Patient Modesty: Volume 59
Thread visitor APRC wrote the following "I think it is very hard for people who work in health care
to accept when a patient refuses care, no matter what the reason. After all,
you have devoted many years of study, hard work and personal sacrifice to this
endeavor, only to be met with obstinance and refusal. I am sure it must boggle
the mind of every health care worker out there and cast patients as little more
than petulant children.
However, it is the duty of the health care worker to try to see things from the patient's perspective, and not the other way around. YOU are the fiduciary and I am the entrustor. As such, you have the duty to act in my best interest and I have the right to expect you to do so. You have chosen the role of provider, but I have not chosen the role of patient. [perhaps aside from a handful of purely elective medical matters]".
However, it is the duty of the health care worker to try to see things from the patient's perspective, and not the other way around. YOU are the fiduciary and I am the entrustor. As such, you have the duty to act in my best interest and I have the right to expect you to do so. You have chosen the role of provider, but I have not chosen the role of patient. [perhaps aside from a handful of purely elective medical matters]".
One could argue, however, it is not that simple. Trust is
not just a one way street in the function of the doctor-patient relationship
despite the fact that the patient is the one who is sick. The physician is the one given the
responsibility to reverse that sickness. Trust in the physician by the patient
has to be set by the limitations of trust the physician can have in the
patient: presenting a complete history, cooperating in the completion of an
appropriate workup, demonstrating compliance with the medical advice and
treatment. And just as the doctor will
have issues of time, full attention and requirements and limits set by others and the
uncertainties of diseases which may affect the responsibility for trust. So too,
the patient may have personal financial, social or emotional reasons which
cause the patient to fail to meet the criteria that the physician looks for in
trusting the patient. Both the physician
and the patient have their own limitations which can negatively affect full trust in the
other.
All of this represents important considerations in how
smooth and comfortable the patient-doctor relationship and interaction with the
medical profession develop. And the limitations experienced on both sides influence how patient's requests for modesty and gender selection of providers is handled. ..Maurice.
Graphic: From Google Images and modified by me with Picasa3
Graphic: From Google Images and modified by me with Picasa3
NOTICE: AS OF TODAY NOVEMBER 27, 2013
"PATIENT MODESTY: VOLUME 59" WILL BE CLOSED FOR FURTHER
COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 60.
posted by Maurice Bernstein, M.D. @ 11:29:00 AM
158 comments
158 Comments:
So -- the key is trust. How is trust established in any relationship? Do I hear that expression "open and honest communication" echoing in the abyss? Just as the patient can harm trust by not disclosing important, relevant information -- so too can the doctor or other provider fail to inform the patient of important, relevant information. Ah...but the words "important" and "relevant" pop up. How does one know what's important or relevant within a relatiionship. By asking what the other considers important and relevant? Doesn't that make senseN
Although patients should "speak up" as we all agree, many will not. Let's not forget, the medical profession pretty much controls the context of the relationship. The doctor isn't coming to the patient's house. Clinics and hospitals can be alien environment to some patients, while those who work there everyy day probably coinsider it their space, even thier home away from home. That's why I contend this isn't a balanced relationship and it's up to the provider to create a context that will help the patient open up.
Is it out of line that somewhere along the way early on, the provider might say to the patient: "I've told you honestly what I consider important and relevant about your illness and the procedures we need to do, now you tell me what you consider important and relevant." Or how about this, before the conversation ends -- "Now, is there anything you're not telling me about how you feel about your illness and the procedures, something that you don't feel comfortable talking about?"
You write about trust, Maurice, and I still say that at the heart of the trust relationship between provider and patient, is open, honest communication on both sides -- with the provider taking lead if the patient will not.
Worth a listen: KCRW Michael Wilkes on getting pts permission for student docs involvement.
http://www.kcrw.com/etc/programs/so/so131027permission_for_sensi
-- amr
Amr, I went
there and listened and responded with the following:
I am not sure that an ill patient or one undergoing a procedure to diagnose or treat an illness should be offered the possibility of having "learners" examine or treat on the basis of some altruistic benefit to society for that practice. If any interview, examination or treatment by a medical "learner" is requested, it should be based on the fully informed consent (including detailing of the specific "learner", what the "learner" will be doing and who will be supervising. While altruistic behavior is to be commended, it is, in my opinion, not appropriate to use as a tool for acceptance of a "learner" for any activity including, of course, the "sensitive" exams described, by an ill patient who is more concerned about her own life than that of some benefit for society.
I teach first and second year medical students and they are told and supervised to inform the patient personally regarding their names, their role (medical student) and precisely what they intend to do and await full consent by the patient before proceeding. No tempting with exclamations of altruism. .. Maurice Bernstein, M.D.
I fail to see how health care can be called gender neutral when 95 percent of health care staff is female. If it were 95 percent male staff would women buy that it is gender neutral. I think you would have a hell of a lot of women avoiding procedures and exams if this were the case. Something would be done to change it in a hurry. When it comes to men nobody in the system seems to care.
Well, at least 95% don't care!
Ed
Maurice
Search Yahoo. With Nurses fired for taking cell phone
pics of patients.
Women accused of taking nude cell phone pics of
patients at
www.Knoxnews.com/news/2009/sep/23/women- accused -taking-nude-cell-phone-pictures
These two nurses had been taking cell phone pics
of their patients since 2007.
Maurice, instances of this are all over the web, yet
you discount these comments on all nurses as if
they are anonymous. People are actually being
arrested for this kind of behavior. We are at thread
number 59 and some 8800 comments. It seems
some for one reason or another simply refuse to
accept there is a Hugh problem of trust in health
care.
PT
PT:
The link about women accused of taking nude phone pictures of elderly patients in Tennessee that you provided did not work. However, I found it. The link is
http://www.knoxnews.com/news/2009/sep/23/women-accused-taking-nude-cell-phone-pictures-pati/. Notice that those ladies are 35 and 50 and not that young.
Jeff:
I am not sure where you live. But some hospitals give gender neutral nursing assignments. I was very shocked 4 years ago to discover that a male nurse gave my grandma a bath without her consent and her family consent. I had no idea that male nurses were allowed to give bath to patients. It was disturbing that the male patients on that floor were assigned female nurses instead of that male nurse.
I am very supportive of increasing male nurses for male patients, but I am very disappointed in how nursing departments just randomly assign female and male nurses to patients without thinking about their genders. I am also very disappointed in medical facilities for not hiring male nurses to work with male patients. I am very disturbed about how many urology clinics across the US have no or not enough male nurses and CNAs.
There are some medical facilities that hardly employ any male nurses. I encourage you to read Dr. Joel Sherman’s article about Patient gender preferences for medical care if you have not already.
Misty
I live in a large metropolitan area, and there is only one all female OB/GYN practice, and it isn't close by. I'd say on average OB/GYN practices have 60% female, 40% male doctors. So even though 90% of CURRENT students are female, pregnant women in my area can't be guaranteed to have a female deliver their child unless they go to that ONE practice.
I grew up in a small city with only one hospital. It was THE hospital. So it makes me mad to hear "you CHOSE to come to a teaching hospital so you have an OBLIGATION..."
I went to a teaching hospital because it was the closest hospital, my doctor told me to go there, and I had no idea I should make a choice on which hospital to go to. I only know it was a teaching hospital because my current doctor said "XYZ? Why I did my residency there!" I now realize it was medical student that pointed to my leg, while I was climbing into the hospital bed, who got all excited, "that's a sebaceous cyst! It's not malignant and you don't need to worry about it!" Thanks, I've had that since I was a child and it never occurred to me to worry about it before and now it bothers me. I thought he was a nurse; I had no clue there were students involved in my care. Actually, I have no idea who anyone was. I don't even think I met the doctor who signed my discharge papers.
Needless to say, now that I'm aware of such things I know never to go to a teaching hospital, and have educated my friends to avoid them as well.
-RJ
Jeff:
Can you provide some resources that support your claim that 95% of health care workers are female? Frankly, that seems like an awfully high percentage especially when you count doctors as part of that number. In my experience I can truthfully say that while females outnumber males in the nursing and perhaps in the medical tech fields male doctors outnumber female doctors so I find it hard to believe that 95% of health care providers are female. Actually, in the last few times I have gone with my husband for medical appointments and visited other individuals in the hospital I have seen a much larger number of both male nurses and male nurse practitioners, as well as many male x-ray techs, male radiology techs, etc. What about others here?
I am very supportive of the male cause for more availability of same gender care for sensitive exams, procedures, etc. but skewing the numbers and implying that women have it so much better, in my opinion, isn't going to make things better. I agree with Dr. B. that instead of airing grievances we should begin to look for solutions, whether those be on an individual basis or by somehow trying to change the systems to be more sensitive to this issue. Misty has begun that process and I think Don has, also, by encouraging and funding efforts to get more males into nursing. Personally, I have made the decision to approach it in an individual way, much like Belinda. I feel more confident in this and better "armed" if and when I need to enter the medical system again: more willing to talk openly, better communicate as Doug has always stressed. And I do thank Dr. B for keeping this thread going as I think it has helped not only me but others even if it is just in this way. Jean
Thanks Jean.
I went to the surgeon today. We discussed all the medical issues and my medical concerns.
She actually agreed with my concerns and the decision whether to go forward or not is to be determined after seeing other doctors in varying disciplines, some tests and then we will decide.
The good news is that she felt assured she could meet my psycho-social needs during surgery (including scrub bottoms) and we had a conversation expressing what's needed, what I need, what they need and there is common ground.
I came prepared with the proper letters and it went very well.
Looks like I'm winning this one too. I would like to say that it would be harder to accommodate a male in the same circumstance, and that this issue needs public awareness. I support that wholeheartedly.
belinda
Jean
That 95% is based on Dept. Of labor
statistics, which breaks the number of licensed
nurses down by gender. The number of female
cna's is actually higher and for medical
receptionists it's actually about 99%. The breakdown
for medical assistants is well over 90% female.
There are more female respiratory therapists
than male and more female radiologic techs than
males. More female ultrasound techs than males
and virtually all nursing directors are female, no
surprise there.
Because of the high number of female
nurses at close to 95%, it's relatively easy to have
entire nursing units female, be it telemetry, ER,
neuro icu, orthopedic floors, med-surg, MICU and
of course L&D, post-op gyn.
It's irrevelant how many male physicians
there are to female physicians although the gap
is closing. What is important is to consider the
support staff and you may choose a male physician
for your surgery, urologist, hospitalist, general
practitioner, podiatrist,orthopedist, neurologist,
whatever. It is the nursing and other support staff
that is predominantly female.
PT
APRC.
Please don't disappear from this site like others have done. I would hope you would use your skills to team up with Misty or someone else so no one else has to go through what you and so many others have. Maybe make up a form that could be down loaded to counter act the consent form. It could help other be prepared for what might happen. Take a negative experience and make something positive come from it. Thanks. AL
Help us with this teaching issue.
As an example, for examination of the chest and lungs, it is necessary to examine the front of the chest (anterior) without a cover, on bare skin. That means for a woman, her breasts which cover significant parts of the contents of the chest, must be exposed. And so, this may be another modesty issue if the breasts are exposed. Why should we teach that the drape be dropped on examination? First let me explain: Beyond modesty issue, a drape is present to prevent chilling which can interfere with a proper examination (and in this regard should also be used with men. Next to understand: there are 4 modes of examination: inspection (looking at the skin of the chest), palpation (touching the chest skin with the hands and chest wall lightly or firmly in specific areas to detect transmitted vibrations from speech (called fremitus), crunchy feeling from gas or air in the tissues (called crepitus) or chest tenderness), percussion (tapping with the doctor's fingers) on specific areas to find areas of dullness of sound)and auscultation (listening with a stethoscope to sounds in specific areas). If a drape is present, inspection is impossible. If a drape is present, palpation is limited only to tenderness, since the looked for sensations to touch arriving to the doctor's fingers and hand would be diminished by the intervening drape material. On auscultation, sound would also be diminished with a drape and further the drape movements with breathing would produce extra distracting sounds of the drape on the stethoscope.
Now that I gave you an explanation of the process of examination of the chest, how would you recommend us teachers instructing the medical students how to interact with the patient with regard to issues of modesty but yet effective examination of the chest contents?
Look: I am actually doing something that is consistent with my visitors' advice: all you potential patients having a say in the way medicine is practiced and the medical education process!
..Maurice.
Maurice,
A patient going for a mammography still has to remove the gown during the exam.
The gown is given to make the patient feel less exposed, just like the gynecological drape (that exposes nothing to the patient but everything to the provider).
