demystifies pap smear risks - 1000 women need to be annually tested for 35 years to save one woman from cervical cancer. Meanwhile, 95% of them (950) will require one or more biopsies that can be harmful (emotional stress, sexual problems, cervical stenosis, pregnancy complications, and even infertility). Another article by pathologist Dr. Richard DeMay "Should we abandon pap smear testing?" exposes the fact that cervical cancer mortality was trending downward before the application of pap smear testing, and that when malpractice suits led to higher false-positive rates (and hence more biopsies) cervical cancer mortality actually increased. Hence, the widely proclaimed association between the introduction of the pap smear and decline of cervical cancer might be more casual than causal.

Most doctors do not tell women that "the best kept secret of cervical cancer prevention" is through practicing safe sex and avoiding smoking, not through pap smears. Some women have microscopically slim chances of benefiting from the pap smear, such as virgins, women who only have sex with women, and long-term monogamous women. The same is true with ovarian cancer screening via pelvic exams: The American Cancer Society recommends against it. Why should doctors keep sticking their fingers in places they do not belong when there are no proven benefits?

It is clear to me that dishonesty surrounds much of these "preventative" gynecological exams. Doctors established these tests (money or fear of being sued), and the individual was disregarded. It became: Every Woman must have these exams with No Alternatives.

I can say with confidence that medical students are trained to think this way. In fact, in our first year of medical school, all students practiced interviewing patients with a standardized list of important questions. We asked ALL women: "When was your last pap smear?". But we asked NO men: "When was your last prostate exam?" It would almost make more sense to assume all older men are candidates for prostate exams, than to assume all women are candidates for pap smears since cervical cancer is an STD and so some women are not eligible. Also, the incidence and death rates of prostate cancer are much higher than those of cervical cancer, so it must not be about the numbers. In addition, cervical screening can be a more vulnerable process than prostate screening, because men often have the option of the PSA test (while the CSA test is never offered to women). So really, our first lesson was that female patients do not mind being humiliated in the medical setting, and that we should assume all women accept traditional gynecological exams, even the ones who could only be harmed by them in the first place!

The tunneled vision that this Dean holds (that doctors and nurses are above human modesty) will lead to suboptimal care for many patients outside of gynecology as well. I respect Dr. Joel Sherman and Dr. Maurice Bernstein, and the medical modesty issues for which they are raising awareness for male patients as well. In many ways, it can be a world more difficult for male patients to request and receive modesty accommodations because it is an overlooked topic without enough attention to draw any intelligent conclusions. In addition, people often view modesty as an unmanly characteristic, which might contribute to the ignorance about men having modesty, as well as the silence that fuels this ignorance because when they know to expect ridicule, men do not want to voice their modesty concerns. And I feel very sorry when I read comments from boys and men who have been traumatized by icy nurses and doctors who stereotype males as having no modesty. Unfortunately, I worry this stereotype will die hard, unless male modesty rightfully becomes a component of medical training and education.

I believe most of this ignorance stems from the way doctors are trained. When medical students learn to take sexual histories, we are trained to ask: "Do you have sex with men, women, or both?" (As a side note, I always thought the question should also include "or none" to represent all patients). Before the gay rights movement, this question was systematically swept under the rug to favor the heterosexual population, and hence made gay and bisexual patients less comfortable to openly discuss their sexual histories. Doctors now know not to assume all patients only have straight sex, and this is something that was strongly enforced at my school. I cannot imagine any of my classmates forgetting this simple question, because we are trained and repetitively graded to ask it verbatim from the very beginning. I think many medical students would feel confident to question one of their superiors if they did notice he or she was discriminating against sexual minorities this way, since it is a highly-valued aspect of our training.

On the other hand, when medical students conduct intimate physical exams, we are not trained to ask: "Do you prefer intimate care from a male or female provider, or do you have no preference?" Currently, this question is sidetracked to favor time-pressed doctors and patients who have no preferences, despite it being a legal request unknown to some patients. Obviously this setup makes patients feel ashamed if they do hold strong preferences and values whether a man or woman does their intimate exams. Perhaps then there needs to be a patient modesty movement that might be as successful as the gay patient rights movement by training and grading students to exercise the sexual rights of their patients in this manner as well.

Unfortunately, medical students know they will be shunned if they advocate for patients this way, since sex preference for intimate exams is not an official part of the curriculum. Not only that, but as I mentioned earlier, the instructors at my school reprimand students who bring the topic up for discussion. Therefore, I think dishonesty and silence are fostered in medical school, because I suspect some medical students make their own requests when they are in the vulnerable position as patients. And so they must empathize with patients, but at the same time they must sell their integrity by not questioning their superiors and fitting into what is expected of them, which is to work toward becoming competent physicians who possess minds too perfectly rational to see anything sexual about the exams, and hence too rational to understand why patients might seek modesty accommodations. In other words, doctors pretend not to "see an ear exam differently than a pelvic exam" since they fear admitting so would be a transgression of their medical conduct, and unfortunately this means distancing themselves from patients who do have modesty concerns about exams due to their sexual nature.

I think many medical students sacrifice their integrity subtly at first, and then succumb to the Domino Effect. At first, maybe a student knows he cannot desexualize the pelvic exam, but fearing how his instructors will react, he says nothing, and performs it poorly at the expense of the patient. Next, he might watch an instructor reprimand a female patient when she admits she is not comfortable surrounded by male medical students for her pelvic exam, and he does not stand up for her even though he believes she should not be reprimanded for her request. Now that he has grown more desensitized and dependent on fitting into what instructors expect of him, he might watch an instructor misinform a patient (out of conflict of interest) that pelvic exams are always necessary to obtain birth control, and even though the patient seems weary about the procedure, he does not question the ethics of his instructor. After all, he cannot express his concerns without implying that the instructor is sexually abusing his patient, which would certainly label him as a whistle-blower.

After that, an instructor tells the student that if he admits he is a medical student, then no patients will not allow him to practice sensitive exams on them, and so he follows the advice to flat-out lie to patients about already being a doctor. Ultimately, he agrees to practice pelvic exams on anesthetized patients who have not consented to it, because his instructor tells him these women would have adamantly refused students using their bodies for didactic purposes, and so it is a great opportunity for them to practice their exam skills on unconscious bodies that cannot protect themselves. The student believes the most important skill with a pelvic exam is to obtain informed consent. He sees this "educational" setup as being no different than gang rape. But he has already jeopardized his ethics so many times in the past in relation to sensitive exams. So he does what apparently many medical students do in this country, and gang rapes his own patients: (http://www.theunnecesarean.com/blog/2010/8/30/medical-student-wont-perform-pelvic-exams-on-anesthetized-pa.html).

Gang raping anesthetized patients is apparently a "time-honored tradition" in medical schools, an ethical problem that has garnered media attention for decades, but has never provoked enough frenzy to encourage change. I never witnessed this practice as a first-year student, but I bet my life it is something I would have encountered had I graduated from [My Medical School]. I strongly suspect this because when I was sent to the OBGYN "Associate Dean for Curriculum", he cautioned that I would face additional dilemmas if I refused to perform pelvic and rectal exams during clinical rotations, and said "You might also have a hard time with... Never mind, we do consent all our patients here." It was patronizing he thought I was gullible enough to believe in his statement when he had to "correct" himself. In any case, I already knew this person was not sincere because he had already lied to me earlier in the conversation. (One of the news articles I brought was about Muslim male medical students refusing certain exams on female patients. When I handed it to him, he casually commented "Oh yes, I have read about this before," when the very reason I brought him articles was because he had told me in our first meeting he was "ignorant" students had problems with aspects of physical exam).

The way he corrected himself mid-sentence told me that in fact [My Medical School] has not enforced any policy to end the gang rape of patients, which according to the press, still routinely occurs in most medical schools. This is a topic that was never officially discussed at my school, and I only learned about it through my own research. Hence, students at my school are not prepared to challenge medical gang rape because they will be branded as trouble-makers for suggesting their instructors are gang rapists. This is why I believe most medical students trade in their ethical tenets to complete school, because otherwise repulsively unethical practices like gang raping patients would have died long ago had students followed their hearts, refused to participate, and reported their instructors for legal action.

Two other quotes from Dr. Robert Mendehlson, the pediatrician at [My Medical School]:

"The tragedy of this dogmatic approach to medical education is not only that it screens out the most thoughtful, intelligent, and ethical students, or that is perpetrates traditional idiocies, but also that it virtually forestalls the application of creative noninterventionist approaches to medical practice. Dr. Roger J. Williams put it well in his book, Nutrition Against Disease: Medical schools in this country are standardized (if not homogenized). A strong orthodoxy has developed that has without a doubt put a damper on the generation of challenging ideas. Since we all have one kind of medicine now - established medicine - all medical schools teach essentially the same things. The curricula are so full of supposedly necessary things that there is too little time or inclination to explore new approaches. It then becomes easy to drift into the convention that what is accepted is really and unalterably true. When science become orthodoxy, it ceases to be science. It ceases to search for the truth. It also becomes liable to error."

"My colleagues who head the nation's medical schools boast that this process of "survival of the fittest" assures Americans of the finest medical care in the world. My observation is that doctors are taught to provide a lot of medical and surgical intervention, but I don't see evidence of very much 'care.' The fittest do survive, but what are they fit for? They are the survivors of a heartless system that too often weeds out the best and the bravest - the students with compassion, integrity, intelligence, creativity, and the courage to resist the destruction of their own moral and ethical codes."

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When they withdrew my scholarship, faculty told me they "firmly believed" future doctors must competently perform these exams. But this obviously is not the case at all, otherwise they would not graduate students who did not complete the exams objectively. All the students who cry and faint and make horrified faces certainly are not demonstrating objective behavior. Moreover, the school does not even give all students the opportunity to prove they have desexualized any type of medical exam, since they enforce their "rule" that one female must be present during the male rectal exam. When problems like this are marginalized, it inevitably translates to a small number of students advancing to clinical rotations ready to hurt patients expecting adequate exams, since these students feel too much pressure to act competent as future doctors, they cannot admit the exam is something they never desexualized (and they cannot admit they might faint or cry on a real patient, like they did on the actors). Students like this avoid pelvic exams as much as possible, and write "pelvic deferred" in patient charts, because they cannot be honest enough about their shortcomings to ask another provider who feels more comfortable to perform the exams instead (Article: "Managing Emotions in Medical School").

So by trivializing something important, like the inevitable cultural and personal attitudes and barriers about human sexuality in medicine, my school is hurting patients by exposing them to students who are too busy hiding their inadequacies. I thought I was more professional than these students to admit I had visceral problems over these exams, than to not admit so and make an already unpleasant exam even more unpleasant for patients. It is blatant that the only thing faculty "firmly believed" was that students never stand up for themselves if they cannot find peace with a small component of the curriculum.

Before I left, I recommended to several faculty members to start screening students. It is unprofessional and unethical to not explain these taboo exams to students before matriculation. When I suggested this to the OBGYN "Associate Dean for Curriculum", he nonchalantly replied that they "might consider it." He said this in a very condescending and indifferent tone of voice, even though as a physician, he should respect and practice full informed consent. The only person who ever got back to me was one of the ECM instructors who sent me an e-mail saying she would voice my concerns for future students but she "can't promise that there will be a change."

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I am not angry I did not graduate from medical school: I do not want to work in such a hostile and uninspiring environment. But I am angry I moved to a new city to start school without knowing that the same problems that mistreated students in the past would mistreat me because my school will not clean up their system. I am angry I had to arrange so many embarrassing conversations with faculty, only to be told I was "too immature", "too sheltered", "too squeamish", and sexually abused as a child. I am angry my school ostracizes a minority of students each year over something personal like their sexualities, and believes they should all have to change their views to assimilate to those of the majority. That is something that has always bothered me.

I hope Dr. Sherman and Dr. Bernstein continue to raise awareness for patients to know and exercise their options and legal rights regarding sensitive medical exams. And as a woman, I hope American girls and women start to explore alternative practices and philosophies about their bodies and reproductive healthcare outside of the rigid setup traditional modern gynecology has to offer. I could never accept non-emergency care from OBGYNs now that I know how they are trained. If I ever wish to have a baby, I will not think twice about home-birthing with midwives because I do not want to be a woman who receives demeaning and dangerous interventions when unnecessary and often harmful to both her and her baby. And I am ecstatic to see that American women are becoming more informed about their birthing options, thanks to documentaries like "The Business of Being Born" by Ricki Lake.

Much of what I wrote here ties into various medical modesty and ethical concerns discussed on Dr. Bernstein's Blog. That is why I agreed to publicize all of it here on his Blog. I also do not mind publicizing this story further anywhere else if it might prompt a change in some of the problems I detailed.

I wanted to end by saying that I believe there should be a requirement at the national level that students are explicitly told about these exams when they apply to medical schools, which should not be laborious to implement because students all use the same application website. I contacted several individuals last fall, told them my story, provided them with news articles about students fainting and crying, and none of them took me seriously. Some of the people I contacted included the "Senior Director of Student Affairs and Student Programs at AAMC" and the "LCME Assistant Secretary". These people told me they thought most students knew about these exams beforehand. First, I have never believed that "most" is ever enough; it does not validate the fact that the system currently tramples over a minority of young students. Second, I do not know where they got their flimsy statistic that "most" know about these exams anyway, since most students have never visited the proctologist, and at least half have never visited the gynecologist. These people also told me different students face different "challenges", and so they cannot cater to one "challenge" over another. I do not believe these intimate exams are "challenges". I believe any exam that could be construed as sexual (and sexually violating) must be fully explained and consented. Otherwise, it could be serial sexual abuse and rape.