A patient would feel more comfortable with a gown until the examination is needed.
Frankly, I've had lung issues for the past ten years and go to major teaching hospitals in a major city.
I have never been asked to sit uncovered at any time. Anything they need to see is on the CT scan.
The lungs are located within the rib cage. Please explain to me what the doctor would see of the lungs on an unclothed patient, male or female.
belinda
Belinda, a CT scan or even a simple chest x-ray is a radiologic procedure involving potentially harmful x-radiation and represents an expense especially the CT. Physical examination of the chest can give the doctor more readily available information about the condition of the lungs with no radiologic risk. With some symptoms, the exam can tell the doctor and patient whether the symptom is more benign or whether it may be more serious and require chest film or CT. In answer to your question, the doctor obviously doesn't see (visualize) the lungs themselves because they are hidden within the chest but their condition can be determined by inspection of the movement of the chest and ribs and muscles, by palpation, by percussion and auscultation. With these techniques the doctor can see the expansion of the lungs, movement of the diaphragm, whether there is pus or fluid within the lungs or in the space around the lungs and whether there is leakage of air from the lungs. But examination on bare skin makes the examination the best and more reliable than a chest which is covered. ..Maurice.
Thanks, Maurice. I suppose in my case, it was an x ray that triggered trouble and since that time, extensive testing is done.
One more question though Why couldn't a woman be in a bra instead of topless. Unless one is small busted, you would probably get a better view of the muscles around the chest if one had on a bra.
belinda
For me the mechanics of what must be done for the most part are up to the provider. My experience has more been how or by who. My vasectomy was my and my MD, my friend MD called his nurse in to provide a very minimal assistance. I had a scrotal ultra sound performed by a female tech when a male was available and never asked if I cared.To your example as in mine I think all you can do is explain the procedure, why it is needed, and then give them choice of gender if posible. That is all you can do. I never question what they needed to do, just how they went about it. The main issues we seem to have here is the liscence providers have given themselves with out modesty. I don;t know if the ultrasound was needed or done properly, I just know no one seemed to care that I might have a preference or be uncomfortable with a specific gender on such a intimate procedure. And I am sorry but have a difficult time believing the didn't know and if they had no clue it might matter, shame on them....don
I've never been aksed to take off my clothing to have my lungs checked - I'm assuming this is done when someone is specifically complaining about their lungs?
And if so... why can't the patient leave their bra on? I can understand needing to see the chest and rib cage but I can't understand why you'd need to see my breasts for a lung issue. I wouldn't allow it.
-RJ
Attempting to evaluate the chest thoroughly and the lungs themselves through a bra is almost worthless and doctors who are doing that and the patients are fooling themselves. Bras are usually thicker than a paper cape and are stiffer and often there is a space between the bra and the skin of the breast. So.. inspection of the skin: impossible. Palpation of the skin and chest wall itself: impossible. Percussion: The tap is poorly, if at all, transmitted through the bra to the chest and the returning sound wave and vibration would be severely dampened (reduce the intensity) by the space and bra. And finally auscultation: again the space and bra will markedly dampen the sounds from the lungs and bronchial tubes. Also the coarse surface of the bra rubbing upon the stethoscope head simply adds a conflicting and confusing sound. In conclusion, a physician examining through a bra is practically and simply an act to simulate to the patient of thoroughness of the examination but the results are unreliable.
So now you know the mechanism of examining the chest and lungs (and by the way the similar mechanism for examining the heart). Now tell me, what should I have my students say to the patient before attempting to examine the chest from the front in order to be able to obtain the best information about the conditions on the surface and within the chest? ..Maurice.
Jean:
You made some excellent points and I agree with them.
AL:
A lot of people disappear from this blog because they feel discouraged that there is no hope that things will ever change. But people should not give up fighting for protecting patients in medical settings. The past few days have been very difficult for me because someone informed me that would be very hard to get for Medical Patient Modesty because many people just do not think about medical modesty and that it is not an important issue. We can only do so much with our limited funding. I wish that people would not stop commenting on this blog. We do have many people who provide excellent insights, but then they leave.
Misty
Maurice, So, if one was examining someone who was well endowed, it would seem that the exam would have to be done lying down in order to examine the patient. Otherwise, gravity and massive breast tissue would completely inhibit the viewing of the chest as would be needed from the front.
Would it be possible to allow a sheet in that cast to be moved during exam?
Asking someone to sit undressed in front of multiple students would be stressful for most women.
I suppose, if permission was requested first and the patient agreed and knew how many students were in the room, and the degree of exposure that would be fine.
However, it's an experience that one might consent to, and afterward, be very sorry due to the aftermath emotional stress of feeling objectified and vulnerable.
To protect the patient, she should be asked for any history of sexual assault/abuse, as even though she may not have ptsd, or not realize she has ptsd, it could invoke
triggers that she's unaware of.
Additionally, if there is any history of a sexual assault, this is an exam that should be done with doctor and patient alone to avoid unnecessary eyes from the medical viewpoint of the patient.
belinda
When and why is this exam done? Because what I'm reading contradicts what you say. Am I reading up on the wrong exam?
For example there is a youtube video: Heart, Lung & Abdominal Exam (Female Patient) posted by BrownMedicine that seems to be very thorough, and while the patient is wearing a gown, she never needs to remove her bra (or even the gown). Are you talking about a different exam?
And how about these?
http://www.revise4finals.co.uk/medicine/learn/examineresp.php
"if you have a female patient, the textbooks classically require bras to be removed for 'full' exposure. It might therefore be worth mentioning to the examiner that 'for the sake of modesty', you will not ask the patient to remove her bra during the examination. This conveys that you appreciate both the need for adequate exposure, as well as the need to maintain a patient's dignity whenever possible."
http://usmle-step2cs.blogspot.com/2011/08/physical-examination-in-usmle-step-2-cs.html
"For auscultation do not ask the patient to remove the bra. You can have help him/her untie the gown (say I need to look at your back now. Let me help you untie your gown) and listen around the bra."
I've certainly noticed that the bras I wear now are smaller and yet offer more support then the bras I had when I was younger. I've seen bras from the 50's and I can see how those might make such an exam impossible, but most modern bras would not.
In the rare case a women is wearing a bra which is in the way during the exam, she should be told this and given a cloth gown to change into (while the examiner leaves the room of course). Then she should still not need to expose her breasts, and she can be examined just like the woman in the video I referenced, gown moved down (but breasts not exposed), gown moved up (but breasts not exposed).
-RJ
Maurice
I think you're missing the crux of the issue. As others have responded, the issue isn't what's being done or even how. The issue for some is what gender is doing it and who might be assisting or observing. That's what this is all about for most. Granted, there are a very few patients who won't expose themselves for anyone of either gender. But most patients expect the need for bodily exposure. The objection is to not having the expectation that they will have a choice as to the gender of the provider or the assistants. So -- back to your original description of the exam and my response to it. Do the exam as it needs to be done, but beforehand, ask the patient the gender they prefer to do the exam.
Doug, are you saying that the issue of modesty is not one of the degree or location of undress but simply the gender of the examiner or the gender of those in the room and whether that particular gender is acceptable by the patient? Does that mean if the patient accepts the student or physician or the others, there should be no issue of modesty in the subsequent examination regardless of the degree or location of undress?
Our students always first ask permission from the patient to perform the interview and examination and patients are systematically told what is about to be examined. A student or attending physicians know that they should get the patient's permission for others to be present during an examination.
RJ, thanks for the links. However, if physical examinations are still thought to be a worthy activity and some degree of modesty has to be sacrificed, it is my opinion that the examination should be allowed to be as productive and definitive as is technically possible. I don't look at a physical examination of a patient as some game but as serious a procedure as a surgical operation and everything should be done to assure that that it will be safe for the patient but must also be productive to compensate for any in this case "emotional" risks.
..Maurice.
I think there also needs to be a distinction as to why the exam is being done.
If you have a patient presenting with specific symptoms, then a focused exam related to discovering the cause of those symptoms may be warranted. It shouldn't be a justification for a witch hunt - don't use it as an excuse to go willy-nilly examining things that aren't specifically related to the complaint. The patient needs to be informed of what specific exams the provider recommends and why along with a detailed description of what is involved, and given the opportunity to ask questions. They should be told who will be present and why prior to consenting to the exam. If exposure of intimate areas is involved, they should be told ahead of time and asked if they have a preference of gender for the personnel involved.
Routine physical exams are of little or no value. This isn't my conclusion, but that of studies done by the Cochrane Institute, University of Minnesota School of Medicine and several other institutions.
As to the the effectiveness of an exam as related to exposure, IMHO some information is better than no information. Do the exam first with limited exposure, and if the initial information suggests a more detailed exam is needed, then explain that to the patient and why. It doesn't need to be an all or nothing situation.
In a teaching situation medical students need to be taught the full exam - I understand that. That said, any patients involved should be fully informed that where a student is involved, the primary benefit of the exam is for the student and not the patient. They absolutely need to be told this prior to consenting to any exam.
For far too many years the medical profession has operated with an attitude of entitlement and under a cloak of mystery, smoke and mirrors. Those days are over, paternalism is dead, and anything short of full disclosure is unacceptable.
I thought you all would be interested in reading this article: Doctor: Full-Body Exams Are Sometimes Necessary. A doctor has been accused of sexually assaulting some women during exams. It is interesting that the defense got a doctor to testify about how full body exams are necessary. Most full body exams are unnecessary.
Misty
#For far too many years the medical profession has operated with an attitude of entitlement and under a cloak of mystery, smoke and mirrors. Those days are over, paternalism is dead, and anything short of full disclosure is unacceptable."
Hexanchus, I could not agree more !
Dr. B, I am a female who once went to a walk-in clinic with a complaint of chest congestion & fever. The doctor was female also, and she actually listened to my lungs and heart over a heavy pull-over sweater I was wearing. Was SHE the one taking modesty to an extreme ? I never had a doctor do that before.
LJ
Maurice
What I'm saying is that the only way one can really know how patients might feel about an exam is to communicate openly and honestly with them. We don't really have the data. As I said, some patients don't want to be exposed to either gender -- they modesty might be absolute. Others may prefer one gender or the other regardless of what kind of exam it is or whether modesty is even an issue. Others, I think most, may not even focus on gender if they feel respected and safe. That depends upon how they are approached. If patients are not asked about their preferences and the exam procedes, the very least is that the provider should ezxplain what he or she will be doing along the way and ask, is that okay. I also agree with Hexanchus.
after numerous years and 1,000's posts this thread never ceases to amaze me with the twists and turns it takes. Not only is it benefical, not only has it helped me, it is really entertaining, i really enjoy the exchanges, thanks everyone especially Dr. Bernstein & Dr, Sherman. Now to the issue at hand, I cannot speak for Doug but for me the situation is fluid, if I have my shoulder inspected I do not care what gender and they are more than welcome to inspect my knee or elbow or most other parts, now if they ask me to drop my shorts...now we are in a different area. If I am willing to let you see it on the beach I will have no problem in your office. It is not as simple as gender, it is gender, situation, area, all sorts of variables. I think that is what most are saying. Providers play that game, well you were ok and did not protest me looking at your throat so you must be ok with me looking at your penis or vagina. On your example of the chest exam, I take a different view than some here. If you the provider says the bra must be removed to get the proper exam you should to a degree trust it is so. Now from there it is the patients choice as to whom they accept doing that. While they may not be comfortable one has to assume it makes sense...now the problem is the medical community does things that undermine the trust that what you are asking is absolutely required. I had to remove my shorts to get my throat scoped...really? That was an actural event. Now that you have done that to me, and I now have reason to not trust what you are asking is absoltuely needed, I look at everything you do under that lens....now this all comes back to your point...we need to communicate, but understand, my skepticism is partly your doing....don
LJ,
It is interesting that a female doctor listened to your heart and lungs through a heavy sweater. As a woman, I do not take my shirt off for a doctor to listen to my heart at all. I usually have a short sleeved and thin shirt or T-Shirt on.
Misty
It’s ridiculous about how many Christians preach about purity and modesty, but they think modesty does not matter in medical settings. Those Christians should stand up for modesty in medical settings. There is honestly no point in preaching to young people that they should save sex for marriage or to married couples that they should only have sex with each other and see nothing wrong with them exposing their private parts to medical professionals of the opposite sex. This is hypocritical. There is nothing special about saving sex for marriage or only having sex with your spouse if you are going to have intimate medical procedures by the opposite sex.