I also want to report the OBGYN "Associate Dean for Curriculum" for not following the law that women can get birth control without pelvic exams, as well as report both him and the head ECM instructor for not properly educating students about the BFOQ patient modesty law. These individuals are teaching and encouraging hundreds of future physicians each year how to be insensitive about sensitive exams, and I want to do something about that. The problem is I do not know how to report these authoritative figures, unless there are freelance lawyers any readers out there might know about who advocate for patient rights.

I look forward to reading any comments and suggestions from readers.

NOTICE: AS OF TODAY AUGUST 27, 2011 "PATIENT MODESTY: VOLUME 43" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 44

Graphic: Photograph of Statue "Water" (1939-1943) by Aristide Maillol taken by your moderator 8-13-2011 at the Norton Simon Museum, Pasadena, CA.

Making Clinical Ethical Decisions: Common Fallacies: 3. False Dichotomy

2011-07-22T22:06:00.000-07:00

False dichotomy is where, in formulating a decision, the decision is based on a belief of “all or none” and forgetting that there may be a middle ground. Not all decisions need to be made as “black vs white” since often there are shades of “gray”, that middle ground.

This concept is particularly important in clinical ethics consultations where in most cases decisions are not emergent. Yes, in an emergency room environment, often decisions regarding diagnosis and therapy need to be made promptly without time available to philosophize over an issue and either something specific in therapy is done or something is not done. In contrast, by the time an issue of management comes to the hospital ethics committee consultation there may be a sense of urgency to some but in most cases there is time to look at and consider the whole clinical, ethical and legal picture in order to come to a satisfactory conclusion. And what first comes to the table as a decision for either a “this” or a “that” may actually during discussion find some middle decision as the most viable and beneficent solution. This finding of a “middle ground” is one of the functions of an ethics committee consult and is part of the process of mediation of conflicts.

As an example, a 75 year old man with chronic emphysema and diabetes who has had a massive stroke and is still unconscious in the critical care unit of the hospital after 2 weeks and there is advice by the attending physician that the patient should undergo a tracheotomy (semi-permanent opening to the windpipe for breathing) since he is expected to continue on the ventilator for a unknown period of time. Also at this time a tube inserted into the abdomen and entering the stomach (PEG procedure) was the professional advice for longer term feeding and hydration. One son sitting at a hospital ethics committee consultation agreed with the advice of the physician. He wants these procedures performed since he wants to continue life-supportive treatment to continue until his father recovers. Another son with whom the father had lived since the mother had died a few years earlier present at the meeting argued against these procedures. He said that his father would never awaken and if he did he would not want to be alive after such a stroke. The son wanted the ventilator to be turned off even if it meant the death of his father. A neurologist on the case presented her opinion that the current 2 weeks duration might be too soon to make a judgment about the prognosis though it was probably poor and if the patient survived he might continue either in a persistent vegetative state or profoundly neurologically impaired. So the possible decisions would seem to be 1) continue with supportive therapy, do a tracheotomy and PEG or 2) terminate life-support now. But this is where overriding the “false dichotomy” comes in: there is a middle ground which was offered by the ethics committee. The neurologist told the family that she might be able to give a more accurate prognosis on examining the patient in one or two weeks. The attending physician said that the ideal time to perform the procedures was now but he would wait for a week or two more but not much longer. The ethics committee suggested to both sons that a compromise of having a followup ethics meeting in 10 days after the patient was evaluated at that time may be the best decision at present. This also provided time for each son to re-evaluate his position on a final decision. This middle ground satisfied all parties who were present and they all shook hands as they left the meeting.

If this was your father and the physicians were in agreement with the conclusion of the consult would you too be satisfied that it was not necessary to have the decision end if not the one way then the other? ..Maurice.

Making Clinical Ethical Decisions: Common Fallacies: 2. Argumentum ad populum

2011-07-21T16:30:00.000-07:00

Fallacy #2 is argumentum ad populum: to sway the decision of others by appealing to sentimentality rather than reasons based upon facts. One obvious example of such a fallacy is the recent popular turmoil regarding the jury decision in the trial of Casey Anthony finding her innocent of murder and other possible felonies related to the death of her lovely child. It was the death of the little child and descriptions of the mother's behavior that led to the conclusions of a host of the public that the jury made a mistake and that Casey Anthony was really guilty. Yet, as the jury understood, the facts did not fully speak to or prove "beyond reasonable doubt" that the mother was guilty and so withstood turning to the argumentum ad populum decision.

In medicine, often the concern about the public's sentimentality associated with a popular person in need of an organ transplant, for example a movie star or sports personality, might suggest to some that the early receipt of a life-saving organ was directly related to such sentimentality. It is not generally proven that this is the case, but, nevertheless this may be a consideration by some.

It is hard, particularly in dealing with significant illness or disability in a child to avoid sentimentality and prevent this from dominating the decision by parents or even nurses or physicians regarding medical management. Sometimes sentimentality dominates the discussion over the known objective findings or statistical probabilities.

The obvious problem that occurs when sentimentality arrives at the medical ethics decision table is that those "who care" (use sentimentality) may attack those who are trying to be objective as possibly "uncaring". Unfortunately, those who define themselves as "caring" may not realize or have forgotten that caring also involves deciding with regard to the best interest of the patient and often what is in the best interest doesn't always depend on sentimentality but the realistic facts.

What role has sentimentality played in medical decisions of which you are aware? ..Maurice.

Making Clinical Ethical Decisions: Common Fallacies: 1. Ad Hominem

2011-07-21T11:12:00.000-07:00

The first fallacy to be considered is “ad hominem” which is translated “to the man”: switching the discussion from the argument or defense of the facts presented to an attack of the opponent as a person.

Here is the scenario in a clinical setting as an example of the first fallacy to consider: ad hominem.

The 68 year old father of 5 children has had known prostate cancer for the past year treated by surgery and radiation but now is experiencing back pain which was found on x-ray to be an apparent metastasis of the cancer. The family had already experienced cancer in the family with the death of their mother at age 62 from breast cancer. One son, upset by the finding of the metastasis and in place of discussing with the urologist the appropriate steps to take next interrupts the urologist accusing the urologist of misdiagnosing and mistreating his father and that the urologist probably just "squeeked through" medical school. On returning home, the son spoke to each of his siblings about his conclusion, to which, however, they didn't agree. Instead of listing the known facts in the physician's diagnosis and treatment of his father and explaining how he reached his conclusion from the facts, the son had simply personally attacked the urologist's professional history and skills. This response by the son was an "ad hominem" attack instead of a reasoned conclusion. This reaction is usually in response to frustration where no definite explanation can be given and so attack is the last approach.

Ad hominem can also occur on the other side of the patient-doctor interaction. Think about the 42 year old male who is suspected by some and known by others to be a drug addict and has come to the hospital emergency room on many occasions requesting pain medication for various aches and pains. He is well known in the ER for this and sometimes he gets what he wants. This time, he came complaining of chest pain of 2 hours duration which he had never experienced previously but was unable to have a chance to say that since he was brought to the attention of the emergency room doctor with the acronym "AALFD" and sent back to the waiting area to later collapse from an acute myocardial infarction. Unfortunately for this patient, the facts were not obtained this time but he was simply given an ad hominem designation. Oh, yes.. you did want to know what the doctor understood as "AALFD"? From messybeast.com : "AALFD - Another A**hole Looking For Drugs"

The fallacy regarding ad hominem is that not only is ad hominem an uncivil act, it is not a substitute for supported facts and supported argument.

In making decisions for patient care, both the ethics consultants and the stakeholders have to avoid the use of an ad hominem assertion in place of providing facts or arguments in supporting ones view. ..Maurice.

Making Clinical Ethical Decisions: Common Fallacies: Introduction

2011-07-20T15:29:00.000-07:00

Hospital ethics committees have as one of their duties, facilitating the decision making process of the stakeholders involved in a clinical situation dealing with the management and care of a patient. The facilitating process involves both education of the stakeholders with regard to the ethical consensus and the applied laws but also involves a skill of mediation, helping each stakeholder to understand and consider the issues that the others are having and attempting, by working with everyone, to get all parties to come to some agreeable final decision which is legally and ethically acceptable.

A mechanism of human misunderstanding which can interfere with this process is that of “fallacies”. Fallacies are misconceptions or illogical expressions which may be part of an argument. They are sometimes unrecognized by all or may be known to the one making an argument to another and sometimes they may be purposely used to win the argument. Generally, fallacies do nothing constructive except to shut down the discussion or distort the facts.The possibility that fallacies may be occurring during a hospital ethics committee consultation is an important consideration both of the ethics consultants but also t he stakeholders themselves. Everyone should be aware of fallacies, look for them, recognize them in the development of an argument but then eliminate or defuse them so they won’t affect logical decision-making.

I have obtained a number of common fallacies to present on my blog separately for contemplation and discussion. There is a list of fallacies published at nobeliefs.com which were "compiled by Jim Walker, originated July 27 1997 and additions made December 1 2009".

The first fallacy to be considered is “ad hominem” which is translated “to the man”: switching the discussion from the argument or defense of the facts presented to an attack the opponent as a person. ..Maurice.

The "Fetus Fetish"

2011-07-05T21:02:00.000-07:00

As a followup of a thread on this blog I wrote August 2007 regarding the power of a fetus vs the autonomy of the mother, I offer another thread providing examples of what the author of the article below considered as the “fetus fetish”. The article is from criticallegalthinking and the “content is published under the Noncommercial-No Derivative Works 3.0 Unported license” and the text is reproduced here as written. After you read the article, let us know what your views are regarding how the fetus, in political, religious and legal views, by some, may trump the autonomy of the mother. ..Maurice.

The Fetus Fetish & the Erosion of Reproductive Rights in the USA

Author: Ruth Cain*

Rennie Gibbs, a 15 year old girl from Missisippi, has been charged with murder for the following reasons: her baby was born dead, and she apparently took cocaine during pregnancy. A direct causal link between the drug use and the stillbirth was not established. In similar vein, the state of Utah recently proposed legislation to criminalise miscarriage, if the mother can be proven to have caused the fetal death. What does this hardening of the concept of maternal-fetal competition in predominantly (but not exclusively) Christian-right, conservative ideologies mean in legal and cultural terms? What types of maternal and fetal bodies are created and envisaged by such punitive risk-focused laws? It will be my argument here that the mother accused of ‘pre-birth killing’ through neglect or toxicity to the fetus is caught in the paradox of what Lauren Berlant in The Queen of America Goes to Washington City (1997) calls the excessive Western ‘focus on the isolate body and the totality of its own political condition’. This paradoxical effect is achieved in two main ways: firstly, the mother’s body becomes construed as uniquely dangerous in and of itself to the fetal body contained within it, in a way which discounts other risks and dangers. Secondly, the ‘isolate body’ privileged in terms of victimisation and consequent rights is that of the fetus, which entirely displaces the mother’s.

An estimated 2% of pregnancies end in stillbirth, and at least 15-20% in miscarriage.The actual cause of any fetal death being in most cases difficult to pinpoint to one factor, this is clearly a move to both punish the ‘unruly’ mother (to use Rebecca Kukla’s (2005) term) for an increasingly broad range of actions deemed dangerous to the fetus, and to bolster up the legal personhood of the fetus itself. What we are seeing is the creation of new fetal legal ‘rights’ which overbear the mother’s. The US states which have created new laws to protect fetuses (Texas, South Dakota, Georgia, Kansas, to name but a few) already heavily proscribe access to abortion, although they cannot entirely ban it, since the Fourth Amendment protects the rights enshrined in Roe v Wade (1973). Maternal punishment for neglect or toxicity to the fetus reinforces the doctrine of fetal personhood from conception. However, given that the ‘crime’ may be proven merely by the fact of fetal death and failure to show complete lack of involvement in it, maternal punishment is in fact achieved through fetal fetishisation- the creation of the fetus as an object or, indeed, person acknowledged as having a sublime value unique to itself, which operates to shut down argument or debate. The fetal fetish is perhaps the most visible, emotive sign of the way certain forms of consumerist individualism and risk-focused thinking focus personal and legal attention on the (faulty) conduct and bodies of mothers. And through its distorting lens, all women of childbearing age are invasively viewed as potential mothers, whatever their personal reproductive plans or histories.

The persistent risk-analysis pervasively applied to all Western pregnancies has produced a new regulative fiction, the ‘pre-pregnant’ body. In mental health practice, for instance, certain drugs such as sodium valproate, which carries around a 0.1% risk of fetal malformation, are not prescribed to any woman of childbearing age regardless of the potential positive effects of the drug. The woman is simply not allowed to choose that risk for herself, regardless of her personal feelings about children, sexual preferences or contraceptive practices. In a different context, corporate interventions aimed at fetal protection have disqualified women of childbearing age from ‘risky’ jobs, as Michael Thomson’s (Reproducing Narrative, 1997) work explores. The fiction of a female body ever-ready to produce a (pathological) pregnancy is a hysterical one, and we see this hysteria in its most malevolent form if we listen to Kansas state representative Pete de Graaf, who in a debate about health insurance coverage, recently argued that abortion should not be covered even in cases of rape and incest. He argued that women should see the risk of pregnancy through rape as something to ‘plan ahead for’. Images of the body as property that the good female citizen would not put at risk echo some of the uglier metaphors of the contemporary rape debates, such as ‘don’t leave your front door open if you don’t want to be burgled’. (DeGraaf expands: ‘I have a spare tire on my car… I also have life insurance. I have a lot of things that I plan ahead for.’)

This is not just a US issue, clearly: the fetishisation of the fetus is taking place across the Western world. No country with access to ultrasound visualisation technologies can avoid the imagery of the fetus, viewable during all ‘normal’ pregnancies and even on advertising billboards. Nonetheless, fetal fetishisation is most clearly illustrated in the Republican Southern and Mid-Western states of America. Take for example the 2011 Georgia prenatal murder bill, which outlaws miscarriage or stillbirth with ‘human involvement’. This broad term would clearly cover a woman who deliberately injures herself, for example by throwing herself down the stairs (although many would argue that a woman in these circumstances needs support rather than criminalisation for such a devastating act of self-harm ), but could clearly also cover pregnant women who drink, smoke, eat ‘junk’ food, drive fast, or work long hours in stressful jobs. US federal law has sent a clear message about fetal personhood through the Unborn Victims of Violence Act (UVVA), enacted in 2004. This allows for the perpetrator of a violent crime against a pregnant women to be charged with crime against the fetus too. As Jeanne Flavin writes in Our Bodies, Our Crimes: The Policing of Women’s Reproduction in America (2008):

The Unborn Victims of Violence Act explicitly states that nothing in the act “shall be construed to permit the prosecution … of any woman with respect to her unborn child.” But state statutes have used nearly identical language (… only after hard-fought battles to get the language included in the first place) and then have gone on to prosecute pregnant women for their drug use in what has been called a “legislative bait and switch.” (As quoted in online blog RH Reality Check).

The state rules recently created to inhibit abortion are legion: 24 hour mandatory ‘consideration periods’ before treatment, obligatory parental consent for women under 18, compulsory counselling (often with anti-abortion ‘scripts’ and/or held in specially-equipped centres designed to help the mother to ‘bond’ with her unborn). In February this year the State of Texas passed a pre-abortion ultrasound law in which a woman seeking abortion will be compelled to view sonograms described by a doctor before the24-hour ‘waiting period’. (This is currently under challenge by the Center for Reproductive Rights (CRR) wich has filed a class action lawsuit challenging the law on behalf of Texas medical providers performing abortions and their patients).

The compulsory viewing of the fetus is a particularly clear instance of the usefulness of fetal personification as an instrument to limit reproductive choice. Since visualisation technologies revealed the womb’s contents to the screen, it has proven difficult to see the publicly lauded fetus as contained within the mother. The ultrasound picture is now almost universally accepted as the first instance of ‘bonding with’ and publicly announcing a ‘baby’. As such, we may understand the newly-enacted Texan law to be a disciplinary form of the medical-social ritual which now confirms most Western pregnancies around the 12 week mark. The law illustrates the principle that the perceived right of the female individual to control over her own reproductive processes reduces with fetal visibility….

It is difficult not to interpret the new US state laws as brutal extensions of the risk-focused philosophy of contemporary pregnancy. Western pregnancy literature already prescribes a limited, careful diet and ‘low stress lifestyle’ to the good and caring future mother. There is now a ‘canonical’ good pregnancy (as noted by Rebecca Kukla in Mass Hysteria (2005)) and a normative public fetus, with which all pregnant women are encouraged to identify themselves and their unborn babies. Maternal punishment for faulty behaviour in pregnancy is not necessarily a direct means of social control, since the woman in question is rarely helped to regulate her own health in pregnancy and may well find herself restricted by poverty, untreated addiction, or personal circumstances; rather, her punishment serves as a deterrent, informing all women that they had better be hypervigilant about the contents of their wombs, even if they are do not (yet) plan to fill them. The legislation maximally intensifies the generally accepted point that in pregnancy ‘your’ body is no longer yours, and your entire life must adapt to produce a safe baby. For the self-disciplined woman who may slip up once or twice, eat unpasteurised cheese or take a sip of wine, the ‘punishment’ (for now, at least) will simply be unease or guilt regarding her responsibility for the health and welfare of the fetus. For the women criminalised for fetal murder, such retribution is dealt out by the law, given symbolic and disciplinary shape. As such, we may see the predominantly poor and young, white or black/Hispanic women prosecuted for crimes against the fetus as performing a disciplinary social function for the entire pregnant, and pre-pregnant, population of women: fail to follow the rules of pregnancy, and you, not just your baby, will suffer the consequences.

The sheer political irrationality and counterproductivity of laws which discourage 15 year old girls from seeking treatment for drug use since they will face prosecution if discovered, after making abortion unaffordable and logistically near-impossible to obtain, following state failure to provide access to affordable contraception (not to mention sex education) is breathtaking. This reduction of women to ever-ready womb combines old-fashioned misogyny with the risk-based thinking which implicates the unruly (usually female, but also black, or colonised, or any other way abject) body in all socially problematic events.

Rebecca Kukla and Barbara Duden (1993) have shown that the concept of fetal individuation and separation from the mother has been in progress since the Enlightenment exalted the concept of the bounded individual, in constant (self-) development. As compulsive individualism has accelerated, the fetishisation of the fetus/hero has entirely normalised maternal-fetal competition. The fetus ‘him’self in ‘his’ public portraits (such as the famous 1965 photographs by Lennart Nilsson) exists in an apparently self-contained world; the boundaries of the womb do not appear to limit him. Living children, post-birth, shrink in stature compared to the glowing fetus in his personal space. Babies, by contrast, disturb the social world with their noisy wants and demands. It has become clear that the most likely ‘remedy’ for the effects of poverty and unwantedness in life of the disadvantaged post-birth American is incarceration. A political system which can only contemplate individual rather than any form of collective responsibility for the health and welfare of children (and mothers) must prioritise the punishment of the unruly mother at whatever cost to her or her living children. Such a system is less about the protection of life than the expression of intense anxiety about, and hatred for, those bodies which threaten the fetish of wholesome fetal perfection.

A 1984 piece by Zoe Sofia, ‘Exterminating Fetuses’, assesses the iconicisation of the fetus as a means to block out and denigrate the ‘messiness’ not only of the female body, but of the material world itself: she explores the allegory of the world-eating fetus (as visualised in the iconic final sequence of 2001: A Space Odyssey) with the mother representing polluted and exploited Earth. Her dramatic vision, written in the context of the Cold War, now looks prophetic. Fetal ‘extraterrestrialism’ mirrors the destructive activities of a neoliberal agenda: a race to the bottom where the rights of living beings to bodily autonomy and a fair share of the things of the earth are eroded in favour of a mythology of self-reproducing life, floating somehow beyond the wombs in which they are really contained. We must thus see the fetal fetish as something more than a reproductive rights issue, although it is certainly that. It is about the dangerous and inhuman denial of reproductive and personal complexity, setting a falsely perfected, ‘pre-born’ fetal bubble against the permeable realities of human bodies and their environment.

*Ruth Cain is a Lecturer in Law at the University of Kent

“Is My Time Up?”: Why the Answer is Not a Simple One

2011-07-03T15:27:00.000-07:00

A 54 year old woman had a heart attack and was taken to the hospital.

While on the operating table she had a near death experience. Seeing God she asked "Is my time up?"

God considered his computer databases and answered, "No, you have another 43 years, 2 months and 8 days to live."

Upon recovery, the woman decided to stay in the hospital and have a face-lift, liposuction, breast implants and a tummy tuck. She even had someone come in and change her hair color and brighten her teeth--since she had so much more time to live, she figured she might as well make the most of it!

After the last surgery, she was released from the hospital.

While crossing the street on her way home, she was killed by an ambulance that was rushing to hospital emergency.

Arriving before God, she demanded, "I thought you said I had another 43 years? Why didn't you pull me from out of the path of the ambulance?"

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God replied: "My goodness--I didn't recognize you!"

What does this story tell you? To me it suggests that generalizations regarding any individual can never be without possible error, whether it is from a computer statistical analysis or from, well… even God.

In ethics and medicine and in law, it is all about the understanding of facts and sometimes, perhaps unexpectedly, the facts change. ..Maurice.

p.s.- The story was related to me by a fellow ethicist. The origin of the story is unknown.

Patient Modesty: Volume 42

2011-06-29T07:52:00.000-07:00

I am awaiting the essay of a former second year female medical student to place on this Volume's front page. She had her future hopes of obtaining an M.D. and PhD degree dashed when her medical school allegedly refused to accommodate her request to avoid performing male genitalia, rectal and female pelvic exams later in her second year as part of physical exam teaching and to avoid the OB-Gyn clerkship in the 3rd year. Her requests were based on her own personal anxiety but also for her personal philosophic reasons against performing these intrusive procedures which also challenged her own and the patient's modesty and sexual concerns. I will write nothing further and await her presentation. I think her story will be particularly pertinent to this thread. ..Maurice.

ADDENDUM: FROM THE MODERATOR-- The medical student's writing has been received as of today July 11 2011. Two apologies to the writer: 1) In my above note, I wasn't fully accurate regarding her concerns. She will explain them in her writing 2) I decided, as an ethical decision, to delete frank identification of her medical school. Please also note that one internet link was inoperative as written but the others work.

I want to wish who we have called our "stressed student" many thanks for allowing her writings to be published here and we wish her the very best in developing an upcoming career. ..Maurice.

ADDENDUM: THE CONCERNS AND EXPERIENCE OF A FORMER MEDICAL STUDENT

July 11,2011

Over the summer, I confided in faculty that even though I understood many people saw these exams as being just another part of the physical exam, I saw pelvic and rectal exams as being violating procedures, and that unless I went through some psychological change where I could perform them without feeling violated, I would decline to perform them, especially in non-emergency scenarios such as practicing on an actor in an artificial environment, and especially since it was not listed as a graduation competency to students beforehand (or even at all anywhere). What happened when I said this is they withdrew my scholarship, and shunned me for asking for "special privileges". I withstood so much abuse when I brought the topic up with faculty, ridiculing me with "What? We have to tell students that doctors touch people?", guilt-tripping me with "If you cared about patients, you would do the exam", and victim-blaming me with "You knew all about these exams before you got here, you just repressed it."

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Over the summer, the first person I contacted was the head instructor of ECM (the physical exam class where we must complete these exams). I vaguely told him I had "concerns" about the ECM course for second-year students. He offered to meet with me, but said most students speak with other instructors of the course first, and then with him if things are not resolved. So I spoke with all the other course instructors, and by then he knew what my issues were, and was no longer interested in meeting with me. I did learn a lot of unacceptable facts about the ECM class from the other course instructors though.

I was appalled and frustrated to realize my school has watched students suffer personal conflicts like me for decades:

1) Every single year, the instructors watch a "few" students resist these exams. One instructor told me these students say "I just can't do this" and "I don't want to do this". Some students abruptly walk out of the exam room, and some postpone their dates, all the way until summertime when they must complete it once to advance to third year.

2) Students have fainted during the exams.

3) Students have cried during the exams. The worst was a recent student who said she was a rape-survivor and had problems with the male rectal exam. My instructors still forced her to do it, and she left the room sobbing in front of the actor and instructors.

4) The instructors have a rule that one female must be in the room for the male rectal exam. The rule was established to mitigate any "homophobia" among male students, and apparently my school thinks the presence of a female neutralizes any viewpoints students might possess that the exam is a "gay thing". I thought this "rule" reeked with discrimination and hypocrisy. It seemed to me this "rule" was conjured up decades ago by the primarily male heterosexual faculty who empathized with problems male heterosexual students as a selective group would face, and made it easier for them to at least graduate, when many male students never even asked for it. The most disturbing part about this "rule" though is that the faculty EXPECT a few young students to be unable to desexualize the prostate exam when it is introduced to them. To then force students to complete the exam, knowing that some cannot desexualize it, must be sexual abuse. But not wanting to "scare students away", these instructors deliberately keep students in the dark until they have invested too much time and money into school. Because at that point, students who find these exams unacceptable must choose between getting sexually abused or crawling away with a mountain of debt as a medical school dropout. The instructor who told me about this "rule" said it was handed down to her when she took the position in 1982. In other words, this "rule" is over three decades old!

What do you think of these four points? I think they unfold like rape scenes. A self-proclaimed rape-survivor leaving the exam room sobbing? Students crying and fainting while doing "intimate exams" that were not explicitly explained beforehand? Students "resisting" and "postponing" the exams for months? One instructor assured me that I was not out of place, and said he always sees students "make horrified faces". Unfortunately, his comments did not make me feel better, they made me feel angry that my school failed to question why this is the case. It disgusted me that nobody advocated for the rape-survivor. I believe they raped a rape-survivor. And it outraged me that this student cried in front of her peers, and then felt she needed to reveal personal information about herself too. There is no justification for the fact that they did absolutely nothing after that for future students.

I was sickened by the degree instructors deny they are hurting a few students each year. They assured me "I always ask those kids who keep postponing the exam how it turned out, and they say it was not as bad as they thought." What else can these students say when their own abusers fish for an agreeable response like that? The instructors even told me matter-of-factly "Students faint during the pelvic exam because they did not eat a big breakfast." They cannot possibly be keeping tabs on 200 students breakfast schedules. It irritated me they never considered why nobody fainted during the ear exam. As of now, their "solution" to the fainting episodes is to remind students earlier in the week when they explain the pelvic exam workshop to eat a big breakfast on the morning of the workshop.