It’s a shame that many Christians and churches won’t stand up for modesty in medical settings. I am not sure how many people here are Christians. But every Christian should educate their church the truth about modesty in medical settings.
-Disturbed With Christians Who Don’t Care About Modesty in Medical Settings
I want to suggest another mechanism for the issues of patient modesty and gender selection which are raised on this thread. I think that for those who have such modesty issues, it is a basic and profound concern that the examination and procedure process is really an exercise of an expression of sexuality and sexual behavior or actually misbehavior on the part of the medical caregiver (doctor, nurse or the others). That all the medical perverts in the news represents a sign of a broader sexual perversion in the medical profession that can affect virtually any interaction with the medical system. "It's there and can happen to any patient".
But this concept is grossly wrong despite any reinforcement by the news items of isolated examples or what is written on allnurses website. I can tell you that the desire for sexual excitement by physician and nurses derived from their patients is a ridiculous generalization of the profession. We all have, in the interaction with the patient, much more to consider (diagnosing, treatment, cure, nursing care, providing a readable echo or CAT scan) than to become professionally distracted by sexual impulses or desires. I am not saying that those in the medical profession are sexuality neutered. We are not, no more or no less than our patients. But sexual thinking during an exam or procedure is not only failing to meet professional standards but if allowed can be fully distracting from the medical responsibilities given to us. And if we act on any sexual desire we are violating not only ethical professional principles but also the law.
But while sex is muted on both sides of the doctor-patient interaction, doctors (both men and women doctors) are confronted by sexual challengers (should we call them "patient perverts" or really something more tolerant of their own emotional distress) titled the "seductive patient". And it can be a problem patient which we warn our students as we inform them about the prohibitions of sexual behavior by the medical profession.
I would like you to go to my blog thread from August 2007 "The Sexually Seductive Patient: How Should Doctors React?" and read the currently 22 comments and perhaps writing your own contribution there.(..but keep it strictly related to the topic of the seductive patient and not the more general aspects of patient modesty as written to our present thread.) You can respond about that relationship here.
I think a basic solution to the issues of patient modesty which has been written and rewritten to this blog thread is first to attempt to eliminate false concepts: that any sexual interaction toward a patient will be opposite gender specific. Think of gay and lesbian sexuality in the general population. And the other is that expression of sexuality or sexual interest is really not what is going on in the minds of any of the professionals. There are much more important things to think about within the limited time we have with a patient. (Including operating room rime!) So there! ..Maurice.
Maurice
I don't think that's a mechanism for most people with modesty issues. I'm not saying it never is there, but it isn't a driving motive. It may be more of a factor for women rather than men. I think lack of control of such a basic concept as body exposure is more of a factor than the fear of being sexual feelings or behavior on the provider's part. I also think the power dymanic is an important factor, i,e. if the patient feels powerless or helpless. Basic embarrassment can turn into humiliation based upon how the patient might read the provider's tone and body language, and whether the unexpected happens, like other people showing up for the exam or procedure. It's a fluid process that is affected by many elements that make up the ultimate context.
Maurice,
I still can't comprehend what benefit a topless exam on a well endowed woman would tell a pulmonary specialist.
Once the bra is removed, all you would see is the breast that would cover the entire chest. There has to be a better way.
Yesterday I went for a neurological exam. The doctor was male and part of the exam was to remove everything (except underwear) and don a paper gown that reached down to the knees.
The part of the exam that involved walking, gait, etc. was done prior to telling me that he wanted me to undress.
Due to issues with hospital attire, I always bring street clothing that supplies access for the doctor as none of these exams are the first time for me.
This is what was involved. Reflexes, knees, feet, elbows, and lots of pushing with resistance.
Bottom line....I could have stayed in the clothing I wore to the exam and achieved the same exact result.
I also told him (as the back is open on the gown) that he may move any clothing that might impede an exam.
He asked me why I didn't want to wear the gown. I told him and I felt he was sincere in his comments to me, although, his attitude was like that of Dr. B, when they can't understand what would prohibit someone for tolerating anything.
Getting back to the lung exam, it is against our normal sense of modesty to sit unclothed in front of a group of people. It is even more troublesome when the patient can't understand the need....and even more disconcerting when the patient isn't told that there would be a room full of onlookers.
There's something perverse about this scenario to the patient, while (giving the benefit of the doubt), nothing perverse to the medical personnel.
A hospital gown that opens in the front would allow the exact same access to the breastbone and by going over or under a hospital gown, the same exam could be conducted. Additionally, if the back needed to be examined, it could be easily done by handing the patient another gown or towel to cover her chest during that part of the exam.
Maurice, please tell me what I'm missing?
belinda
Maurice,
While I recognize that in a normal situation, sexuality doesn't enter the equation.
What if a patient had a prior experience in a hospital with a sexual deviant that had nothing to do with the surgery and had no business being in the OR at that time? How does that bode for future confidence in a system that does nothing to weed out the bad apples?
Patients who have had terrible experiences are unwilling to put trust in the system. Why should they?
belinda
belinda
It is my opinion (only an opinion based on a long history of medical practice and not statistical facts) that the majority of patients unlike most of those writing to this thread have had no apparently traumatic experience with their healthcare providers in the past. And currently, when they are under care of healthcare providers in an office, clinic or hospital find no sexuality involved in their care and (as I have repeated here many times) are solely interested in their illness, to diagnose, treat and recover, all with as much comfort and safety as is realistically possible. It is their bodily health that I believe is on patients' mind and not dominating concerns about sexual behavior on the caregiver's part or even on their own part. But, as I said, this is only my opinion based on experience and if there are controlled sociological studies which prove otherwise, I would appreciate that they be identified.
Again, for those who find sexual behavior concerns or gender issues paramount in their consideration of how their illness is being handled by the professionals, you all have got to "speak up". Express your concerns and questions to the caregiver, it will be therapeutic for your emotions and may direct the caregiver to more attention to those concerns and also answer those questions. And, if not, and you are ignored, well, that would surely be a sign you are in the wrong place! ..Maurice.
IJ, examining the chest, lungs and heart all through a thick sweater in a patient who is symptomatic as you described is what I would call a "gesture" and not a physical examination in an attempt to obtain reliable physical findings. Ask that doctor if she could hear any rales within the lungs through the sweater which would be confirmatory for a pneumonia. If she said she heard some, ask her how she distinguishes them from the rubbing of the moving sweater on the head of the stethoscope. Ask her how she can validly percuss for dullness in a specific lobe of the lung when percussing a normal lobe through a sweater will produce the sound and touch feeling of dullness.
I am sure her examination of you was not what she was part of her medical training but was simply she had to move on to the next clinic patient. ..Maurice.
Maurice
It would be very difficult to follow your advice
by "speaking up" when you are under and/
or vented. Most inappropriate cell phone pics are
taken when the patient is unaware or unable to
voice their concern as was the case of many
abused nursing home patients.
PT
When individuals go to a hospital because they are sick their expectations far exceed much of the treatment received.
Surely their concerns are on their health. However, once there is a breach you are left with the ramifications of such a breach.
Patients (me included) do not expect sexual behavior, inappropriate behavior. When it happens though it is a traumatic experience because you think you are in a trusted environment.
If patients went to a hospital with the expectation of sexual or modesty violations, it would be right at the top of their healthcare, right next to their illness.
Want proof. I will find it for you but I will tell you that I have ready surveys that list dignity as patient's number 2 concern, right after pain management.
belinda
Of course you haven't gotten complaints. In all industries, customers do not complain to the business but rather stop going to the business and tell all their friends about it. It shouldn't be a surprise at all that patients rarely complain, they just stop going to their doctors. Cherish the patients who complain!
I had a friend who went to a gynecologist for the first time about two months ago, and she was asked to strip while the gynecologist (female) was present and then wasn't draped for modesty. She didn't think to question it because you are supposed to trust your doctor, but she was embarrassed because she doesn't even like her fiance watching her take her clothing off. We've told her never to go back there.
Another friend was fat-shamed by the doctor he went to this year and never went back to that doctor.
I hear stories like this all the time from friends, family members, and co-workers. So to say "If there are no complaints there isn't a problem" isn't rational.
-RJ
This is an article about a women admitting her fear of sexual assault during a medical procedure:
http://tigerbeatdown.com/2012/04/30/on-anesthesia-assault-and-fear/
You'll realize it's not sexual assault per say - but the lack of control over what happens when a patient that is under.
"I fear the thought that I might be assaulted, that my body might become an object of humour and mockery and amusement. I fear the potential that I may never know about it, and that if I do, I may be powerless to take action, because victims of medical assault are rarely believed when they attempt to file complaints."
-RJ
It seems all the research on mental trauma is being done by psychologists, so even though the fact that medical procedures cause mental trauma is widely recognized, studied, and published in peer reviewed journals, it's not getting across to medical personnel.
Is there any way to advocate to add a class on trauma and patients reaction to it to the medical school curriculum? I know if I have to have a procedure done, I'd want ONE advocate on my team - my doctor, a nurse the doctor is willing to listen to as an expert, etc, that understands trauma to advocate for me. I wish there was a "trauma certification" for surgeons, nurses, doctors - not psychiatrists. Not psychologists. For all MEDICAL PERSONNEL. I would prefer to be able to locate medical personnel who really understood trauma without me having to explain it to them - because in my experience most doctors don't listen when you try to explain and belittle your concerns as unimportant. They simply don't understand because they weren't trained about it.
I came across a really good article that had a list of "what made trauma worse" (of course I can't find it now). Most are out of a medical personnel's control. But the last two items on the list were things that CAN be controlled, and it's key for medical personnel to know about them.
-Not having control during the event
-Support structures after the event
During medical procedures, patients need control. Therefore, empower the patients:
-Knowledge about what the medical personnel is going to do is a form a control.
-Discussing patient preference is a form of control.
-Making accommodations for patients is a form of control.
-The right to refuse or delay treatment is a form of control.
Medical facilities should have support structures in place to help traumatized patients.
-Know how to screen for trauma
-Have staff on site who can evaluate and provide services
-Have special staff to respond to patient complaints by offering emotional support of the patient, and use patients complaints as opportunities to improve service.
Think about the lawsuits you've seen in the news about organs removed without consent because cancer was suspected. What if all surgeons talked about the possibility of finding cancer during all surgeries BEFORE the patient had surgery, and asked about patient preference so they had a chance to think about it and make their wishes known (to their surgeons AND their next of kin). It would reduce lawsuits while decreasing stress and increasing trust in the provider.
Anonymous from 11:32am today, there are many events in our lives where the individual does not have full control: the weather or natural disasters or in man-made activities such as being a passenger on a commercial airline. In medicine, even though neither the physician and the patient have full control of the illness what is needed is "patient cooperation" in many ways including during history taking, physical examination and procedures. Without acceptance and cooperation by the patient all these attempts to resolve the illness are stymied if not prevented.
Students are definitely taught to look to the patient for acceptance and for cooperation in all the parts of the patient's diagnosis and management. What is tough for the doctor is a patient who is unconscious and can't communicate their personal wishes for care or a patient who is unable to cooperate.
Communication by the patient as well as by the physician is essential. Neither party are "mind readers" and need the other party to "speak up" to make decisions. Yes, students are taught to inform the patient about themselves and what is the student's intentions in the interview and exam and to encourage questions by the patient and to await the patient's acceptance (consent). The students are instructed to be aware of general modesty issues. For example, with regard to taking a sexual history from the patient, students are instructed to indicate the personal nature of the questions and that what they are told will be held in medical confidentiality. The student are taught general patient modesty concerns and the importance of draping and sequential uncovering with the patient's assistance. What they are not told to do is to directly ask the patient whether the patient is concerned about specific modesty or sexual issues related to the physical examination itself. Would the patient on their own speak up about that subject? If they did, I am sure that the student would enter into that conversation with attention and reassurance. As physicians for the patient, we don't need to speak to unprofessional behavior like it was a possibility to consider in consent.
With regard to sexually "traumatized" patients and the response of the medical community, again the system not being "mind readers", the patients should "speak up". ..Maurice.
"If you didn't speak up, how could anyone know?" IF you had any training in trauma and how it works, you'd realize you are victim blaming when you say that.
Trauma isn't ONLY sexual. Here's an example list of "childhood trauma" - note it mentions medical procedures which are widely accepted to be traumatizing:
An unstable or unsafe environment
Separation from a parent
Serious illness
Intrusive medical procedures
Sexual, physical, or verbal abuse
Domestic violence
Neglect
Bullying
That's why I'm saying doctors should be taught to see the signs so that they know. PTSD is pretty common in our society and is caused by a wide variety of experiences.