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I read a book "Public Privates" by Terri Kapsalis. When I learned halfway through the book the author was a pelvic exam actor at [My Medical School], I was shocked to discover she wrote an entire chapter about [My Medical School] students having problems with pelvic exams. This book was published 20 years ago, and nothing at my school has changed. Here are some quotes from her book about my school:

1) [The author discusses a paper by a physician named Buchwald] "Students seem to find it very difficult to consider female genital display and manipulation in the medical context as entirely separate from sexual acts and their accompanying fears. Buchwald's lists of fears makes explicit the perceived connection between a pelvic examination and a sexual act. "A fear of the inability to recognize pathology" also reflects a fear of contracting a sexually transmitted disease, an actual worry expressed by some of Buchwald's student doctors. Likewise, "a fear of sexual arousal" makes explicit the connection between the pelvic exam and various sexual acts. Buchwald notes that both men and women are subject to this fear of sexual arousal. "A fear of being judged inept" signals a kind of "performance anxiety," a feeling common in both inexperienced and experienced clinical and sexual performers. "A fear of disturbance of the doctor-patient relationship" recognized the existence of a type of "incest taboo" within the pelvic exam scenario."

... "Buchwald's work deviates from most publications dealing with the topic of medical students and pelvic exams. Largely, any acknowledgment of the precarious relationship between pelvic exams and sex acts is relatively private and informal, taking place in conversations between students, residents, and doctors, sometimes leaking into private patient interactions. For example, as a student in the 1960s, a male physician was told by the male OB/GYN resident in charge, 'During your first 70 pelvic exams, the only anatomy you'll feel is your own." Cultural attitudes about women and their bodies are not checked at the hospital door."

... "In his article about medical students' six fears of pelvic exams, Buchwald accepted student fear without either questioning why young physicians-to-be would have such fears or searching for the cultural attitudes underlying them."

2) [The author discusses that schools hired prostitutes to teach the exam] "In a sense, the patriarchal medical establishment took the position of a rich uncle, paying for his nephew, the medical student, to have his first sexual experience with a prostitute. This gendered suggestion assumes that female medical students are structurally positioned as masculinized "nephew" subjects as well."

3) [The author quotes a fellow pelvic exam actor] "I think the students are afraid it's sexual. They're afraid about how they're going to react, whether they're going to be aroused, but it's so clinical."

4) "Only with the use of GTAs [pelvic exam actors] have medical schools attempted to incorporate women patients' thoughts, feelings, and ideas into pelvic exam teaching. And yet, as these feminist teachers pointed out decades ago and as my experiences have occasionally confirmed, it may be impossible to educate students properly within the medical institution given unacknowledged cultural attitudes about female bodies and female sexuality."

The author of this book is correct: There is no validation from faculty at [My Medical School] that some students suffer problems regarding these exams, and there is no effort to investigate why this is the case. I also agree there is no search for "cultural attitudes" that could underlie students perceiving these exams differently. In fact, although I have American citizenship, I was raised overseas from age four and returned to America for college at age nineteen. I retrospectively learned that in many developed nations, the thought of asymptomatic women paying strangers in white-coats to routinely penetrate their vaginas is the exception rather than the norm. In Korea, for instance, some women use vaginal swabs in the privacy of their homes. In Japan, screening for cervical cancer at all is not commonplace. In other developed countries, there are self-pap tests that some women use because they find the traditional gynecological exam to be inappropriate in the absence of symptoms. In addition, the developers of the CSA blood test cite "cultural taboos" as being a primary motivation for them inventing a non-invasive alternative to check for cervical cancer. So I think my school is very ethnocentric to believe all incoming students automatically agree not only with these exams, but also with practicing them on asymptomatic actors. It is undeniable some students discover personal clashes that might derive from cultural upbringings while learning about the most taboo aspects of physical exam for both sexes, and I find it unethical that schools would not inform students about these potential problems before they move to new cities and matriculate.

At the same time, the author conveys similar beliefs as the instructors I met at [My Medical School], hastily diagnosing students as having "anxieties" and "fears" that they can "cure" us of via "education". I think the quote the author provided from a fellow pelvic exam instructor ("Students are afraid it's sexual") is nauseatingly narrow-minded. How does this woman believe she can tell all adults that an exam, mechanically the same as digital sex, is not sexual? Why does she think she can speak her mind for all adults about human sexuality in medicine by resorting to empty buzzwords like "professional" and "clinical" to do so? In fact, she cannot define what is and is not sexual (or sexually violating) for any other adult.

This reminds me of one instructor who concluded I had an "irrational phobia". Do you think it was fair for this instructor to tell me I had a "phobia" of being forced to have digital sex with an actor without my consent? Because you could easily make the reverse argument: Students who do not want to do these exams when introduced to them (as this apparently happens each year), but still complete them have "phobias" about disobeying orders from faculty, or have "phobias" about standing up for themselves, or have "phobias" about what instructors will think of them if they admit they see a medical exam as being sexual. The same with patients too: I have seen peer-reviewed papers written by gynecologists investigating why some women have "fears" about getting exams. But the counterargument here is that women who dread the thought of being humiliated and penetrated by strangers, but force themselves to suck it up, have hypochondriac "fears" about developing a rare cancer and benefiting from a notoriously inaccurate exam. Depending on their lifestyles, some women are more likely to be harmed than benefited from the outdated pap smear, and the World Health Organization does not recommend ovarian cancer screening via bimanual exams. For these reasons, I believe smart and responsible women can decide to never submit to these exams while asymptomatic, without being diagnosed by pushy and one-sided doctors as having "curable fears".

It is too easy for instructors to label and ostracize students as having "fears". These instructors told a rape-survivor she was being irrational to "fear" the prostate exam. What is particularly evil is they knew this teenage girl or young woman likely did not know about taboo old men healthcare to decide for herself before starting school whether or not she found completing a prostate exam to be acceptable. In any case, her "fear" turned out to be a rational one because the experience did cause pain, as she expected, seeing that she left the room crying. These instructors pride themselves on walking over students and their problems, and believe that with their supremely rational minds, they can triumph over anything, when in fact they have not proven any strength unless they have all been raped themselves. So who are they to judge a rape-survivor student with long-term effects of depression? And then to boast that they gave this student such a valuable educational experience, just because they cannot relate to her suffering from traumatic life events? I thought that was just plain childish.

I do not think my instructors are very intelligent. There is more to intelligence than exercising the rational mind. The author refers to these exams as being a "first sexual experience" for many students. If it is indeed true (that medical exams can be sexual experiences), then forcing teenagers and young adults to perform them without consent using shame and blackmail, when it causes problems for a few of them each year, is institutionally-sanctioned serial sexual abuse and rape. At least that is how my intellect - both rational and emotional - sees it.

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After I spoke with all physical exam instructors, they sent me to the "Associate Dean for Curriculum", who is also an OBGYN. I met with him twice, and our second conversation bothered me.

He told me he was "ignorant" medical students had problems. But really, he was anything but "ignorant" since he works with the same instructors who watch students cry and faint.

I asked him if I could bring in "evidence" that students have problems. So the second time we met, I brought detailed information about [My Medical School] students having problems, as well as news articles about students across the nation being "known to faint, cry, vomit, become hysterical and sweat" over these exams (http://www.nytimes.com/1998/06/02/science/teaching-doctors-sensitivity-on-the-most-sensitive-of-exams.html?pagewanted=all).

I also brought one article about teenagers and women getting unwanted pregnancies because they could not obtain birth control from gynecologists when they refused pelvic exams. I brought this last article because I empathized and related to the female patients, as I would also refuse the exam if I were in their positions. The article was pointing out that because the medical community does not respect and accommodate these women and their opposition to pelvic exams, it leads to bigger problems like unwanted pregnancies. And I felt that was a similar message to what I was trying to voice to my school: I think a small number of medical students can find out they disagree with exams, and they should no longer be marginalized and ignored for it because that only leads to bigger problems.

When I handed him the paper, his demeanor changed from the previous meeting, and he suddenly raised his voice at me (even though I never raised my voice at him). He actually balled up his fist like he was holding pills and growled at me "If I have something a patient needs, I withhold it until they get the exam!" He was steaming with anger, even though I never thought to question his practice at all. I had read about why it was unethical to require pelvic exams for birth control (http://www.law.harvard.edu/students/orgs/jlg/vol27/dixon.php), but I assumed the doctors who abused their power in this manner were working in private clinics out in the boonies. It never even crossed my mind that an OBYGN Dean of a medical school would fit that profile.

Shocked and creeped out, because I saw his true color, I asked "Shouldn't doctors at least tell patients they could go elsewhere and get birth control without a pelvic exam?" I thought it would be lacking informed consent not to do so. He just sneered at my comment. It was very clear to me this person went into gynecology for all the wrong reasons one might expect. It infuriated me he could not even pretend to empathize with the girls and women in the article who found pelvic exams to be intolerable, just as he could not empathize with his own students who have felt the same way for years. Any gynecologist, especially one who is training the next generation of gynecologists, should understand and respect how various patients feel about their reproductive rights and healthcare. Hurdles should never be imposed for women seeking contraception. In my opinion, this has nothing to do with health care, and everything to do with power, control, and making money.

His thinking and practice is outrageously sexist: When he was a teenager who needed a condom, he did not need to confront an old woman in a white coat who withheld what he needed until he had digital sex with her first. He presents himself as someone who cares so much for women, but then dupes them into accepting pelvic exams for birth control, even though the World Health Organization and numerous medical associations have consistently stated that the only recommendation is a blood pressure check, since hormonal contraceptives are as hazardous as Aspirin. Medically speaking, there is no greater logic to requiring pelvic exams for women who want birth control than there would be for requiring prostate exams for men who want Viagra.

You can only imagine some terrible scenarios he has exploited: An adolescent patient from a poor family shows up for birth control but does not want a pelvic exam, and does not know beforehand that she will be pressured to accept one. Once in the office, she might view doctors as authoritative figures whom she cannot question. She might be time-pressured for immediate access to birth control. She might be too scared to challenge a doctor. She might find it more embarrassing to try to resist the exam. She might be fooled that the pill will harm her body if she does not accept the exam. She might be intimidated by the medical setting, and maybe cannot speak fluent English. At that point, she can either run away from the exam room (and get undesirably pregnant), or reluctantly submit to the exam (and suffer rape-like symptoms). And I am not just speculating here, I have read about female patients who realize they were mistreated after being coerced into something they adamantly did not want but ultimately accepted because of false guidelines presented to them. I have also read about women feeling "raped" from this practice, and driving for miles to find a doctor who actually follows the law.

I wonder why no students speak up when they see him mistreat patients? Maybe their voices have no impact. Maybe they worry they are out of line to defend patients. It agitates me because I know his misogynistic attitudes have an exponentially poisonous impact, seeing that his peers actually respect his philosophies enough to bestow him the responsibility of training future gynecologists at the largest public medical school in the country.

When I was about to leave the room, I recalled a discussion I had with a kind-hearted classmate who recently drove me home. I told him I had problems with these exams, and he urged me to speak with faculty and resolve the issue. Then he told me although he did not have problems performing the exams, he did have problems the way some instructors handled them: He said he shadowed the head ECM instructor, and watched him reprimand each female patient who asked for a female to do her pelvic exam. Evidently, the instructor believes such requests are backwards and bigoted.

So when the "Associate Dean for Curriculum" asked me if I had anything else to add, I said I was concerned about the head ECM instructor teaching students to reprimand patients when they prefer one sex over another for intimate care. The Dean scolded me, and said he applauded the instructor. He believed it was sexist for me to assist these patients and their wishes. He asked me "Would you ask a black person to leave the room? Would you ask a Jewish person to leave the room? Would you ask a short person to leave the room? Probably. Because you would ask a man to leave the room!"

I thought his analogy here was meager and self-serving. Funny how he was offended by modesty in medicine to vilify it as condoning sexism, when he is the one who abuses his position of power to do such despicably sexist things as withholding birth control from girls and women who refuse pelvic exams.

Patients requesting same-or-opposite-sex care for intimate exams was legalized under the Bona Fide Occupational Qualification (BFOQ) by humanitarians who advocated for patient rights to preserve cultural and personal beliefs about sexuality and bodily modesty. There are scenarios where patients know they will experience the exam as being less sexual because of their sexual history and preferences. For instance, a heterosexual man who has only had sex with women might prefer a male to do his exams because he might experience that as being less sexual. But another heterosexual man who has only had sex with women might prefer a female to do his exams because he might experience that as being more natural. And yet another might have no preference. So really, all individuals have unique sexualities both in and out of medicine. For these reasons, I believe my instructors are the ones who pass judgements on their patients and their sexual values and identities.

Some patients might find it more logical to speak with a provider who has experienced physical problems, like a female patient talking about cramps. And some patients might prefer same or opposite intimate care to protect the intimacy between their partners and spouses. How can a health provider admonish a patient and his or her relationship values?

In all honesty, I do not believe that a woman asking for another woman to do her pelvic exam is sexist. Many women perceive the act of getting naked and spreading into the lithotomy position as being sexually vulnerable and submissive. Even if a woman consciously believes that male and female doctors are equivalent caregivers, her natural instincts might strongly prefer a female examiner because she could not get impregnated by a strange female, as opposed to a strange male, between her naked legs strapped in stirrups. The consistent prevalence then of females requesting female intimate caregivers must have instinctive and deeply emotional roots, and must be accommodated by doctors without judgement or ridicule. Because when these women are demonized for making reasonable requests, doctors are punishing them for protecting themselves at a primitive and instinctual level. Hence, these doctors are docking points off patients for being human, known as dehumanization.