"Fight or Flight" has been long recognized as a response to stress. "Playing dead" was only for animals. But we now know people respond to stress in three ways, "Fight, Flight, or Freeze." Rapists are really good at identifying people who will freeze - that's how they find their targets.
If you've got a patient that "freezes" you end up with a nice completely compliant patient that is being horribly traumatized, and is frozen and unable to respond. They don't know they'll react that way going in. They can only tell you afterward. (One example of research - there's a lot more):
http://bps-research-digest.blogspot.com/2011/10/when-humans-play-dead.html
I read an example where a woman was described as being completely unfazed by the birth of her child, a total champ - when in reality the woman was in so much distress she didn't remember giving birth.
-RJ
RJ, I just can't accept that performing a physical examination for a purpose and with the consent of the patient represents an act of "trauma" or even one of such magnitude which would cause persistent mental illness associated with PTSD. I tell my students to inform the patient what is to be done next in the physical exam and observe for any rejection of the proposal. Should I tell my students, beyond this, that some patients find the exam as severely emotionally traumatic which can lead to serious mental consequences and they should be on the alert to attend to the consequences of the students acts? I have a feeling that such a warning will temper the efficacy of their examination. The student will be hesitant, fail to uncover the patient when necessary for effective exam and rush through the physical afraid that prolongation or repetition will elicit more mental distress in any patient. And, of course, I should tell them that the patient may have "frozen up" and would be unable to communicate to the student the emotional stress that the patient is actively experiencing. Are you sure this teaching information for the medical student will not end up being more injurious to the majority of patients who want a proper examination from their physicians for their best health and recovery from illness and are not fixated on modesty or PTSD? ..Maurice.
Maurice -
There are two separate topics to address:
1. Medical Trauma in a patient who does not have a prior history of trauma. This is usually a serious event, but it's more important how the patient feels about the event that how serious the event was. It's important for medical personnel to recognize this and screen patients and their families for medically caused trauma, especially among children. There may also be a genetic component that makes one more venerable to developing PTSD.
2. Triggering a patient with previous trauma. A patient can be triggered by anything. A touch. A smell. Anything that reminds them of the trauma. Triggers aren't the FAULT of people who do them, rather they bring back the original trauma.
When a patient with PTSD is triggered, they can be helped. The patient needs to be "brought to the present". This can be simple things like saying the patient's name and reminding them of where they are. (If interested in how to do this more, look up "grounding techniques"). It's also pretty obvious when it happens if you've seen it before, and it's something patients can learn to do.
To learn the signs, learn how to handle it, etc, it's more than a 15 minute conversation. It's a commitment to learning a lot of material. We've barely broken scratched the surface of the knowledge on this subject. A superficial approach to the subject isn't really useful. That's why "tell the doctor" doesn't really work, they need to know what to do with the information you give them.
Then, you also have to add on the fact that disclosure can lead to the provider not taking the patient's symptoms seriously and deciding they are "all in the patients head". Damned if you do, damned if you don't.
This is why I'd love a certification program for providers who want to learn to deal with the medical concerns of patients who also have PTSD. There are a lot of correlations between PTSD and specific diseases as well, so knowledge of that is useful. For example, if your patient has PTSD they are at an increased risk for autoimmune disorders. PSTD also causes permanent changes in the shape of the patients brain. (Meta analysis of brain shape studies: http://www.sciencedirect.com/science/article/pii/S0149763406000285)
There is just SO MUCH research on PTSD that goes beyond mental health and into physical health that it's a shame not to be able to see someone who knows that information.
-RJ
RJ, I appreciate your interest in PTSD and spreading the word of its importance and need for provider education about the disorder. But do really think we need to teach first and second year medical students (outside of whatever is taught in their psychiatry lectures)the need to change classical teachings in how to perform an effective history and physical examination. I wonder which medical schools teach PTSD in that specific context. Yes, we have sessions in relating to interacting with patients, "telling the patient bad news" and we go over issues regarding the students' professional behavior on taking a history and performing a physical and we do mention, in that regard, dealing with the seductive patient. But PTSD itself specifically in terms of its effect on history taking or physical exam is not covered in the "Introduction to Clinical Medicine" in which I teach my group. But, are you saying it should be? Is PTSD so wide-spread in the population that with each patient we see we should be considering an occult PTSD and skip classic approaches toward performing an effective physical exam because of concern that we will be causing more harm than good? As you see, I am skeptical. ..Maurice.
Maurice
There are over 2.7 million patients in intensive
care units each year and over 20 million patients
undergo surgery each year with general anesthesia.
Are we to assume that each and every one of
these patients are treated respectfully during their
medical procedures. Who "speaks up" for them when
they can't? Why is it that female nurses always let's
the medical or surgical team know she is a nurse. Is
this a que that suggests "hey, i'm one of you, treat
me professionally."
PT
I have no idea why you keep going back to "history and physical examination" when my comments weren't in that context.
10% of women and 3.6% of men will develop PTSD during thier lifetime (United States Department of Vetrans Affairs). That's a lot of patients.
-RJ
RJ, you may be interested in this article. Women's College, a teaching hospital affiliated with the University of Toronto is doing research on trauma and medical care. http://www.womenshealthmatters.ca/health-news/feature-articles/psychological-trauma-health-care
J.
RJ, you write "I have no idea why you keep going back to 'history and physical examination' when my comments weren't in that context.
"
But the issue of PTSD in the context of physical examination and procedures including nursing is being repeatedly being brought up on this modesty thread. If I am interpreting the writings here correctly, it appears that the behavior of doctors and nurses actually initially precipitate PTSD event itself or precipitate the symptoms of an ongoing PTSD from the past. There is implication from these writings here that there are components of the physical examination which do the precipitation.
Therefore, my questions about how to teach physical examination to medical students and about how they should be aware of the potential of PTSD starting or being aggravated by the examination is perfectly in the context of what has been written here. ..Maurice.
Maurice
Another interesting note to be made as well,
physicians always make a point to let everyone know
they are a physician when they seek healthcare. Yet,
equally interesting is the fact that physicians and nurses
virtually violate hipaa by letting everyone know when
any particular patient is an attorney!
PT
Maurice,
The triggers will be different for each person, however, there is common ground.
Attacks will happen if things occur unexpectedly and the patient is triggered. They include: bodily exposure especially with multiple visitors, lack of informed consent, a sexual assault history, things done against a patient's will, coercion of any kind.
At the current time there's coercion all the time. The medical community picks and chooses what they tell the patient leaving out the psycho social aspects. You might feel that a patient should expect to be exposed in the operating room, however, if it's the patient's first visit and they don't know what to expect, that can be extremely traumatic.
This is why it's important to get real informed consent, and...let the patient know that they can say NO to any part of an exam that is uncomfortable. They feel empowered having their prepping and draping done in the presence of a few rather than the whole team.
These psycho social issues are not being discussed with the patient.
Because of the strength of our social norms, some of the things that the medical personnel consider all in a normal day are outrageous, humiliating, traumatizing causing the patient to feel a sense of outrage. Then the medical community tries to tell them that they are focusing on the wrong things. Blame the patient. The lack of support further traumatizes the patient.
This entire issue could be put at rest with standardized protocols developed by the medical community for certain types of operations, tests, and procedures. Then put them on the internet for all to see.
This gives power to the patient to decide what they want to divulge to the medical personnel and take control enabling the patient to seek medical care instead of forcing them to avoid it at all costs.
Realizing that I have taken control, give consent or lack of it but always searching for finding better ways to accomplish what I need to. This power gives me the tools to march into the hospital and get done what's needed.
The approach is simple. Get support from your doctors. Get them to write you letters concerning your needs. Then when you schedule your procedure you are prepared and will get what you need if at all possible. When you can't, you have the option of compromise or going to another facility.
The patient must also understand the necessity for the bodily exposure (that's why I kept going on the lung exam) and agree with the doctor that it's necessary.
The patient must also feel empowered to (and this, the medical community can surely help), by telling the patient it's okay not to participate without negative comments or intimidation.
belinda
Belinda, I really don't understand what you mean when you write: "The patient must also feel empowered to (and this, the medical community can surely help), by telling the patient it's okay not to participate without negative comments or intimidation."
If I think an exam or procedure or operation is in the best medical interest for the patient (that is my job!) I am NOT going to tell the patient NOT to participate. I will provide information which has led to my conclusion for participation as part of the patient's informed consent. The patient must then make the decision autonomously of whether or not to participate (on their own). ..Maurice.
The patient in me continues to be deeply disturbed by the stories of other patients. It is clear to me that hospitals simply do not take modesty concerns seriously. The links to the threads by nurses that were posted in earlier threads really illustrate how little we matter beyond our disease and their job. Many of the medical personnel express disdain and contempt and regard patients with such concerns as an object of scorn, unworthy of their attentions. They are just too busy with things that actually matter to address our petty little tirades that dare to question their professionalism, [whatever THAT is supposed to be].
It seems the biggest point of contention seems to be whose responsibility it is to mitigate the distress caused to patients by providers. Should providers look for it? Screen for it? Should patients speak up? The answer to all of these questions is yes. Medically induced PTSD is real. It is just as real as any disease that can be seen on a scan. Many people, all smarter than I, have studied PTSD and found that a significant portion of patients exhibit PTSD symptoms following a cancer diagnosis, stroke, ICU stay or other significant medical event. So, the question of whether or not it exists, is not a question. It is a fact.
So. . .what do patients and their doctors do?
First, I would say, it is one thing for a patient to arrive on your doorstep already emotionally bruised and battered by something someone else has done. I think in this circumstance, the patient has his or her own responsibility to begin the difficult process of transitioning from being a victim, to being a survivor of abuse. Such a patient should convey to the provider in some basic way whatever issues might exist. Full disclosure may not be necessary, but patients should give the provider a "heads up" so that he can do his job more effectively and structure the treatment in a way that is least likely to exacerbate the situation. Don't make his job harder by requiring him to develop some mystical power to peer into your soul while taking your blood pressure. Doctors should be trained to identify "Red Flags", but patients should give providers a basic rudimentary explanation.
A more complicated situation arises when it is the medical establishment that inflicts the trauma. This is unforgiveable and an outrage. Medical personnel cannot seriously contend that they are stupefied by the notion that patients feel traumatized when they are exposed in front of a roomful of strangers, especially when many of those strangers are of the opposite sex. No one is that obtuse and to pretend otherwise is disingenuous. Surgeons and OR personnel seem to the biggest offenders here. Perhaps they have become desensitized to nudity over the course of their career, the same way first responders become desensitized to danger or chaos. However, I simply will not accept that it never crosses their mind that a woman does not want a male GYN who is a stranger and approximately her same age involved in her surgery along with a male anesthesiologist and male scrub nurse. Do not pretend that you think a laboring woman is A-OK with male medical students whom she has never laid eyes on attending her exams and eventual delivery. Give me a break! Doing something that would cause distress to any normal person and then pretending that the distressing event is in fact, not distressing, but instead completely routine and any trauma on the part of the person experiencing it is due to their own immaturity or shortcomings is not professionalism. It's a personality disorder.
This resistance adds insult to injury, blames the victim and adds to the mind bending crazy making experience PTSD victims have. If you are a provider, know that we don't expect you to read our minds, but don't dump kerosene on the fire and then tell me it's my fault I got upset when the fire singed off my eyebrows.
APRC
Maurice, The whole idea is the feeling of shifting the power from the doctor to the patient.
Example..."We expect you to allow students to observe and help with your care"
OR
Example..."We in the medical community appreciate the willingness of participating and helping us by allowing the next set of doctors to get the training they need
The patient also needs to know the state of dress or undress to make an informed decision, how many people and the gender of the students.
Should they give you a reaction that does not meet the expectations of the doctor, then, it's time to give them another chance to either participate or not by saying something like...
"We know that these exams are uncomfortable and we do need the help. However, the final decision is yours.
95% of the time patients will cooperate because they feel that they have been asked permission properly, given all the information to make an informed decision, and that they are part of the process and can feel proud of their participation. They are empowered.
It's all in the asking. Doctors should be trained to field out those who say the right things but whose body language, expressions don't match and when an objection does arise ask the patient what makes them feel uncomfortable and then attempt to overcome the objection still making this all about the patient.
That's what I meant.
belinda
I encourage everyone here to take a look at Medical Patient Modesty’s web site and look at different articles we have. We are looking to do more articles about issues such as unnecessary underwear removal for surgeries, what patients should know before they submit to surgery, etc. in the near future. There are many more issues we need to deal with.
I also encourage people who feel passionate about patient modesty to consider volunteering for MPM. One person from this blog said that many people just complain about patient modesty, but they won’t do nothing about it and that if you really care about something like patient modesty you would make time to volunteer.
We have a blog at http://medicalpatientmodesty.blogspot.com/2012/03/issues-we-need-to-address.html. Please share what issues you would like for Medical Patient Modesty to address.
Misty
Every medical teaching facility that I have worked at
ask patients beforehand if they want to be teach or
non teach. I really don't see a problem here in this
discussion. Nearly every physician I have seen in my
life has been by my own choosing, no problem with
that issue either.It's the nursing staff I believe that this
thread should be focused on.
PT
PT, It probably varies depending on where you are. I once had a doctor who told me she doesn't see non teaching patients. She continued to see me after I clarified.
I will say on numerous hospitalizations I have never been asked whether I wanted to participate in the teaching program. It was always taken for granted that everyone wants to participate.
NOT TRUE!!!
PT
Taken for granted they wanted to partcipate or taken for granted if you don't ask the patient won't tell?
The Gila Medical Center, who brought you the infamous Dr Twana Sparks, is in the news again! A guy runs a red light, cops pull him over, think hes hiding drugs, so they take him to Gila where he is abused and humiliated in the worst way. They find no drugs.
http://www.kob.com/article/stories/s3209305.shtml#.Unm6mFOmYlQ
The cops first took him to an ER, they refused to perform the "exam". But at Gila, they know all about abusing male patients.
The KOB news story is documentation of terrible behavior and casts a degraded form of "professionalism" upon the police and physicians involved. Right? ..Maurice.
This is DP. I have not been reading this blog for a couple of months as other things have taken priority. I have spent the last several hours "catching up" and would like to ask for a response from Dr. Mo regarding a statement you made on 09/26. To whit:
Next comes to issue of simply "looking at the patient" for medical educational purpose and value but not "laying on of hands" (that is, actually touching the patient) such as done in a physical examination or performing some procedure. "Looking at the patient" by a medical student for the purpose of medical education (which has the potential of benefit not only for the student but for society in general beyond that of the individual patient) does not represent assault or battery and is not the same invasion of privacy as that of a "peeping Tom" where there is no benefit except for the prurient interest of the Tom. This medical educational "looking at the patient" should not require direct patient consent particularly if the patient is aware that this is a teaching institution.
I read this and now I would like you to go back and re-read my recounting of my surgery experience as I commented on from 07/13 and 07/16.
I was grossly violated during a very intimate surgical procedure for the "educational" purposes of NURSING STUDENTS!! These are people who were flipping burgers at McDonalds 6 weeks earlier. Are you kidding me???
How can this not require direct patient consent?
Also, since I'm probably again running out of space, I want to recount to you my recent experience having arthroscopic shoulder surgery (rotator cuff) and I want to ask for opinions and insights.
Best,
DP
Our focus should be on the victims. How traumatized were they? How humiliated did they feel? What kinds of avoidance problems will they have in the future with authority and hospitals?
What responsibility does the medical community have in accommodating patient needs when they have been subjected to police or medical abuse?
Let's look at the moral responsibility of thee institutions. Many of us have had similar or worse experiences than what was cited.
Why should those people have to fight this uphill battle to get the care they deserve because the system is to pompous to recognize their responsibility and instead of looking at this from a systemic problem, they force the patients to go it alone, one by one. Does that seem morally right, just, or fair?
belinda
One comment on the "we've seen it all before" as a reason why you should not be concerned about medical personnel seeing you nude and unconscious. This was used on me recently. My response. - " if that was true, pornography wouldn't exist. After all we've seen it all before."
This is just another example of the paternalistic duplicity constantly used by the medical profession - nurses in particular.
DP
I would suggest everyone here visit www.kob.com
and read what happened again at the gila medical
center, this could happen to anyone.
PT
Help me understand one argument presented here:
If a patient was totally unaware and have no proof that they themselves were "nude when unconscious" in the operating room, how could this be an explanation for the development of PTSD or aggravate a prior PTSD? Is what is being discussed as "nude and unconscious" about a presumption based on hearsay of others who say they know what really goes on in the operating rooms but, as I stated, not proven to have occurred in that patient's individual presence in the operating room.
Couldn't the assumption be a wrong assumption for a patient who was unconscious to make? It would be more reasonable to understand why a patient who was conscious and nude in an operating room might have modesty issues of varying degree depending on the limits set by that individual patient based on their understanding of what is happening to them. But, again, modesty and emotional distress on the assumption of "unconscious and nude" seems difficult to explain or for me to understand. ..Maurice.
Here is the full link to the KOB article:
http://www.kob.com/article/stories/S3211354.shtml?cat=500
Whether the police had previous facts which led to the decision to investigate current drug possession to make their concerns valid is one matter. The other, however, is whether it was ethical for physicians to engage in this bodily assault (that is, assault-- without their patient's permission) at the request of the police. It is almost like the situation in the Guantanamo Bay detention camp and physicians in the armed forces being ordered and following the order to carry out devising and monitoring torture activities on their "patients". Being aware of the necessity for ethical professionalism as a physician in relation to their patient should have moved those New Mexico doctors to reject the orders of the police...unless, of course, those doctors were more interested in the fee paid for by the citizens of the county or state than professional ethics. ..Maurice.
To DP from earlier today, "inspection of the patient" for the student's specific medical educational benefit and with the permission of the patient for that "inspection" by that student is perfectly ethical. There is a difference between the motivation and behavior of that student and a "Peeping Tom". ..Maurice.
Maurice, There's a very interesting book written about trauma and how it is held in the body. It's called, "Waking the Tiger" by Peter Levine.
It talks about that even if the mind doesn't register trauma, the body does and it talks about the release.
During sessions of EMDR, patients have been known to re-experience the feelings of helplessness in their bodies even though they may have disassociated or have been asleep.
The body remembers.
I will also check with my friend who holds a ph.D in health psychology if just the notion of an even can trigger ptsd, if, there were previous traumatic events and even if there weren't.
An interesting read.
Belinda
Hi Dr. Mo,
To answer your question of how a patient can experience PTSD if he is unconscious, I will relate to you again the salient parts of my operation from 11/13/2007 which I continue to deal with today.
On the day of the surgery, November 13, 2007, I went to admissions and, like most patients, I suspect, signed the admission papers without reading them too carefully and took a seat. I was eventually admitted and prepared for surgery. The anesthesiologist came in and introduced himself, but at no time was I informed or introduced to the other people that would be present in the operating room.
At the appointed time I was wheeled into the operating room and helped from the gurney onto the operating table. To my surprise, besides my doctor, the anesthesiologist and a few nurses, there were a number of other people in the operating arena. In all, I counted 11 people. I was trying to register all of this as a drug named Versed was administered to me via an IV in my hand. At about the same time, the gown was removed and I was asked to lean forward for what I later found out was a needle in my lower spine. I was never informed of what was going to take place once I was in the OR and I was never informed as to who all of the staff present were.
I later discovered that my operation had been observed by a number of nurses and nursing students. When I wrote to your hospital to protest this gross invasion of my modesty, dignity and privacy, I was informed that the hospital is a teaching institution and that I had signed the admission forms allowing this to occur.
According to the medical records of my operation that I obtained, the patient (me) was placed on his left side and a colonoscopy was performed. There is no mention whatsoever of any draping or adherence to patient modesty standards as this procedure was performed not only for my benefit but for the benefit of unnecessary nurses and student nurses. The records further show that AFTER the colonoscopy, the patient was placed in a jackknife position on the operating table, still undraped in any way. I was then “prepped” by a nurse, again in full view of students, my buttocks were spread and taped open, and only then was I draped. At this point the anal fistula surgery was performed. All of this in front of people that I had no idea would be present and who were allowed to view an extremely private moment. The concept of INFORMED consent was never addressed in my case.
Since that time. I have had innumerable flash backs to the feelings of dread and helplessness I felt upon being wheeled in to this strange environment, literally being observed as a piece of meat, being undraped as the epidural was administered and then feeling unconsciousness come on while trying to voice my objections.
Yes, I was unconscious during the procedures. But I got the surgery reports and I've read and re-read them. No one can tell me that mere observation is harmless.
When I, 6 years later, had to have 2 elective surgeries, all the feelings of dread returned and were amplified because in both cases the consent form that I've already talked about was thrust in my face 45 minutes before surgery. Read my posts from 07/13 on to understand my reaction to this.
DP
I disagree with this statement:
"There is a difference between the motivation and behavior of that student and a "Peeping Tom.""
We cannot read minds, therefore we can not determine the intent or motive of any other individual, at best, we can guess.
To a victim, intent and motive do not matter. The result matters.
Have you heard of that new Movie "Ender's Game"? The theory of the book is that "since the child did not intend to murder two individuals, then commit genocide against an entire race, he is not guilty of the crimes".
The book tries to convince us that even in such extreme cases as murder and genocide, intent is what confers guilt.
Entire books are written about the subject arguing both view points (does intent matter in issues of guilt), because it's not a black/white issue that can simply be declared. Your position is nothing more than opinion.
DP - I've read your story before and I understand and validate your feelings.
-RJ
Here is a step by step procedure that occurred to the
suspect(patient) at Gila medical center over that 14
hour period.
www.kob.com/article/stories/s3209305.shtml#.
Unw56Nr5msm
Yet, people wonder why some us blog about this
subject. I truly hope everyone involved gets sued,
reprimanded, jailed and lose their jobs. It's amazing
what uniform does to some people.
PT
What difference does it make of the motivation of the spectator from the perspective of the patient.
The only thing that matters is that the patient is gawked at by onlookers and the searing debasement of being objectified in that way stays with you forever.
DP, I, too, understand and validate your feelings.
When the medical community tries to blame the patient by telling them they are focusing on the wrong things, etc., it only creates more of a possibility of developing PTSD.
DP, you are among friends here. You were brave to tell your story and I'm glad that you did because the obsurdity of the situation was so outrageous, it's almost unbelievable, except that many of us on this blog have had experiences that were different than yours, but as outrageous. We know the truth.
belinda
I also understand and validate DP's feeling. The way I look at it is this: how would anyone in that operating room (doctors, nurses and students) feel if they were the ones in the patient's position? I honestly feel that most, if not all, of them would not be comfortable being in that patient's position. They would not like to be exposed to so many people for such an intimate procedure. To me it sort of boils down to treating someone as you would like to be treated. Jean
A law that was passed some years ago has been enacted. It says that the insurance industry cannot discriminate differences between mental health and physical health and cannot restrict benefits for mental health needs.
The law implies that mental health shares equal importance to physical health and that it cannot be ignored or brushed away.
This is the first step to having mental health issues addressed when entering the hospital.
belinda
I am not sure how many of you heard about the case where a lady was forced to have vaginal/anal probe, X-ray, CT Scan because it was suspected that she was carrying drugs. This case happened in El Paso. This case sounds similar to the cases of the other men.
It is horrible that this is happening in the US. I am very disappointed in the doctors who did not stand up for this woman’s rights.
Misty
DP’s feelings about what happened to him during surgery are very understandable. Many patients have no idea what happen to them during surgery.
This is exactly why it is prudent for every patient to have a personal advocate not employed by the medical facility such as spouse, family member, or friend to be present to make sure his/her wishes are not violated.
I am hoping to do some articles about steps patients can take to ensure that their wishes are honored once they are under anesthesia in the near future. It’s sad that medical professionals think that they can do anything to patients once they are under anesthesia.
Jean made some very good points. I have heard of some nurses, doctors, and medical students refusing to have procedures at the hospitals they work at. I guess it is because they know what could happen to them once they became patients.
I have observed that most people who come to this blog or MPM have already had bad experiences. I really would like to change that. I would love for us to reach out to educate people before they have bad experiences. I wish we could get many newspapers and news channels to do stories on Medical Patient Modesty and how easy it is to have your modesty violated in medical settings. Does anyone here have any connections to newspapers or news channels that might be willing to raise awareness about Medical Patient Modesty and how patients can protect themselves?
Misty
Just got back from the hospital (again) having another test. The female staff was accommodating and it was easy to tell that the staff went out of their way to make me feel comfortable.
All was well until....the test is over. I'm not yet back in street clothes and there's a knock at the door and a male tech proceeded to walk in on us.