I have to say I find it troubling that these male providers harasses female patients for requesting same-sex care. The power differential is too unfair. Most (American) female patients are very young when they have their first pelvic exams and are too often pressured by biased propaganda and brainwashed mothers to get them without the opportunity to judge for themselves whether it is really necessary or whether they are candidates for less invasive alternatives routinely offered in other developed countries. The pelvic exam is also longer in duration and so much more visually exposing than the prostate exam. Women also face additional hurdles since our society is still a very patriarchal one, where women are sexually abused by men at much higher rates than any other combination of sexes. Even if a woman has not been directly sexually abused, she has certainly been emotionally abused from a very young age, knowing female friends who have been sexually abused (often by men), reading newspaper articles about women being raped (often by men), reading history books about villages of women being raped (often by men), receiving catcalls and verbal sexual abuses (often by men), and knowing about pornography and prostitution and late night clubs where women are sexually belittled (often by men). She has been surrounded with evidence her whole life that some men might view sexual parts of female bodies differently. Unfortunately, OBGYN is not much different than these phenomena anyway, as it is a field that has abused the sexual organs of women for decades and was created primarily by male minds. And so when a female patient requests same-sex care, it may be because she has read books such as "Women and Doctors" by John M. Smith, MD, which revealed frightening statistics such as how much more likely it is for male gynecologists to recommended unnecessary hysterectomies, and how much more prevalent it is for male gynecologists to be reported as sexually abusive.

So how can this Dean, who holds birth control hostage from girls and women until they submit to stirrups, relate to patients who ask for modesty accommodations anyway? Any physician or nurse, male or female, should be open-minded and accommodating with all patients and their valid and legal requests for same or opposite intimate health care, as well as their legal right to refuse degrading exams for contraception. Unfortunately, instead of accepting his patients as human beings with modesty concerns, he exploits their situations to elevate his own status as the heroic physician who is educating students to end what he conveniently believes to be sexual discrimination in medicine.

Even if these instructors are so black-and-white in their thinking to believe they are being discriminated against, they still hold responsibility to follow the law and teach students to do so as well. If they dislike the law, they can always orchestrate their own rallies to advocate for fewer patient rights. But I wonder how honest and humanistic they would feel about their pursuits. All they would be doing is transferring the alleged target of discrimination to the group of people who are in the much more vulnerable position, the patients.

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The OBGYN "Associate Dean for Curriculum" said he did not support my conflicts with the curriculum, and sent me to the "Senior Associate Dean for Educational Affairs". This Dean gave me an unhelpful psychotherapeutic session the moment I walked into his room. Before I could explain in my own words what I came to speak about, he asked me "Do you remember anything happening to you that would make you see an ear exam differently than a pelvic exam?"

I thought it was unprofessional for him to ask me personal details about my life, but I told him I have never been sexually abused. I told him some students might find the exam itself to be violating if they are not told about it beforehand. He shook his head like I was a child trying to convince him Santa Claus was real, and told me the only explanation for a person to feel angry over medical exams was if he or she had been abused. Even when I reiterated this was not my case, he told me to seek help from a psychiatrist and "connect the dots" to my abusive upbringing. He went so far to ask if I had siblings, and suggested they also seek help.

I did not think this Dean seemed like an intelligent person to preach about sexual abuse inside or outside of medicine, seeing that he gave no exemption to the student who did admit to an abusive past, and maybe even believed the prostate exam granted her the ability to stop overreacting to whatever caused her to cry.

When searching for criticism of modern gynecology, I came across a popular book "(Male)Practice" by Dr. Robert Mendehlson, who was a pediatrician at [My Medical School]. The author stated:

"I will never forget a student of mine who wanted to specialize in obstetrics but couldn't swallow all of the ridiculous obstetrical intervention that he was being taught. He began to ask questions of the obstetricians: Why were the mothers' feet up in stirrups? Why were they giving the women analgesia and anesthesia? Why were they inducing labor at such an early stage? Why were they performing Caesarean sections when there was no clear indication of need? Did he get answers? No, but he got action. He was referred by the chairman of the department for a psychiatric examination, because any student who asks a hostile question in medical school is presumed to be 'disturbed.'"

This book was written in 1982, and still thirty years later at the same school, when students disagree with sensitive medical procedures, the Deans immediately send them in for psychological evaluation. I whole-heartedly concur with the author: Instructors at [My Medical School] stubbornly maintain there is something wrong with individual students each year, and never with the system itself.

Even worse, this Dean promotes a philosophy to his students that as long as nudity, touching, and penetration occur in the medical setting, then no sane person could possibly feel violated. This is far from the truth, and patients are beginning to speak up about their rights to refuse, request accommodations, and seek alternatives for "intimate" procedures.

For instance, I read the term "birth rape" has been coined. While I understand the term may be legally problematic, I find it conceivable that some women can only describe it this way after what was done to their bodies without permission. And I do not think these women are upset having life-saving C-sections, instead of natural dreamy births. They are upset having unnecessary and aggressive interventions without consent. Can it really be true that so many women must have their labor induced (a known risk factor for pelvic floor damage, perineal tears, epidurals, and C-sections)? Do so many women need episiotomies, when there is no evidence that artificial tears are safer than natural tears, which are rare anyway? Large studies of home births with trained birth attendants show that the majority of women can give birth without interventions, with less injury to mothers and babies, and no increased risk of mortality to either.

There is an unfair rule from doctors that all women automatically accept fingers and instruments in their vaginas if they wish to deliver a baby, even when births are proceeding smoothly. Doctors have an obsession with "checking progress" and recording numbers, with no respect for women who feel the procedures are barbaric. Some insurance providers cash in $250 per bimanual exam, which generates big bucks when doctors perform multiple "cervical checks". There are less demeaning maneuvers that cause less vaginal infections, but these alternatives are never offered. Instead, women who decline pelvic exams and episiotomies receive them against their wills! The baby needs an emotionally healthy mother, and that does not happen when she leaves the experience with so much trauma to call it "birth rape".

As for cancer screening, women are kept in the dark about less intrusive methods to test for cervical cancer (CSA blood tests, urine tests, vaginal swabs, and self-pap tests). Unlike this Dean, I strongly believe patients could feel mistreated by undergoing traditional pap smears should they discover that alternatives, which could have preserved their dignities, were not fairly discussed with them, or should they discover they were not even candidates for cervical testing in the first place.

A report released by Dr. Angela Raffles (cervical cancer screening expert from the UK) demystifies pap smear risks - 1000 women need to be annually tested for 35 years to save one woman from cervical cancer. Meanwhile, 95% of them (950) will require one or more biopsies that can be harmful (emotional stress, sexual problems, cervical stenosis, pregnancy complications, and even infertility). Another article by pathologist Dr. Richard DeMay "Should we abandon pap smear testing?" exposes the fact that cervical cancer mortality was trending downward before the application of pap smear testing, and that when malpractice suits led to higher false-positive rates (and hence more biopsies) cervical cancer mortality actually increased. Hence, the widely proclaimed association between the introduction of the pap smear and decline of cervical cancer might be more casual than causal.

Most doctors do not tell women that "the best kept secret of cervical cancer prevention" is through practicing safe sex and avoiding smoking, not through pap smears. Some women have microscopically slim chances of benefiting from the pap smear, such as virgins, women who only have sex with women, and long-term monogamous women. The same is true with ovarian cancer screening via pelvic exams: The American Cancer Society recommends against it. Why should doctors keep sticking their fingers in places they do not belong when there are no proven benefits?

It is clear to me that dishonesty surrounds much of these "preventative" gynecological exams. Doctors established these tests (money or fear of being sued), and the individual was disregarded. It became: Every Woman must have these exams with No Alternatives.

I can say with confidence that medical students are trained to think this way. In fact, in our first year of medical school, all students practiced interviewing patients with a standardized list of important questions. We asked ALL women: "When was your last pap smear?". But we asked NO men: "When was your last prostate exam?" It would almost make more sense to assume all older men are candidates for prostate exams, than to assume all women are candidates for pap smears since cervical cancer is an STD and so some women are not eligible. Also, the incidence and death rates of prostate cancer are much higher than those of cervical cancer, so it must not be about the numbers. In addition, cervical screening can be a more vulnerable process than prostate screening, because men often have the option of the PSA test (while the CSA test is never offered to women). So really, our first lesson was that female patients do not mind being humiliated in the medical setting, and that we should assume all women accept traditional gynecological exams, even the ones who could only be harmed by them in the first place!

The tunneled vision that this Dean holds (that doctors and nurses are above human modesty) will lead to suboptimal care for many patients outside of gynecology as well. I respect Dr. Joel Sherman and Dr. Maurice Bernstein, and the medical modesty issues for which they are raising awareness for male patients as well. In many ways, it can be a world more difficult for male patients to request and receive modesty accommodations because it is an overlooked topic without enough attention to draw any intelligent conclusions. In addition, people often view modesty as an unmanly characteristic, which might contribute to the ignorance about men having modesty, as well as the silence that fuels this ignorance because when they know to expect ridicule, men do not want to voice their modesty concerns. And I feel very sorry when I read comments from boys and men who have been traumatized by icy nurses and doctors who stereotype males as having no modesty. Unfortunately, I worry this stereotype will die hard, unless male modesty rightfully becomes a component of medical training and education.

I believe most of this ignorance stems from the way doctors are trained. When medical students learn to take sexual histories, we are trained to ask: "Do you have sex with men, women, or both?" (As a side note, I always thought the question should also include "or none" to represent all patients). Before the gay rights movement, this question was systematically swept under the rug to favor the heterosexual population, and hence made gay and bisexual patients less comfortable to openly discuss their sexual histories. Doctors now know not to assume all patients only have straight sex, and this is something that was strongly enforced at my school. I cannot imagine any of my classmates forgetting this simple question, because we are trained and repetitively graded to ask it verbatim from the very beginning. I think many medical students would feel confident to question one of their superiors if they did notice he or she was discriminating against sexual minorities this way, since it is a highly-valued aspect of our training.

On the other hand, when medical students conduct intimate physical exams, we are not trained to ask: "Do you prefer intimate care from a male or female provider, or do you have no preference?" Currently, this question is sidetracked to favor time-pressed doctors and patients who have no preferences, despite it being a legal request unknown to some patients. Obviously this setup makes patients feel ashamed if they do hold strong preferences and values whether a man or woman does their intimate exams. Perhaps then there needs to be a patient modesty movement that might be as successful as the gay patient rights movement by training and grading students to exercise the sexual rights of their patients in this manner as well.

Unfortunately, medical students know they will be shunned if they advocate for patients this way, since sex preference for intimate exams is not an official part of the curriculum. Not only that, but as I mentioned earlier, the instructors at my school reprimand students who bring the topic up for discussion. Therefore, I think dishonesty and silence are fostered in medical school, because I suspect some medical students make their own requests when they are in the vulnerable position as patients. And so they must empathize with patients, but at the same time they must sell their integrity by not questioning their superiors and fitting into what is expected of them, which is to work toward becoming competent physicians who possess minds too perfectly rational to see anything sexual about the exams, and hence too rational to understand why patients might seek modesty accommodations. In other words, doctors pretend not to "see an ear exam differently than a pelvic exam" since they fear admitting so would be a transgression of their medical conduct, and unfortunately this means distancing themselves from patients who do have modesty concerns about exams due to their sexual nature.

I think many medical students sacrifice their integrity subtly at first, and then succumb to the Domino Effect. At first, maybe a student knows he cannot desexualize the pelvic exam, but fearing how his instructors will react, he says nothing, and performs it poorly at the expense of the patient. Next, he might watch an instructor reprimand a female patient when she admits she is not comfortable surrounded by male medical students for her pelvic exam, and he does not stand up for her even though he believes she should not be reprimanded for her request. Now that he has grown more desensitized and dependent on fitting into what instructors expect of him, he might watch an instructor misinform a patient (out of conflict of interest) that pelvic exams are always necessary to obtain birth control, and even though the patient seems weary about the procedure, he does not question the ethics of his instructor. After all, he cannot express his concerns without implying that the instructor is sexually abusing his patient, which would certainly label him as a whistle-blower.

After that, an instructor tells the student that if he admits he is a medical student, then no patients will not allow him to practice sensitive exams on them, and so he follows the advice to flat-out lie to patients about already being a doctor. Ultimately, he agrees to practice pelvic exams on anesthetized patients who have not consented to it, because his instructor tells him these women would have adamantly refused students using their bodies for didactic purposes, and so it is a great opportunity for them to practice their exam skills on unconscious bodies that cannot protect themselves. The student believes the most important skill with a pelvic exam is to obtain informed consent. He sees this "educational" setup as being no different than gang rape. But he has already jeopardized his ethics so many times in the past in relation to sensitive exams. So he does what apparently many medical students do in this country, and gang rapes his own patients: (http://www.theunnecesarean.com/blog/2010/8/30/medical-student-wont-perform-pelvic-exams-on-anesthetized-pa.html).

Gang raping anesthetized patients is apparently a "time-honored tradition" in medical schools, an ethical problem that has garnered media attention for decades, but has never provoked enough frenzy to encourage change. I never witnessed this practice as a first-year student, but I bet my life it is something I would have encountered had I graduated from [My Medical School]. I strongly suspect this because when I was sent to the OBGYN "Associate Dean for Curriculum", he cautioned that I would face additional dilemmas if I refused to perform pelvic and rectal exams during clinical rotations, and said "You might also have a hard time with... Never mind, we do consent all our patients here." It was patronizing he thought I was gullible enough to believe in his statement when he had to "correct" himself. In any case, I already knew this person was not sincere because he had already lied to me earlier in the conversation. (One of the news articles I brought was about Muslim male medical students refusing certain exams on female patients. When I handed it to him, he casually commented "Oh yes, I have read about this before," when the very reason I brought him articles was because he had told me in our first meeting he was "ignorant" students had problems with aspects of physical exam).

The way he corrected himself mid-sentence told me that in fact [My Medical School] has not enforced any policy to end the gang rape of patients, which according to the press, still routinely occurs in most medical schools. This is a topic that was never officially discussed at my school, and I only learned about it through my own research. Hence, students at my school are not prepared to challenge medical gang rape because they will be branded as trouble-makers for suggesting their instructors are gang rapists. This is why I believe most medical students trade in their ethical tenets to complete school, because otherwise repulsively unethical practices like gang raping patients would have died long ago had students followed their hearts, refused to participate, and reported their instructors for legal action.

Two other quotes from Dr. Robert Mendehlson, the pediatrician at [My Medical School]:

"The tragedy of this dogmatic approach to medical education is not only that it screens out the most thoughtful, intelligent, and ethical students, or that is perpetrates traditional idiocies, but also that it virtually forestalls the application of creative noninterventionist approaches to medical practice. Dr. Roger J. Williams put it well in his book, Nutrition Against Disease: Medical schools in this country are standardized (if not homogenized). A strong orthodoxy has developed that has without a doubt put a damper on the generation of challenging ideas. Since we all have one kind of medicine now - established medicine - all medical schools teach essentially the same things. The curricula are so full of supposedly necessary things that there is too little time or inclination to explore new approaches. It then becomes easy to drift into the convention that what is accepted is really and unalterably true. When science become orthodoxy, it ceases to be science. It ceases to search for the truth. It also becomes liable to error."

"My colleagues who head the nation's medical schools boast that this process of "survival of the fittest" assures Americans of the finest medical care in the world. My observation is that doctors are taught to provide a lot of medical and surgical intervention, but I don't see evidence of very much 'care.' The fittest do survive, but what are they fit for? They are the survivors of a heartless system that too often weeds out the best and the bravest - the students with compassion, integrity, intelligence, creativity, and the courage to resist the destruction of their own moral and ethical codes."

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When they withdrew my scholarship, faculty told me they "firmly believed" future doctors must competently perform these exams. But this obviously is not the case at all, otherwise they would not graduate students who did not complete the exams objectively. All the students who cry and faint and make horrified faces certainly are not demonstrating objective behavior. Moreover, the school does not even give all students the opportunity to prove they have desexualized any type of medical exam, since they enforce their "rule" that one female must be present during the male rectal exam. When problems like this are marginalized, it inevitably translates to a small number of students advancing to clinical rotations ready to hurt patients expecting adequate exams, since these students feel too much pressure to act competent as future doctors, they cannot admit the exam is something they never desexualized (and they cannot admit they might faint or cry on a real patient, like they did on the actors). Students like this avoid pelvic exams as much as possible, and write "pelvic deferred" in patient charts, because they cannot be honest enough about their shortcomings to ask another provider who feels more comfortable to perform the exams instead (Article: "Managing Emotions in Medical School").

So by trivializing something important, like the inevitable cultural and personal attitudes and barriers about human sexuality in medicine, my school is hurting patients by exposing them to students who are too busy hiding their inadequacies. I thought I was more professional than these students to admit I had visceral problems over these exams, than to not admit so and make an already unpleasant exam even more unpleasant for patients. It is blatant that the only thing faculty "firmly believed" was that students never stand up for themselves if they cannot find peace with a small component of the curriculum.

Before I left, I recommended to several faculty members to start screening students. It is unprofessional and unethical to not explain these taboo exams to students before matriculation. When I suggested this to the OBGYN "Associate Dean for Curriculum", he nonchalantly replied that they "might consider it." He said this in a very condescending and indifferent tone of voice, even though as a physician, he should respect and practice full informed consent. The only person who ever got back to me was one of the ECM instructors who sent me an e-mail saying she would voice my concerns for future students but she "can't promise that there will be a change."

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I am not angry I did not graduate from medical school: I do not want to work in such a hostile and uninspiring environment. But I am angry I moved to a new city to start school without knowing that the same problems that mistreated students in the past would mistreat me because my school will not clean up their system. I am angry I had to arrange so many embarrassing conversations with faculty, only to be told I was "too immature", "too sheltered", "too squeamish", and sexually abused as a child. I am angry my school ostracizes a minority of students each year over something personal like their sexualities, and believes they should all have to change their views to assimilate to those of the majority. That is something that has always bothered me.

I hope Dr. Sherman and Dr. Bernstein continue to raise awareness for patients to know and exercise their options and legal rights regarding sensitive medical exams. And as a woman, I hope American girls and women start to explore alternative practices and philosophies about their bodies and reproductive healthcare outside of the rigid setup traditional modern gynecology has to offer. I could never accept non-emergency care from OBGYNs now that I know how they are trained. If I ever wish to have a baby, I will not think twice about home-birthing with midwives because I do not want to be a woman who receives demeaning and dangerous interventions when unnecessary and often harmful to both her and her baby. And I am ecstatic to see that American women are becoming more informed about their birthing options, thanks to documentaries like "The Business of Being Born" by Ricki Lake.

Much of what I wrote here ties into various medical modesty and ethical concerns discussed on Dr. Bernstein's Blog. That is why I agreed to publicize all of it here on his Blog. I also do not mind publicizing this story further anywhere else if it might prompt a change in some of the problems I detailed.

I wanted to end by saying that I believe there should be a requirement at the national level that students are explicitly told about these exams when they apply to medical schools, which should not be laborious to implement because students all use the same application website. I contacted several individuals last fall, told them my story, provided them with news articles about students fainting and crying, and none of them took me seriously. Some of the people I contacted included the "Senior Director of Student Affairs and Student Programs at AAMC" and the "LCME Assistant Secretary". These people told me they thought most students knew about these exams beforehand. First, I have never believed that "most" is ever enough; it does not validate the fact that the system currently tramples over a minority of young students. Second, I do not know where they got their flimsy statistic that "most" know about these exams anyway, since most students have never visited the proctologist, and at least half have never visited the gynecologist. These people also told me different students face different "challenges", and so they cannot cater to one "challenge" over another. I do not believe these intimate exams are "challenges". I believe any exam that could be construed as sexual (and sexually violating) must be fully explained and consented. Otherwise, it could be serial sexual abuse and rape.

I also want to report the OBGYN "Associate Dean for Curriculum" for not following the law that women can get birth control without pelvic exams, as well as report both him and the head ECM instructor for not properly educating students about the BFOQ patient modesty law. These individuals are teaching and encouraging hundreds of future physicians each year how to be insensitive about sensitive exams, and I want to do something about that. The problem is I do not know how to report these authoritative figures, unless there are freelance lawyers any readers out there might know about who advocate for patient rights.

I look forward to reading any comments and suggestions from readers.

NOTICE: AS OF TODAY JULY 23, 2011 "PATIENT MODESTY: VOLUME 42" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 43

Should Early Prediction of a Personal and Family Quality of Life Disaster Lead One to Consider Suicide?

2011-06-28T15:38:00.000-07:00

If scientific research can lead to tests which can predict that years ahead an individual will develop symptoms of quality of life destructive disease and one that is currently unpreventable and untreatable, should that individual plan now how to cope with the prediction? For example, should the individual seriously consider ending his or her life prematurely through suicide at some point rather than awaiting suffering and loss of any acceptable quality of one’s life?

One example is predictive testing for Alzheimer’s disease. Parens and Johnson writing in TIME set a social duty now to consider the pros and cons of suicide or assisted suicide decisions made by individuals prior to becoming severely symptomatic with diseases such as Alzheimer’s. They write:

“It is time to listen to and take seriously those people who, upon seeing their own parents spend years, even decades, suffering with Alzheimer's, say that they refuse to expose their partner or children to the same. We cannot ignore competent people who say they would rather die than no longer recognize their children or the partner with whom they built a life. Nor should we dismiss those who say that they can't themselves afford to pay for years of nursing home care, don't want their children saddled with that expense, or would rather that the money be used for their grandchildren's education.

When it becomes possible to detect Alzheimer's disease before it has progressed, these arguments will no longer be academic. The question for our society, including our legal system, medical practitioners, religious institutions and patient support groups, is whether we will dismiss those who make these arguments as depressed and misguided or whether we will engage with them on their terms.”

Well, what do you think? Can you begin a societal discussion about the rational planning of suicide in the face of early prediction of a disease such as Alzheimer’s? ..Maurice.

Health Advocacy Groups Deserve Scrutiny or Do They?

2011-06-23T08:19:00.000-07:00

Health advocacy groups such as those who champion goals to cure or better the life of patients with HIV, breast cancer, mental illness, autism, muscular dystrophy, epilepsy and more should not be taken by their face value but scrutinized. Sheila M. Rothman PhD writing in “Commentary” in the Journal of the American Medical Association (June 22/29 2011) issue concludes "However valuable independent advocacy organizations are for a democratic society and however important their services provided to targeted populations, their advocacy positions and the related underlying assumptions must be scrutinized with the same diligence as those of other stakeholders. There should be no automatic assumption that all health advocacy organizations deserve special standing or represent the common good."

The professor expresses as an example concern about some health advocacy groups which “are so committed to securing diagnostic and treatment interventions for their targeted populations that they minimize the value of evidence-based medicine (EBM) and comparative effectiveness research. They also ignore the potential effects of their advocacy on healthcare costs.”

(EBM represent professional evaluations of the results of controlled and statistically valid experiments regarding the causes and treatments for various diseases. These evaluations can then be used to guide the public and physicians regarding approaches to diagnosis and therapy.)

Do you think that what I wrote here as examples of Dr. Rothman’s view of these groups hold merit? Do you support one or more of the health advocacy groups? Are you a patient with one of the diseases? If so, do you want diagnosis and treatment set by the group’s conclusions rather than that of published results of scientific experiments? ..Maurice.

Doctor-Patient Relationship:"Be a Fountain and Not a Drain"

2011-06-16T09:21:00.000-07:00

“Be a fountain not a drain”, an expression used by baseball announcer Rex Hudler is one that has motivational content particularly in terms of an individual included as part of a team. I would suggest that this expression would be appropriate when considering a basic team in medical practice: the doctor-patient relationship. As I have noted repeatedly throughout a number of threads in the past on my blog, it is critical in most clinical situations that both the doctor and the patient assume responsibility for making progress toward the goal of diagnosis and therapy and hopefully a cure. The doctor-patient relationship is not one of the patients simply “taking” or “draining” the knowledge and skills of the physician or one of the doctor simply “spouting” those capacities to the patient. Each member of this team has a responsibility to contribute and not just “take”. That means that the patient must realize that the doctor can usually fail to make a diagnosis without a full history provided by the patient. It also means that to examine the patient, a certain degree of patient cooperation is required for the exam to be of value. And when it comes to treatment, patient compliance is also essential. On the other hand, the physician should understand that looking at the patient simply as an “object” of a disease and a resource to demonstrate one’s skills for an income is not what the doctor-patient relationship is all about. It is not about “taking” but is about considering the patient as a “subject” of physical and mental concerns giving the patient not only a chance to be physically healthy but also a feeling of comfort in the relationship and support of the patient’s emotional health.

Now, one may argue that the doctor-patient relationship is not really a equally balanced one in that it is the patient who is sick and may be ignorant of the facts of the illness and treatment whereas the doctor is not. Therefore, it should be only the doctor who should be required to be the “fountain” and, well, the patient receiving and taking the results, the “drain”.

Which view do you hold? ..Maurice.

Patient Modesty: Volume 41

2011-06-03T19:50:00.000-07:00

I think I have tried to bring up this aspect of patient modesty in the distant past volumes. It has to do with the psychodynamics which lead to genital/female breast modesty in examination or procedures carried out by healthcare providers of the opposite gender. This modesty is particularly of importance if the modesty leads to failure to diagnose and failure to treat. Why is it that some patients have this modesty issue and some don't? Is there any relationship to childhood experiences which left some psychic trauma? Could it be somehow related to lack of self-confidence or even an expression of depression. Cultural and religious pressures may also play a role in some patients. Or should we say that patient modesty has no particular cause but is a stand-alone phenomenon of human behavior and should be treated as such and there should be no reason to dissect it for cause or causes? Just asking... ..Maurice.

NOTICE: AS OF TODAY JUNE 29, 2011 "PATIENT MODESTY: VOLUME 41" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 42.

Morally Acceptable or Not?: The Gallup's 2011 Poll Provides Popular Conclusions

2011-05-31T16:21:00.001-07:00

Discussing ethical issues has been the purpose and the value of a blog such as mine here but the views expressed here provides no statistical strength to validate popular conclusions. That is why, to me, the current 2011 Values and Beliefs Gallup Poll is so important besides being interesting in looking at the results. From the Gallup website: "PRINCETON, NJ -- Doctor-assisted suicide emerges as the most controversial cultural issue in Gallup's 2011 Values and Beliefs poll, with Americans divided 45% vs. 48% over whether it is morally acceptable or morally wrong. Having a baby out of wedlock and abortion also closely divide Americans. However, stronger public consensus exists on 14 other issues tested."

Go to the above link and think over the all the results and come back and write about what interesting statistics you learned or surprised you about what folks in America think is morally acceptable and what is not. ..Maurice.

No Right to Say "NO"as a Patient Research Subject?