I quickly scolded him for not asking permission to enter. He ignored me and quickly took what he came in for. The nurse was mortified and so apologetic. She was probably well trained. She insisted that I speak with the nurse manager. Its then when I realized how angry I was and told the manager that I wanted to talk with the tech.
She went and got him. I explained who I was, how the staff bent backward to help me achieve my goals and quietly explained to him that not only didn't he wait for permission to enter, but walking out on me was even more damaging.
It was explained to him that his reaction was just as important or more than the initial incident and that I was there to educate him on what's needed. I then added and told the nurse manager that there need to be protocols documenting such occurrences and that anyone can make a mistake or two, but then a pattern of behavior and consequences must ensue.
It was a very empowering day. I offered to speak to the hospital staff on this subject. The nurse manager was interested in seeing published work too.
One day and one person at a time. It will get through.
belinda
Belinda, I applaud you for the way you handled the situation...but you didn't mention how the tech reacted or responded to your "education." What did he say ?
LJ
belinda
Is everybody observing? This is what I'm talking about -- at the moment these violations happen, that's the time to educate as the patient, just like belinda did. This kind of education is what it will take to gradually change things. It will work. How long it takes depends upon how many people are willing to engage at the right moment.
Belinda, what happened to you is unfortunately not unusual and it indicates the lack of respect so many medical personnel have for patient modesty. Several times I have been in examining rooms with a male physician when there was a knock on the door and a female nurse entered immediately. Do they really think that knocking means anything if they do not allow time for the doctor or patient to respond and grant permission? Fortunately for me, I was not intimately exposed during these incidents, so I said nothing.
I now realize that your response was and always is the correct one and I commend you for that. In the future no matter what degree of exposure is involved, if an incident like this takes place again I will express my criticism to both the nurse and the physician. As Doug Capra wrote, "This kind of education is what it will take to gradually change things."
MG
Doug, MG, Thanks for you comments.
When the nurse manager came into the room I was clearly aware of how angry I was and realized I was ranting. During the rant I told the nurse manager I wasn't leaving the hospital until I spoke to the technician.
She brought him into the room and it was as if a light bulb went on and I was able to put aside my feelings and use this as an educational opportunity.
The technician seemed to be a shy, tall, thin and something about his appearance and sweet face made me realize that this person wasn't thinking and that he was rushing around doing his job. He was visibly shaken.
I told him I understood that he's busy, rushing and didn't mean to walk into the room. I then told him some facts about my past and mentioned that you never know who is on the other side of a door. It was explained that the staff went above and beyond to help me have a same gender team. I mentioned how my feelings of emotional comfort were compromised by his coming into the room.
I also explained that his walking out on me as I was scolding him was worse than the original infraction and that an "I'm sorry" goes a long way in medicine.
I thanked him for coming as his doing so kept me from fretting over the incident for weeks and I'm sure he'll never knock and walk in without thinking about who is on the other side and what a closed door to an exam room means.
He responded that I helped him from also fretting about the situation for weeks. He apologized and I realized I probably traumatized him. Poor guy, just messed with the wrong patient.
I thanked the nurse manager, and also mentioned accountability, and a record of infractions. Anyone can make a mistake but after awhile it becomes a pattern of behavior and must be dealt with.
I also mentioned my book. She ran down the hall without explanation going to get a business card as the hospital was working hard to taking these kinds of things seriously and that she wanted a copy of my book when it is published. I offered to come speak to the staff on this subject.
Today I wrote to the hospital administrator detailing what occurred and what needs to be done, offering a marketing program promoting dignity has a highest priority at their hospital and an offer to educate the staff on what needs to be done when a previous victim has been violated (either by mistake or on purpose) and what doesn't work. I also offered to speak at the hospital bringing the ph.D I work with who is a Health Psychologist.
Let's see where this goes. It could be the beginning of great things and I'm using the situation to promote our agenda (on this blog).
PT and all the guys, you'll be happy to know that I also told staff how difficult it is for men to get what they need and how more male staff is absolutely required and will be part of any presentation that is offered.
Wish me luck. Will keep you posted
You were all with me yesterday.
belinda
The below website is about patient rights. If you go to privacy and safety, note the comment on the second #1 having to do with putting the patient in protective privacy!
http://www.chal.org/about/privacy-policy/
belinda
An article on sexual abuse at a hospital
http://res.dallasnews.com/graphics/2013_02/parkland/#day1main
This is a systemic problem in healthcare. The ph.D in psychologist that I work with sees abuse all the time from her patients.
Maurice, for every person abused (and according to this ph.D happens more than you would want to know), there are victims. They are like us, on this blog. Time will make the problem worse. The medical system must make necessary changes to change the way they are doing business. Needed background checks, protecting patient privacy, documenting misconduct and worse,
accountability and responsibility.
They cannot sit back and do nothing and they must take responsibility to taking care of those they harmed.
It is the right, ethical thing to do.
belinda
Here is a comment by LL posted earlier today which was accidentally deleted. ..Maurice.
Regarding Dr Bernstein's comment "I have no knowledge of what the parents are specifically told other than it is commonly known that this hospital is a teaching hospital"
I've had a few surgeries as an adult and I still to this day don't know whether or not they were considered teaching hospitals. I have no idea who was present during my surgeries. At the time it didn't really make any difference since I was allowed to wear shorts and there was no reason for me to be stripped or fondled.
But after researching this stuff the last few years I am now suspicious of EVERYONE in the healthcare field, so if I ever need another procedure I intend to ask a lot more questions and will try to assess if I'm being lied to. (I never trust nurses)
Thanks Dr Bernstein and to all the participants on this blog. Misty, it's great to finally meet a woman that cares about men's issues.
LL
belinda
The statement your referred to in your last post:
"1. To refuse to talk with or see anyone not officially connected with the hospital, including visitors, or persons officially connected with the hospital but not directly involved in his/her care."
Yes, BUT -- the words "officially connected" can be interpreted differently. I assure you, that most doctors would consider, in most cases, anything they considered education/teaching or a consult to be "officially connected." Same with nurses.
So -- again, this is a communication issue. The patient needs to make it clear that what's "official" needs to be run by the patient and discussed. Some doctors and nurses will do this as part of their practice, some will not.
This is one of the problems with many hospital policy statements like this. When they're put together, it's often assumed that everyone agrees on the definition of words like "officially connected" and "respect" and "dignity" and "patient-centered" and "patient values," etc.
Rarely if ever are words like this discussed as part of the policy's construction. There are too many assumptions on both the part of the patient and the system. For example, the patient reads the policy statement I quoted above and just assumes that it means they're covered by whatever concerns them, modesty, medical students, opposite gender care, etc.
Too much as assumed.
Doug, in this technological age with all forms of communication available what approaches are there for communication between hospital and patient in both directions within the limited time set by the patient's immediate symptoms and the amount of time available for individual patient hospital introduction procedures by the admission officers? If the patient brings in a self-prepared document setting the patient's own standards for care and the hospital presents to the patient their document, how is the differences going to resolved by the admission officer to meet the standards set by the patient and not unilaterally disrupting the functioning of the hospital nor delaying treatment and worsening the patient's medical condition? ..Just wondering. ..Maurice.
Belinda:
I am sorry to hear about your experience the other day. I am glad that you were able to use this as an educational opportunity. This male technician who walked on in the room with you could be a huge asset to male patients. It is exciting to hear that you could make a presentation at the hospital.
I’m also glad that you brought up the male patient modesty issue. I hope you will be able to publish your book soon.
LL: Thank you for your positive comments! One of the board members for MPM who does volunteer work at the hospital is very concerned about male patient modesty too. She has done some research and shared insights that were very helpful.
Misty
Maurice
Good questions. As to an answer -- I don't know. Unless the communication can somehow take place beforehand, perhaps the way belinda handled it will have to do -- right at the moment the two come into conflict as to the meaning of words.
I just can't see how it is practical for an attempt to be made at the time of admission for differences in interpretation of words and differences of practice between the the patient and the hospital to be solved or resolved. For the present, for each individual hospital and individual clinic, communication between potential patients and administration about changes in wording and changes in procedure and staff behavior should begin with a "sit down" conference between the two parties. The conference must include a group of potential patients who have previously together worked out a protocol and now presented to the administration (who is backed up by lab, physician and nursing staff). I see no other practical and safe way for attempting change. Forget admission time resolutions. Forget law suits. I suspect once one or two hospitals and clinics listen to patients and change, others may more easily follow to stay competitive.
OK. So, in your various communities, wherever you are, get a bunch of potential patients together, discuss and come to conclusions and then together set up a meeting with administration.
Sorry, Belinda, I am not sure that a patient by patient approach at the time of a procedure or admission is going to make persistent and effective change. .Maurice.
One element of belinda's recent account I think needs emphasis. She writes about the tech that
knocked and just entered her room without waiting for an answer:
"The technician seemed to be a shy, tall, thin and something about his appearance and sweet face made me realize that this person wasn't thinking and that he was rushing around doing his job. He was visibly shaken."
I think it's extremely important that most of these kinds of violations are not done on purpose. They're done without thinking. How belinda handled this was especially humane. She calmed down and practiced some empathy. She didn't speak in anger, but in a caring way.
That's the key to this kind of education -- even if you're met with an uncivil response. Keep your cool. Use reason and empathy.
to Maurice: Whether this kind of activism will work or not depends upon how it's done and how often it's done. If it's done civilly, and if hospital and clinic providers experiences this a few times a week, you can be that it will make an impression. If it happens a few times a year or less, you're probably. It won't take effect.
Maurice,
It takes effect 100% of the time for me. Perhaps the focus should be on a supposition that all patients should expect a safe caring environment, define what that means and then put it in the patient bill of rights. The current medical environment is not safe for me.
Patients acting on their own with the right documentation are going to get what they need when the hospital realizes that by not doing so, they are violating their own codes.
As an underwriter in another field, I took all those aspects and worded them in such a way all I get is cooperation that is tailored to fit what I need.
It is doctor stamped and approved with credentials showing on letters I bring, my own statements and then I work for a protocol that works for me.
I realize in an emergency I have to make some very tough decisions and don't know what they will be until I"m put in that position.
belinda
Please look at my next posting below for a response to what has been written to my blog thread "I Hate Doctors: Chapter 3" by a visitor who appears to be a British doctor. I thought you all might be interested in his post there. Please also note that the Hate Doctors which was first begun 8 years ago, about the time that "Patient Modesty" thread was started is only currently at Chapter 3 and we are here at Volume 59. Doesn't that tell you something about about the public's disgust vs admiration of the medical profession? ..Maurice.
Posted today from a visitor on "I Hate Doctors: Chapter 3". ..Maurice.
As a doctor it makes me sick reading some of these comments - fibromyalgia is a load of rubbish for example, I've not met anyone with it who wasn't a malingering waste of space. My ex-girlfriend had so called fibromyalgia but she was able to climb a fairly large hill with me one night. I showed her the door pretty quickly. It was clear she was just lazy, a result of the lax UK benefits system. A lot of so called "symptoms" are just a normal consequence of growing old. I feel like rubbish and tired all the time and everything hurts but I realise there is nothing wrong with me except the fact that I am no longer young. As far as I am concerned you actually have to be sick to qualify as a patient. I find female patients to be the worst by a long chalk and yes, a lot of their so called "symptoms" are indeed psychosomatic and often caused by an inadequate sex life as freud so rightly deduced. And I agree about the sore throat thing. When I have a sore throat I put up with it like a man without whinging like a little girl, unlike most of my patients, and I go to work as usual. And if you think I am some incompetent uncaring jerk of a doctor, let me tell you that I always go above and beyond the call of duty to help the genuinely sick and I am very highly regarding by the vast majority of my sick elderly patients and colleagues. I have never faced litigation as I believe I have only made one clinical error in my whole career which I am completely honest and open about when I was an inexperienced junior doctor working under incredible pressure with minimal supervision, and no one blamed me at all (except for myself). Everytime a patient has disagreed with my diagnosis, I have been proven to be right. Every single time. If I am not sure or I don't know I say so. A lot of problems cannot be cured by western medicine, I am honest about this and I expect my patients to accept this and not blame me for the fact that I am not a miracle worker. If you think you can do better than me, you are welcome to give it a try. I bet you will last 5 minutes before you have had enough. Try seeing 50 patients in a morning with only 2 nurses to help. That is not an exaggeration. And everyone left happy(ish), despite some having to wait for an hour to see me. And I am not a slow worker by any means but it is physically impossible to see so many walk-in patients without running late. Especially since most of them did not need to be there - it was an emergency clinic. Unfortunately, as always, the genuinely ill suffer and have to wait longer because of the demanding, entitled worried well who feel "tired all the time", who cant be bothered to go to work because they have a cold or who have a fungal nail infection etc etc. The patient who really takes the biscuit is one stupid (working class of course) woman who complained that I could not stop her feeling jealous about her (non-cheating) husband, despite my best efforts to be sympathetic and reassure her. Since when has (completely normal) jealousy been a medical problem? If you can show me a drug that can cure jealousy I will eat my stethoscope. I am sure you all agree that what she really needs is counselling which is what I tried to persuade her to undergo. This is what I am up against day after day. Its never ending. No wonder most doctors hate their lives, jobs and "patients"( many of whom are not patient at all). Except the genuinely sick, needy elderly patients many of whom I genuinely love like my own parents. I wish I could help them more but you worried well make it so difficult for them (the patients) and us (healthcare staff). You deserve to burn in hell. GP
Dear British Doctor
You are not alone in your frustration and it's
the one idiot I recall who actually had a PICC line
so she could recieve pain meds for her chronic
fibromyalgia. TOP that one! How about the ones
who go to the ER for an mva that happened 2
months ago. I just love the ones who are frequent
flyers for migraines, they expect a cat scan and
morphine! They don't realize I have checked and
they have been to three ER's in the last two days.