2011-05-18T19:06:00.000-07:00

Autonomy is an ethical principle applied to patients to the effect that the patient can make their own medical decisions of the options available with regard to their medical care and management. The patient has an autonomous right to say "No!".This principle has been followed both by ethical consensus and law for many years in how patients should be and are treated in the healthcare system.

The April 2011 issue of American Journal of Bioethics has an article by Sarah J.L. Edwards (page 3) provides a complexity to the application of that autonomy in the case where a patient volunteers to become a research subject in a medical investigation. The suggestion is that medical research subjects should be denied full autonomy during participation particularly in removing themselves prematurely from further participation in the study or reject or fail to follow instructions about the protocol, fail taking the study drugs or failing to permit some non-invasive or harmless procedures. The argument presented is that this behavior may harm the study, “harm science” and potentially harm future patients. The idea is to have the study participants sign a contract which they must follow or otherwise be subjected to penalties. What this means is that the subjects who are patients have just lost part of their autonomy at the outset to prevent “harm”. Yet as volunteers for research a reasonable assumption to make is that the nature of the studies usually provide no practical self-benefit (including monetary) to the patient except for the subject being and feeling altruistic. The reason for the true absence of benefit is that good studies are usually performed in a blind and randomized way so that no subject knows what treatment they are receiving. Also, the study is devised because science has not yet established whether one treatment is more effective than the other. One could argue that participation in the study makes the individual no longer a patient but simply an experimental subject and no longer fully autonomous.

So, my question here is: do you think there is "harm" and should all subjects sign away their full autonomy as a patient with a contract not to leave the experiment and to follow fully its details otherwise subject to penalty of one sort or another? ..Maurice.

One Man’s Art is Another Man’s Graffiti: What is Ethical vs What is Immoral?

2011-05-03T15:54:00.001-07:00

Unfortunately, what is deemed ethical or not ethical is something like what is considered art or simply graffiti. It all depends. It all depends from which perspective you are looking at the issue. It all depends on how you define or characterize the elements of art or the ethical issue that you are considering. It all depends on the nuances that can be introduced into the decision and which may be important in the final decision. It all depends on whether you are looking at the paint through the eyes of an art aficionado or looking at the ethical question through the eyes of a religious follower. Graffiti can be defended as “street art” and what appears as immoral or unethical can be defended as “controversially ethical”.

For those of us who would like to obtain a simple answer to what is art or what is ethical, well.. we can’t. Since, in the final analysis.. “it all depends…”

Or.. are there some of my visitors who find my conclusion an unnecessary misrepresentation and find that both art and ethics have clear guidelines with regard to establishing their presence and worth? If so, tell me about your ideas. ..Maurice.

Graphic: Recent photographs, I took, of a sequence of paintings on a local flood control channel wall, 2011.

The Physician Selling, The Patient Buying: Should Patients be Considered Consumers in a Medical Care Market?

2011-04-24T22:24:00.000-07:00

It all boils down to autonomy, the principle of ethics that permits the patient the right to make their own medical decisions. But these days, patient autonomy seems to be extended beyond decisions of whether to accept, reject, not start or terminate treatments. Patient autonomy seems to have been extended into areas of clinical decision-making which have always been the responsibility of the trained and treating physician. It has become a patient’s activity to make requests for tests and treatments, essentially selected by the patient from a pool of possibilities not presented by the patient’s physician but by advertisements and the internet and the next-door neighbor. It thus appears that patients are behaving like consumers, entering a market environment with their cash provided by their insurance or government and expecting their physician to provide them with the components of healthcare the patient desires just as the patient will select the items off the shelf or table in that market. And so the physician as expected will follow through on those requests whether it is a procedure, a test or a treatment, irrespective of the physician’s medical opinion. And so the clinically unnecessary and unneeded procedure or drug is provided by the doctor and the cost of medical care continues to rise.

The question is whether this is the way the patient-doctor relationship was supposed to end up, the doctor selling and the patient buying? Wasn’t there supposed to be something different in that relationship? Wasn’t there supposed to be a relationship based on professionalism, mutual trust and both parties, together setting a goal beneficial for the patient but still meeting rational criteria set by the profession of medicine? What do you think?

For more on this topic, read the Op-Ed presentation by Paul Krugman in the April 21, 2011 issue of the New York Times. ..Maurice.

Patient Modesty: Volume 40

2011-04-24T10:28:00.000-07:00

So now we move on to Volume 40. I started the thread on patient modesty concerns back in August of 2005--approaching 6 years ago. Much has been written to this thread in the intervening years but I think it is interesting to go back and read the initial Volume of the thread named "Naked"and then compare with the more recent Volumes. I think what you will find is that there has been a shift in conversation about solution to the patient modesty concerns from one of frustration and futility to currently more about some success by patients "speaking up" to their healthcare providers to express their need and even to have their requests satisfied. I look forward toward more optimism than despair or is this just wishful thinking? ..Maurice.

NOTICE: AS OF TODAY JUNE 3, 2011 "PATIENT MODESTY: VOLUME 40" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 41.

Parental Refusal of Vaccination: What Should the Pediatrician Do?

2011-04-22T12:44:00.000-07:00

There may be many reasons for parents to refuse a physician's advice to have their child vaccinated for significant diseases which can be acquired in childhood or later. But what is the pediatrician or family physician to do next after the refusal. Certainly the doctor should, after explaining the benefit of vaccination to the child but also the benefit to the community and any realistic risks involved, ask questions to the family about what they understood as the value and risks and then why they are continuing to refuse vaccination. But what if the refusal is not based on some personal financial or some medical or scientifically proven contra-indication but on a religious or some personal idiosyncrasy? Should the physician then discharge the patient from further care and tell the parents to find another physician? Should the physician report the parents to the appropriate governmental child protective agency or the health department? Or is it professional and ethical for the physician simply to accept the refusal as a parental right and continue caring for the child?

If you were the pediatrician.. what would you do? ..Maurice.

Should Physicians be Paid Based on Professional Quality and Cost-Effectiveness Rather than Simply Completing a Job?

2011-04-14T21:54:00.000-07:00

Physicians are now paid just for completing some job. The job may be reading an X-ray or treating an infection. The payment is essentially the same whether the job was performed with excellence and contributed to a successful outcome or whether the job was simply performed one way or another. This approach as practiced in the United States may lead to sub-optimal results but at higher costs of medical care. In the era of health maintenance organizations, payment made to participating doctors is based on doing a job which provides the greatest service with the higher rewards and least expense to the industry. In these days with the need to reduce the costs of medical care, thought has been given to having a payment incentive to doctors for not just completing some job but ending up with high professional quality and an ending that is cost-effective. My question is whether physicians should be paid for such performance. That means, if the performance results in a lesser quality, the physician should not be paid or paid less.

Read the article “The Risks of Rewards in Health Care: How Pay-for-performanceCould Threaten, or Bolster, Medical Professionalism” by Matthew K. Wynia, MD, MP in the Journal of General Internal Medicine Volume 24 Number 7 2009 and available at this link:http://www.springerlink.com/content/xq2151wv04r4xx37/fulltext.pdf

Return and write your opinion here on my question. ..Maurice.

Stopping Life Supporting Treatment without Patient/Surrogate Consent

2011-02-26T13:08:00.000-08:00

Under what conditions, if any, should a physician deny further attempt to keep a patient alive but continuing comfort care in defiance of the known request of the patient or the family to continue life supportive treatments?

Modern medical science has provided physicians the ability and tools to continue life despite inability to cure the patient of the illness yet maintaining the patient’s life even if the life is one of being permanently unaware or, to an average patient, a life of no further personal value.

It is not unusual these days that physicians are challenged by the patient or the patient’s families to continue the life supportive treatments until death regardless of the negative consequences to the patient and others.

Should physicians be permitted to reject such requests? Currently, physicians can reject requests for treatment which has not been found to have any scientific basis for its use and which its use is not in keeping with professional standards. Such a treatment is characterized as “physiologically futile”. But what if the treatment has a scientific basis for use and if used can keep the patient alive but the treatment doesn’t cure? This form of treatment cannot be considered futile (of no value) if on continuing such a treatment the patient accepts the consequences of maintaining their life with this treatment but without cure. Nevertheless, does the patient's or family's desires trump any advice of the physician to terminate life support? Any answers? ..Maurice.

Patient Modesty: Volume 39

2011-02-18T15:48:00.000-08:00

Is there anything more to discuss regarding patient modesty issues that hasn't been discussed in all the previous literally thousands of previous comments on this thread? I suspect there still is..so here is another chance to start the discussion going on another aspect of the issue. ..Maurice.

NOTICE: AS OF TODAY APRIL 24, 2011 "PATIENT MODESTY: VOLUME 39" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 40.

Should a Non-Identifiable Picture of a Patient's Body or Tissue be Posted on Social Media without Patient Permission?

2011-02-14T19:30:00.000-08:00

[Note: This thread here is a copy of the Question I posted today on Medpedia and to which I encourage my visitors to go there and read the responses of the Medpedia subscribers to my question.]

Randy Cohen, columnist and ethicist, received the following request and then wrote about his response in his New York Times column "The Ethicist" Here was the request: "Some of my Facebook friends are medical students who post cellphone pictures of patients with what these friends believe to be comical maladies, with captions like 'A 5-foot-9 Hispanic male walks into a bar . . ' under a picture of a patient with a piece of rebar piercing his abdomen. The postings don’t include faces or names but still seem questionable. Doesn’t this violate patient privacy? NAME WITHHELD, NEW YORK"

Would a rebar piercing an abdomen be an identifying feature or would adding " a 5 foot 9 Hispanic male" make the picture identifying?

How about a nursing student posting to Facebook a picture of the students holding up a placenta but with no patient identification?

What if a photograph was published in a medical book without patient identification? If such book publishing of a picture of that placenta is legal, wouldn't holding up a placenta by a group of nursing students also be legal to publish on Facebook?

What are "identifying features" and if there are no identify features, would the INTENT of an unidentified body or body part on a social media be the guiding factor with regard to whether such public distribution is ethical or not? Would the intent to be funny or any other reason except for strictly educational intent be considered an ethical (and ?legal) violation of patient privacy? ..Maurice.

The Rare Cure and Doctors’ Goal: Recognizing the Goals of Their Patients

2011-02-07T22:01:00.000-08:00

When a physician proposes a treatment for any illness, there become two goals which must be reached and resolved, one of the patient and one of the doctor. The goal the patient usually would be a cure, relief of pain and suffering and a return to an active and normal life. If cure is unlikely some patients’ goal would be to continue the attempt while others would accept the prognosis and seek other reasonable goals. Treating an illness, the goal of the doctor would be to control the pain and suffering and to perform what could be professionally accepted as clinically reasonable management to reach for a hopeful cure. If the cure is found to be rare, then some doctors might find the goal should be to follow what they think the average patient would want, a cure, and continue with energetic treatment toward that goal but failing to ask for their patient’s own goals. Other physicians faced with the possibility of only a rare cure would communicate with the patient and learn about the patient’s goal and then provide education of the patient about the reality of the situation and go from there stressing realistic management.

An example of the behavior of two doctors facing the incurable disease of the same patient can be found in the blog description by the patient “Can Good Care Produce Bad Health” by Amy Berman. Read the story and return and tell me what you think. If you had a disease with only a rare cure, what would you want? ..Maurice.

Should a Dead Pregnant Woman’s Body be Preserved until Term Delivery of the Baby?

2011-02-05T13:55:00.000-08:00

So consider this realistic scenario: a 23 year old woman is 3 months pregnant and suffers a massive brain hemorrhage which cannot be stabilized and the woman is pronounced dead on the basis of neurologic criteria (“brain dead”). On her driver’s license she permits, upon her death, for her organs to be removed for the use of transplant to a needy patient. She has never written an advance directive nor had prepared a legal Will. She has a husband, a mother and father and several siblings. There is chance, by prolonged intensive medical care, supporting her breathing, heart action and blood pressure and many chemical and endocrine changes that occur with death that her body can be preserved long enough for the fetus to be developed sufficiently so that it can be safely delivered into the world. And, at that time, organs can be removed for transplant. (Want to read how this has been done? Go to this link.) But who should give permission or deny permission to attempt to continue the pregnancy? If no prolonged support to the mother’s body is given and the fetus perishes, would this be considered an abortion? What if State law doesn’t allow for the fetus to die along with the mother and the State at this point assumes responsibility to direct the physicians to maintain the pregnancy? Who should pay the perhaps millions of dollars cost to continue the pregnancy? It would seem that the medical insurance company would not pay for preserving the body of a woman who was already pronounced dead. There are many other aspects to these real but rare scenarios, but first I would be interested to know what you think might be the right decision to be made. ..Maurice.

Do You Care About the Affordable Care Act?: Is it Ethical?

2011-01-25T11:43:00.000-08:00

There has been and currently (January 25 2011) is much controversy over President Obama's administration Affordable Care Act (so called "Obamacare") which was passed by Congress and signed by the President into law last year. At present there is much talk about getting rid of this Act and indeed the House of Representatives passed legislation recently to do so. There is much controversy about the politics of the act but I fear not much discussion about the ethics related to it. Isn't the purpose of the law is to provide the best healthcare available to all the people in the United States (beneficence) and to be fair (justice) in the distribution and management of the

rules governing the practice of the law to all the stakeholders? It is.. but some still wonder "is it?"

What I would like my visitors to write on this thread is their understanding of the Affordable Care Act in terms of whether they feel it is in everyones best interest or whether important parts are missing or parts of the law are unfair. What is your understanding? What are your suggestions? Do you care about the Affordable Care Act? ..Maurice.

Patient Modesty: Volume 38

2011-01-08T08:29:00.000-08:00

As of the beginning of this Volume 38 dealing with patient modesty issues, it is the beginning of a new year, 2011, and it is time for everyone to consider their own the New Year Resolution. Such a resolution should be that the individual resolves to a change in behavior or action which was not previously attempted or completed but is possible of being followed during the remainder of the year and beyond. So, now, what should the resolution be about as written to this thread?

Well, we are all patients or potential patients and we all, at some time will or have in the past, been involved in the doctor-patient relationship. So let's think of a New Year Resolution, pertinent to this thread of patient modesty that the visitor as a patient will resolve now to follow to develop or improve such a relationship. Of course, the relationship is not one sided and the doctor also has responsibility to make the relationship the best, towards primarily the interest of the patient.

But without the product of your resolve, the relationship may never be fully satisfactory. What do you think? ..and what do you resolve? ..Maurice.

ADDENDUM 1/31/2011: WE ARE PUBLISHED ON AMA NEWS!

I want to announce that Doug Capra and myself have had our article
published today in the AMA News (weekly newspaper of the American
Medical Association) website. The article is titled “What can physicians and patients do to improve the medical encounter?”
It deals with both the doctor and patient making a New Year’s Resolution, the patient to “speak up” to the doctor and for the doctor “to listen and pay attention to the patient.” There is a scenario where the doctor and patient engage in a colloquy with the main concern of the patient..guess what? Patient modesty!

Go to the website and read the article and then return and post your comments here or on Doug’s and Dr. Sherman’s website and maybe you could write a comment directly to the editors of AMA News. ..Maurice.

NOTICE: AS OF TODAY FEBRUARY 18, 2011 "PATIENT MODESTY: VOLUME 38" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 39.

The Treatment of Animals for Science vs Food: Is One more Ethical than the Other?

2011-01-03T16:10:00.000-08:00

Joel Marks writes in the Hastings Center “Bioethics Forum:

“If it’s okay to confine animals for their whole lives in cages or other artificial environments, perform sometimes painful and/or disfiguring procedures on them, and finally kill them at an early age, as is done routinely in biomedical research, then why wouldn’t it be okay to do the same for nutritional purposes?”

Are not animals selected for human consumption treated with unnatural confinement, subjected to unnatural procedures and then killed for a premature death?

Those who are against animals used for experiments for the understanding and treatment of human as well as animal illnesses with the associated pain and suffering, shouldn’t they be also vegetarians who reject subjecting animals as a food source for humans? Unlike most scientific experiments whose goal is for the medical benefit of humans, there is evidence that suggests that eating meat provides no nutritional benefit that could not be attained with the consumption of vegetables and fruits and indeed eating meat can be harmful to some.

Read the Bioethics Forum article and return here with your comment regarding the ethics of using animals for human and animal scientific research versus killing animals for our food. ..Maurice.

Graphic: Meat. Photograph copied under fair use from http://backpackingrecipes.net .

Medical Students' Experience: A Few Hours in the Coroner's Office

2010-12-25T19:49:00.000-08:00

Dr. Elizabeth Douglas orbited the cool, stiff body on its steel gurney, and examined the 42-year-old man's fleshy canvas of faded tattoos like an art aficionado in a gallery.
She committed each to her notes in painstaking detail and debated whether to use the word "cowboy" or "bandit" to characterize the dull, smudgy image of a horseman midgallop.
But that would be the last time the doctor would let herself consider who the man on the gurney once was -- at least for the next two hours, while Douglas ferreted out a cause of death among his organs and entrails.

To read more about what goes on in a coroner's office and how pathologists are trained, read the original article in Cleveland.com. Though I am not a pathologist, as a internist who teaches 2nd year medical students, I find that the special experience of a few hours watching the work of pathologists and their helpers in the coroner's office is a popular and thought-provoking experience for the students. The session provides an additional dimension to their experience with the deceased which was started in the opening days of medical school in gross anatomy. Though the coroner's office provides some refreshing of their knowledge of human anatomy, more importantly it emphasizes the complexities of human behavior and the diseases which lead to and terminate in death. Leaving the coroner's office, having been fascinated and perhaps a bit emotionally shaken by what was seen, by this experience, I think, the students will have significantly matured to the understanding of both what will be their upcoming clinical medicine challenges in diagnosis and treatment but also remind them, in case they forgot, about the, at times, unexpected or unwanted conclusion of all lives. ..Maurice.

Graphic: Coroner. Reproduced here as fair use. Graphic was copied from In the Opinion website.

Would you dare to refuse to have the batteries replaced?

2010-12-04T21:48:00.000-08:00

Here is a question that I posed on Medpedia, medical information and discussion site. I thought I would also challenge the visitors here. ..Maurice.

You are the son or daughter and legal surrogate of a very elderly mother, care for her at home, who has
severe Alzheimer's Disease and has a cardiac pacemaker whose batteries are now failing. Would you
dare to refuse to have the batteries replaced?

Would your decision be any different if she was being cared for in a nursing home institution? Would refusal to replace failing batteries be any different than making a request to the patient's doctor to have the pacemaker with functioning batteries to be turned off? In answering these questions let's assume your mother never had anticipated having the need for a cardiac pacemaker so had never discussed with you about replacing batteries or for what reasons to request that it be turned off.

Patient Modesty: Volume 37

2010-12-04T14:42:00.000-08:00

..and the story continues. For those who haven't been following this thread over the years, the story is one of patient bodily modesty and the need by some for gender selection of their healthcare providers. This need is apparently often not satisfied by physicians or other parts of the medical system, particularly in the case of male patients who desire a male provider. There are other aspects of the patient modesty issue that have been discussed including the inability of the patient to be assured that his or her modesty concerns will be attended to during operations or other procedures where modesty sensitive parts of the patient's body could be exposed to unknown persons of a gender unacceptable to the patient. If you haven't been here before and have an entirely different view, please be welcome to express that view here. As usual, keep the comments constructive and civil but write. ..Maurice.

NOTICE: AS OF TODAY JANUARY 8, 2011 "PATIENT MODESTY: VOLUME 37" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 38.

Patient Modesty: Volume 36

2010-11-01T14:47:00.000-07:00

And the patient modesty issue continues with concerns about which gender is more at risk for modesty abuse and which healthcare provider and provider gender is doing or not doing what.

One solution to the concerns continues now to appear and that is the importance of any patient with modesty concerns to SPEAK UP to the providers and to the system. I can't believe that any patient should find it necessary to avoid a necessary medical workup and treatment because of concerns that their modesty issues will not be attended by the provider. If it ever should come to that, and according to some writing here it has, there is something drastically wrong with the system or perhaps the initiative of the patient to make their wishes known. ..Maurice.

p.s.- I haven't put up a graphic to symbolize the current discussions here. If any of my visitors have found one which would be appropriate and publication allowed with recognition of primary source, I will put it up. I am running out of ideas for a graphic here despite my Google-ing as of Volume 36 !

NOTICE: AS OF TODAY DECEMBER 4, 2010 "PATIENT MODESTY: VOLUME 36" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 37.

Not Knowing What You Don’t Know: Is Ignorance Ever Bliss?

2010-09-27T14:21:00.000-07:00

As I see it, there are two aspects of “not knowing what you don’t know” as applied to health and medicine. One is related to the behavior of the physician and the other is related to the behavior of the patient.

A physician who does not know what information is missing from his or her medical knowledge or understanding may be diagnosing and treating patients with a mental blinder. Doctors simply cannot know about everything clinical and indeed there is some information that is simply unknown to all professionals but all physicians should be aware of these unknowns. A physician assuming that he or she is aware of some knowledge but doesn’t really know is in fact performing guessing and then to proceed without being aware of one’s ignorance of some element of diagnosis or treatment can cause damage to the patient through possible subsequent error. Also without knowing what the doctor doesn’t know, the doctor can be delaying a consultation on the case by a physician whose medical knowledge is more complete in the particular information.

How does “not knowing what you don’t know” apply to the behavior of a patient? It does apply but in a different meaning and context than that of the physician but can be just as potentially harmful to the patient.

A person who is without symptoms and is unaware that they have tuberculosis may be made aware of the disease by skin tests and chest x-rays. If that person would agree to take these tests as an appropriate screening the person would then know and could be promptly treated. But what if a patient doesn’t want to know what is yet unknown to the patient? If a patient has trouble swallowing but fears that cancer is the cause, the patient may elect to delay going to the physician for a diagnosis, fearing the worst. By “not knowing” what is yet an unknown there may be some temporary comfort to the patient by the ignorance than being aware of the diagnosis of cancer, if present, but that would be delaying final diagnosis and treatment of whatever was causing the symptom.

I have written above that either the doctor or the patient “not knowing” can be harmful. Are there any reasons in either application of “not knowing what you don’t know” to the physician or to the patient could be accepted as something appropriate and an ethical “good”? Is ignorance ever bliss? ..Maurice.

A Taste of Pain and Suffering and the Role of the Physician

2010-09-17T08:37:00.000-07:00

Should every human taste some individual pain and suffering so as to gain a better perspective of their own life? Can we agree that we will better understand our good life if we suffer a little?

The medical profession has always had its goal aimed toward the relief of pain and suffering. But is that really a professional action that is ethically untouchable? Could there be times when it would be to the patient’s benefit and good for the physician to allow some pain and allow some suffering? Should it be the physician's decision as to when to permit that pain and suffering? I await your response. ..Maurice.

p.s.- I posted the same issue on Medpedia. You might want to go there to read the responses there as they are made.

Who Should Assist in "Assisted Suicide": Doctor or Family?

2010-09-13T16:12:00.000-07:00

Think about a chronically ill patient who is suffering, debilitated and can't seem to get relief. Think about the patient with an end-stage cancer who is not obtaining relief of suffering from established medical treatments. Suppose these patients ask their doctor to "help" them die and end their suffering.

In the United States, only two states, Oregon and Washington, permit, under restrictions, physician assisted suicide. Physicians can prescribe a lethal dose of pills that the patient can take by themselves at their own time if they desire. Despite the two states laws allowing physician assisted suicide, there is, I think, ethical reasons why physicians should not be doing this.

But what are the ethics of assisting a patient in their act of suicide? Should society really allow this generally as it has in the two states, by physicians and with requirements? But why physicians? By assisting in suicide, wouldn't they be violating professional principles? Wouldn't they be degrading the professional trust that society has expected from doctors? Wouldn't this lead to physician encouragement for suicide rather than the patient electing end-of-life palliative care?

Why not allow family to assist their suffering family member in the patient's own wish for suicide? The family members who assist have no professional oaths to uphold. Is there concern that family members who have attended and cared for the patient and now tire will have their own personal interest to accelerate the patient's death?

Any suggestions for the answer the question: Who should assist in "assisted suicide": Doctor or Family? ..Maurice.

What Kind of Doctor would You Select to Be Your Doctor?: Engineer, Priest,Colleague or Contractor?

2010-08-29T17:03:00.000-07:00

I put this question up as a Question on Medpedia but would like to also present it to my visitors here. You might go to Medpedia and look at any responses but also access the link below and then return and write your comments here.

The ethicist, Dr. Robert Veatch in an article” titled “Models for Ethical Medicine in a Revolutionary Age" published in the Hastings Center Report 1972;2:5-7.has set these 4 possible models: engineer, priest, colleague or contractor for society's current and/or future view of the relationship between the doctor and the patient. A review of these four models is nicely written by E.C. Hui MD, PhD (Medical Ethics Unit, Faculty of Medicine,University of Hong Kong, Hong Kong) and can be accessed at the following link: http://www.hkmj.org/article_pdfs/hkm0506p222.pdf

What do you see as the ethically good and the bad with each of these models? If you had only one to select, which would it be? ..Maurice.

"I Hate Doctors": Chapter 3

2010-08-25T19:28:00.000-07:00

This Leonardo da Vinci masterpiece I think is fitting to the introduction of a bit of a twist I would like to introduce in the "I Hate Doctors" commentaries which has been going on in the previous two chapters. I would like to offer my visitors two possibilities which might lead to the "I hate doctors" expressions that have been repeatedly written on this thread.

One is: Doctors consider themselves Gods and behave in that way upsetting many patients.

The other is: Some patients consider the doctors as Gods and then are greatly disappointed when they turn out by their behavior or perhaps outcomes not to be Gods.

What do you think? ..Maurice.

Would You Accept a Gay or Lesbian Physician as Your Doctor?

2010-08-05T21:48:00.000-07:00

A question I would like to pose to my blog readers today is about whether patients should request information about their physician’s sexual orientation and decide on the answers as to whether to have this doctor for their own and their family’s care. Would it make any difference to you whether your doctor was gay or lesbian or bisexual, if that doctor appeared and acted in a knowledgeable and humanistic manner and was performing a competent job? Would you accept a gay or lesbian physician as your doctor? Or is a physician’s sexual preference none of the patient’s business? This is a question probably not many patients think of as they acquire or continue care by a physician. Nevertheless, as physician Henry Ng writing in the current August 2010 issue of the AMA’s “Virtual Mentor” the matter of sexual orientation may come up with an innocent question by the patient, “are you married?” To understand the significance of sexual preference disclosure by the physician and the dilemmas that the doctor faces when challenged with questions by the patient regarding the physician’s personal life, read the article by Dr. Ng, return and write your opinions here. ..Maurice.