With all the debate about Obamacare and
the loss of health insurance, there is a method to
the madness. STOP ABUSING HEALTHCARE!!!
PT
PT, why don't you go to the Chapter 3 link above and write your support so that doctor visitor can read it because he will be unaware of your comment here? It should also raise some interest by others on that "hate doctors" site. ..Maurice.
With respect to the modesty posts and the I Hate Doctors Posts and GP's response, I see several issues.
1. Modesty is the minority. We live in a reality TV, fast food, let it all hang out instant gratification society. No one is modest about anything and far too many people have no concept of the word privacy. People feel the need to update Twitter with information about where they are going to dinner and then post a picture of their meal on their Facebook page. Reality TV shows depict people at home arguing with their spouse and even show people going to the bathroom, getting ready to go out and vomiting on the street after a night of hard partying. It is utter nonsense. If you are a person who is emotionally sensitive and value both bodily and mental privacy, you are in the minority. Being in the minority is not a bad thing. Most people just go with the flow and never speak up. A small minority actually questions the status quo and those people are agents of change.
2. People hating doctors. I have no personal like or dislike towards doctors in general. I can tell you unequivocally I do not trust them. Once you have had a doctor lie to your face, place you under anesthesia and then proceed to allow you to be a guinea pig and then allow a learner to commit a surgical error you view all doctors as suspect. Nearly every member of my immediate family has suffered a misdiagnosis or some form of medical error. I am truly astounded by how little doctors sometimes know. I diagnosed one of my own family members with a medical condition his doctor repeatedly missed that was confirmed by an emergency room doctor who referred this person for urgent surgery. . .and I am not even that smart for crying out loud. I just listened and paid attention and thought, "Gee, that sounds an awfully lot like _________". While I may personally like a doctor, I would not trust him to make independent decisions about my health. He is just serving too many masters. Insurance company mandates, teaching hospitals' need for learners to practice and the financial bottom line are all interests opposed to mine. This conflict of interest is just too strong for me to think I will ever come first.
3. Doctors hating patients. I don't even know what to say there. Assuming GP is an actual doctor, I am even more glad I won't let one near me. I do think doctors thought their education and credentials would insulate them from the pressures that are impacting other sectors. It's a tough world. Everyone, lawyers, teachers, scientists, etc. is having to work harder, longer hours for less pay. Unemployment is high, wages are going down and employers are more demanding. As far as his complaints about working conditions, in the US, you have the insurance companies to thank for that. I am sure every insurance company in America would squeal with delight to see doctors hating patients and patients hating doctors, that is, if they weren't too busy counting the money. Just my thoughts.
APRC
Maurice
Of course there are "bad" patients. But what I often see is, as I see with your recent post, is burned out doctor taking all the examples of his "bad" patients, and then reducing that to definition to patients in general. There are many other factors contributing to doctor burn out than "bad" patients.
I would really like to hear your response to the following article called "Physician Burnout: Don't Blame the Patient." I would like to hear other response to this as well.
http://www.kevinmd.com/blog/2013/11/physician-burnout-blame-patient.html
Doug, I never have and never will blame the patient. I will, however, blame the system: the medical system and yes the legal system and the political system and finally blame the pharmaceutical and medical appliance system..and..and the media, all systems affecting both doctors and patients in ways that in the end degrade the best of doctor-patient relationship and the needed work of the doctor. Are the doctors to blame? We are part of the medical system. Are the patients to blame? Blame, only if they don't take medical responsibility for themselves despite being able to do so being free of social, psychological or physical restraints. But not too many patients to blame..since they do have such restraints being real patients. ..Maurice.
Let's just deviate from the norm for a moment and
reflect where we are. Most patients refuse to take
responsibility for their healthcare, yet expect others
to pay for it. In my view, healthcare is like car
insurance. Those in good health and who take care
of themselves are paying for those who don't, and
most importantly for those who don't have insurance.
Why should I be penalized for the bad habits of
others and why should my care deviate from the
norm only because of my gender. Specifically, why
are women afforded extra privacy with response to
the gender of the nurse or technologist in regards
to specific tests or exams.
PT
I agree with you Maurice. It's basically the system -- and there are some patients that make it worse. Of course, there are some providers who make it worse, too. But I see patients reducing the blame to the providers, doctors and nurses -- and I see providers reducing the blame to the patient. We're using each other as scape goats and neglecting the factors that are to blame. The way the system is run today can be extremely stressful for both providers and patients, real patients I mean, the ones who are really sick. That's the way it is. We can work to improve it, but we must accept the reality. The big bottom line is this, i think -- in most cases, real sick people don't have a choice to be sick or not to be sick. Providers have a choice ot getting into their profession and/or remaining in that profession. If the stress becomes too much, they can always get out. For a really sick patient, if the stress is too much, well, that's too bad. They just have to deal with it.
GP did look at this Volume 59 thread here but returned to "I Hate Doctors: Chapter 3" to respond. I have taken the moderator's liberty to present what he wrote there for your consideration here. ..Maurice.
Had a look, dont have a problem with anything they say. Patients have a right to see a doctor of any gender they choose. I prefer male doctors personally if I am ever forced to see my own GP by my wife. I hate doing intimate examinations on women. I avoid it at all costs. Its embarassing, time-consuming (you have to often find a chaperone which is harder than it sounds) and often unnecessary. 99% of medicine is history and observation - with diagnosis is often clear within 1-2 minutes if you shut up and listen, which I admit not many doctors know how to do. Examination is often for show. I always offer female patients the opportunity to have intimate examinations done by female doctors. That's actually not true - I usually quite sneakily TELL them to see a female doctor (or nurse) for intimate examinations as it saves me loads of time (a properly conducted one will take 5-10 minutes) while I organise pelvic scans and hormone profiles (which takes 1-2 minutes). As you can see, every second counts. Besides, I probably already know the diagnosis. This is what some patients seem to find hard to understand - that tests and examinations are to confirm what the doctor already knows. Its no surprise that Sherlock Holmes was written by a doctor - those same skills of history taking/interviewing, observation and deduction are invaluable to detectives as well as doctors. And I agree with what another commentator has indicated above - that a sign of a doctor is a deep concern with getting the diagnosis and treatment right (rather than with merely keeping the patient happy). I prefer a live unhappy patient to a happy dead one. GP
This is DP,
I have been reading with heightened interest the last few days comments because of something that happened this past week.
Coming up on the 6th anniversary of the surgery from hell I described earlier. I decided to make an appointment with my doctor who had performed the surgery. I went to his office on 11/12/13 and was ushered into an examination room. When he came in he asked me what I was in for. I told him I wanted to have a conversation about the surgery he had performed. I shared with him, in more detail, the writings of my earlier comments of patient modesty. He became very uncomfortable, being asked specific questions about the surgery, why he had allowed unauthorized nursing students into the OR, why the surgery had failed, etc. He told me it was a teaching hospital and he had every right to allow others in the OR. I pointed out to him that nowhere in the consent form did this authorization exist and I pointedly asked him again why he had allowed this and specifically hidden it from me. He tried to belittle me, saying this was 6 years ago and, looking at me, asked me what I wanted. I told him I wanted an apology for his behavior. He laughed a nervous laugh and said "I'm sorry if you are having problems with this." I said, that's not an apology. He stood up, opened the door to the examination room, and told me to get out of his office. I stood up, looked him in the eye, and told him he was an a-hole. He then lost it, and started to physically attack me, in front of his staff and a patient in the waiting room. I'm a big guy, 6'3", 205 lbs. He kept pushing me. He was shoving me in the chest and shoulder, where I had had rotator cuff repair 7 weeks earlier, yelling "get out of my office". His chief nurse stepped in, looking bewildered and frightened at what he was doing to me and held her hands up in front of him. It was like a light switch turned off and all of a sudden he stopped. Turning he walked swiftly away and, as he rounded a corner, the coward yelled to his nurse to call security. I said I thought that was a good idea and yelled after him that he was an unethical doctor and an a hole.. I looked at his nurses and said your boss just got confronted by a patient who was stripped of his dignity, modesty and privacy in the OR.
No one called security. I never fought back or touched him. The true nature of this doctor was on display for all to see. I know I feel MUCH better for getting this off my chest, once and for all. I also know that I will never allow anything like this to happen to me again. I'm done being a victim. While I was angry with him, I never raised my voice or made a scene until he put his hands on me. Even then I knew better than to fight back. I have a couple of small bruises on my shoulder from the incident and I'm trying to decide what action, if any, I should take. I'm inclined to just let it go. He did more damage to himself in front of his employees than I ever could. On the other hand, if he has this tendency to violence - he's in his early 40's, I'm 62, maybe I should report this? But then, to whom would I report it?
DP, thanks for detailing your experience with the surgeon. I am sure it will stir up a bit of conversation here on this thread.
With regard to your last question, I am no lawyer but I would say that if 6 days have passed, it probably would be too late to press assault charges if even that would be a wise decision considering all the consequences resulting upon you. To me, the place to notify professional misbehavior is your state's medical board.
What happened, to me, is not surprising since I think that many surgeons have an "I am the boss" attitude for their practice and for a patient to challenge them and their view, personally, represents a verbal assault and, if it continues, they want to fight back. I believe I wrote this somewhere on my blog of my experience with an orthopedic surgeon when I was an intern standing across the operating table and watched that surgeon throw a scalpel at a scrub nurse (luckily missed her) when she upset him. Good luck! ..Maurice.
DP,
I would be interested to hear how your shoulder surgery went with regard to your modesty and dignity in the OR. And if it went well in that regard, how did you approach the situation to make sure you got what you wanted? (And hopefully the surgery was successful on a physical level and that holier than thou surgeon didn't cause any further damage.)
DP,
It's probably not too late to file charges. There are statutes of limitations on such things but six days isn't it. You have an opportunity to use this experience and the behavior of this physician to file assault charges, files a complaint with the institution.
In discovery, depositions would be taken and his own staff would be forced to testify against him.
Additionally, while you might feel better, you did not get what you came in there for and you are still entitled to that whether it be from the physician (who isn't capable) or from the hospital.
Congratulations on going back and addressing things. All the best.
belinda
DP wrote on 11/18 what his surgeon said: “He told me it was a teaching hospital and he had every right to allow others in the OR. “
On Sept 27th, Bernstein wrote (IN ALL CAPS): “HOWEVER, SIMPLY OBSERVING A PROCEDURE OR OPERATION PERFORMED BY OTHERS GIVEN SPECIFIC PERMISSION BY THE PATIENT IN A KNOWN TEACHING HOSPITAL BUT WITHOUT REQUESTING SPECIFIC PERMISSION FOR THE MEDICAL STUDENT TO OBSERVE IS PROPER.”
Question: Is there any daylight between these two statements?
-amr
Amr, the two statement are separate. My comment was specifically about first and second year medical students (those I teach) and, yes, those students, within a teaching hospital, who will be in the operating room simply to watch others perform a procedure does not require more specific detailing of the names of the students. I am not writing about "detail men" nor some other "guest". I was writing about my first or second year medical students. However, in the paragraph following, it is clear that 3rd and 4th year students, who become more directly involved in patient care must have full specific understanding of that student's role and consent by the patient, teaching hospital or not.
And about surgeons having "every right" allowing "others" in the operating room because this is a teaching hospital, I think "others" must be defined as I did. ..Maurice.
Dr. Bernstein,
The reference to “others” was CLEARLY “students” observing the surgery in the DP blog entry of 11/18.
Go ahead, define who you mean as a “justification” for your actions. Your response may be longer, but the number of words you use does not create daylight between you and the a-hole doctor.
You are making a distinction without a difference to justify your behavior.
Did you read carefully DP’s entry or did you, as you have in the past, ignore his statement that the observers were students because it doesn't fit your argument?
It is now clear to me that you believe that your need as a teacher trumps the need of the patient – the essence the modesty issue. The same justifications herein have/are being used to condone non-consensual pelvic exams save for the “distinction” regarding observation. But as the medical student progresses that veil is dropped.
I say the above because, having been associated with this blog since 2006, I believe you have lost your credibility as an honest broker to lead this discussion further. Perhaps you should hand it over to Doug Capra and/or end this blog as you recently suggested.
-- amr
Amr, if my "need as a teacher trumps the need of the patient", why prior to my reading of your comment would I have altered (added to) a printed teaching hospital statement on a form that I was required to sign in order to obtain a hospital badge. The original statement was as follows: "I fully understand that medical students are only permitted to provide care to patients appropriate to their level of education, training and experience and at the discretion of the attending physician." Before I signed I added the following: "and with the specific informed consent of the patient." Not only that, I specifically wrote to an administrator my concern about the original statement and how it should be modified.
With regard to first and second year medical students observing surgery and not participating in any way, I see no sense in having the patient any further informed or having each student identified for permission except for the patient being reminded that there is a possibility of such an occurrence in a teaching hospital.
I cannot see any modesty issue related to observing an anonymous covered patient being operated upon by students who do not participate in the surgery and are there only to learn how patients are treated during surgery as a specific part of their education.
Yet, as seen by my above change to the statement, I am concerned about any student interviewing or examining any patient without the specific informed consent by the patient regarding the identification of the student and what is to occur.
So there! This is my opinion and as you see I even acted to change a system in my individual way. ..Maurice.
With regard to my statement above:
"With regard to first and second year medical students observing surgery and not participating in any way, I see no sense in having the patient any further informed or having each student identified for permission except for the patient being reminded that there is a possibility of such an occurrence in a teaching hospital", I want to provide a followup to our student's observation of surgery in a children's hospital as noted in Volume 57. The issue of "informed consent" by the parents regarding the presence of medical students observing their children's surgery was important enough to me to, before leaving the hospital, I was attempting to find out how or whether they gave such consent. I spoke about this and was told by hospital staff that the parents knew this was a teaching hospital and that often the resident physician would inform the parents specifically about this and the implications. To me, this seems fair enough for our students to watch operations on children and learn. ..Maurice.
"I spoke about this and was told by hospital staff that the parents knew this was a teaching hospital and that often the resident physician would inform the parents specifically about this and the implications."
The standard "teaching hospital" staff BS disclaimer! And "often" doesn't remotely meet any informed consent criteria that I'm aware of.
I'm not surprised that you found such hollow platitudes acceptable. Did it occur to you to actually ask the parents (or the kids for that matter) whether they were really ok with multiple observers watching their kids get sliced open? Obviously not because that would interfere with your agenda which has absolutely no interest in the thoughts, feelings, and welfare of the patients.
Ed
It’s sad to hear about how traumatized DP was about the way he was treated in surgery. I believe that patients should always be asked for specific consent for medical students to participate in their surgeries and procedures. It is obvious we cannot trust the medical profession. It is prudent for us to educate patients about steps to take to ensure that their wishes are not ignored. Again, I think every patient should have a personal advocate not employed by the medical facility to be present with them to ensure that their wishes are not ignored. One husband prevented a male scrub technician from coming in the room where his wife was having C-Section.
Here are two articles I encourage everyone to check out:
1.) Disturbing blog by an operating room nurse. She shares about how patients are naked and Versed. You can see that paragraph about Versed later in the article.
Look at this particular paragraph:
You’re lying on a gurney, naked except for the gown, right? Often patient’s question, why, that when they are having a tonsillectomy, do they have to take off their bra & underwear? The simple answer is: if we need to perform emergency interventions on you, we need access to EVERYTHING. A bra would get in the way of defibrillator pads and underwear impedes the ability to insert a catheter into your bladder, to monitor your kidney function. These are things we don’t want to tell a patient mere minutes before rolling back, for obvious reasons. So, if you are planning on having surgery, digest that information and accept it. Generally we let little kids keep their clothes on (don’t want to psychologically damage them), but rest assured, we whip their clothes off as soon as they are asleep. The subject of “What can go wrong” will be a later post.
There is no reason for patients to be stripped for tonsillectomy. Underwear can be removed in seconds if there was an emergency. Urinary catheters are not necessary for most surgeries as we know. I can understand why they would not want patients to wear underwire bras. But other kinds of bras like digni-bras should work fine for certain surgeries.
It is obvious this nurse does not want patients to know the truth about being naked and having urinary catheters inserted. It is disturbing that she shares that they do not take kids’ clothes off until they are asleep because they do not want to psychologically damage them. I think that it is very deceiving to let patients keep their underwear on and then take them off once they are under anesthesia. Many patients have been traumatized to learn that they were stripped naked under anesthesia. I am tired of how patients under anesthesia are treated.
2.) Anesthesiologist guilty on all counts of molesting women during surgery - I am glad that this doctor was found guilty. But it is still very sad that he molested so many women under anesthesia. He was able to abuse them behind surgical drape without other medical professionals noticing what he did. That’s horrible.
Misty
Dr. Bernstein,
I’m glad to hear that you are doing “something” based upon this blog. However, what you are doing serves merely as kabuki dance around the core issue as Ed stated on 11/19 in different words. You are building fences around the core issue which serve to insulate you and by inference the medical community from addressing the issue. You point to what you did as if it solves a problem. The only problem it solves is providing a cloak you can wrap yourself in to protect you from the “issue” and makes you feel good that you did something.
I’m not surprised you don’t get it. You have spent a lifetime inculcating yourself in the medical mythos. Heck, even your esteemed “ethics committee” is impendent to effect change per your own words. (Again, another cloak.)
I get why you would react negatively to criticism. I’m calling your baby ugly and I don’t expect a lifetime of practice to be undone. But you are passing on you beliefs to your students and you are a part of the “hidden curriculum,”
Again, I before asked you why you didn’t ask the patients directly. You state that there is no need because, blah blah blah blah.
And before you discount my comments and “ventilation” (another cloak), please remember I have been attempting to constructively engage you since 2006.
Now, how would this been different. Had you gone to the “parents” and directly found out what they knew about the OR experience and directly asked them for permission in the presence of your students, THEN your cloak would be removed. But I just can’t see how you could ever bring yourself to do that. Your discourse has continually proven you feel that step is “unnecessary.” And don’t give us the crap that your students would not be exposed in the OR suit to some patients that may be undraped. (Again a cloak.)
-amr
To all: As I have written here before and recently also, the purpose of this blog is for discussion of ethical issues. The writer's views based on philosophy or facts are presented for others to read and debate by writing their comments. There is no guarantee or requirement that participants here must accept the views of others. Discussion (the back and forth of views) is a form of communication and non-conversion of the other participants to a particular view does not degrade the value of discussion which is to present ones views to others and learn about and consider the views of others. Everyone has the right to hold to their views in a discussion if the philosophy or facts presented by others fail to impress.
My own view of what is most important is that there is truly informed and specific consent by patients for accepting all procedures and all their participants in whatever venue it occurs and that includes medical students interviewing and examining patients. My view is that patients should give permission for an attending physician examining them on "medical rounds" with others, students, interns or residents also present. Unfortunately, this is not the general practice but when I go into a patient's room with my 6 students to demonstrate a physical finding, I always talk to the patient and get their permission before the students enter the room.
Yes, I accept that medical or nursing students as part of their education should be allowed to observed surgical procedures on an anesthetized patient if the patient had been informed about this teaching activity beforehand and that students may be present. In the case of students' observing a procedure with the patient awake, more attention should be paid to detailing who and how many students will be observing and asking for specific permission, just as I do for taking my group of students into a patient's room.
I would like to know from my visitors whether they think that physical modesty is a conscious psychologic/emotional reaction and requires the presence of an awake individual and modesty cannot be felt or expressed by a patient who is under anesthesia. ..Maurice.
..Maurice.
Amr, perhaps my wearing cloaks is to protect my modesty of inability to fully accomplish all the modesty goals of those writing here within the current medical and medical educational system and still provide under this current system the necessary education for my students. It is easy to say I should identify and look up every parent of every child to be operated upon and into which operating room my student might enter in order to get that parent's informed consent. It's easy to say but practically impossible to carry out therefore I have to assume, but I may be unsatisfied, that the hospital which has given our medical school the opportunity to do this experience has taken care of that duty. For more to be done, it requires pressure by the community of patients to change the medical education system and to change the medical system to meet the goals that community has required regarding patient modesty issues and healthcare provider gender selection. So, all those with that goal, get together and do it! ..Maurice.
Maurice
You said this blog is for the discussion
of ethical issues. What exactly do you expect
to be resolved or what conclusion do you expect
to be reached? Physicians took an oath, I will
respect the privacy of my patients and nurses
take a similar oath, what's to be discussed?
PT
PT, I am not setting what should be discussed here except what my visitors have decided since I initiated the topic of patient modesty in first posting "Naked" 2005 reporting on an article in the New England Journal of Medicine by the surgeon, two years out of residency, Atui Gawande, describing issues of "undress" as he saw it in the medicine practiced in the United States and elsewhere in the world. My visitors then took it from there up to the current Volume 59. ..Maurice.
Dr. Bernstein:
I have read this thread as well as others and can state that in general I agree with you on some points and disagree on others. However, I do know that reasonable minds can differ.
With respect to patients under anesthesia, clearly, they are unconscious and therefore unaware, or at least unable to remember who is there. That is the point of anesthesia. It is this fact that makes informed consent all the MORE important when a patient is under anesthesia, not less so. If 6 medical students enter my room and I am conscious, I am free to tell them to leave. If I am unconscious I have no voice at all and I am looking to YOU and trusting YOU to protect me and honor my wishes because I am unable to do so. Patients often can and do find out after the fact their modesty, dignity or bodily integrity was violated under anesthesia. This feeling of betrayal is indescribable. It is my opinion that a patient should be introduced to what some teaching hospitals call a "care team" and that anyone from this team can view the surgery, with consent of the patient. I do not think multiple non-essential observers should be allowed in an OR without specific detailed informed consent and that to do so is a violation of the sacrosanct trust surgical patients place in their surgeons and his or her team. Other patients may not feel this way and I am certain my own previous experiences are informing this. It may be enough to tell some patients in general terms that there may be students observing the operation and if the patient is OK with it, then you can likely proceed. However, I think many people would be upset to find out after the fact that 6+ people observed them having surgery. I do not want any extra people in my OR, period. I am appalled to think that however many people who are utter strangers to me are walking around in their life with that memory of me in their mind. My own personal experience has eroded my trust and left me in my current predicament of refusing any care that renders me unconscious. General anesthesia is the ultimate vulnerability and that is when we need protection the most. It is not the time to rely on boilerplate consent clauses and assume we won't care because we are unconscious anyway. I agree on some level that we should DO IT, however, when I am unconscious you are my voice and I am completely defenseless and dependent on you. My trust is so eroded that is it no longer an issue for me, however, I do not advocate my position for others and would want them to be able to seek care without fear of the very people who are supposed to be taking care of them.
APRC
APRC, beautifully said. My feelings are similar to APRC. The fact that someone is under anethesia, whether aware has no bearing on behaviors that are different than the patient wishes while awake. They may not know what's happening at the time, but if a doctor knows a patient's wishes and violates those wishes is a complete betrayal.
For those who have had previous bad experiences an instance like that would keep that person from ever trusting the medical community again. The emotional damage would be so intense that it could be considered abuse if the medical team knew the patient's wishes ahead of time.
So, to answer the question, it is irrelevant and consequences for abuse of trust should be punishable.
belinda
I understand AMR and Ed’s frustration with Dr. Bernstein’s belief that he does not need to go to patients or parents of children to ask them for permission directly about medical students being present for surgeries. Just telling patients that medical students could participate in their surgeries is not enough. Each medical student should be introduced and then the patient can make a decision.
APRC made excellent points. Patients under anesthesia are as important as patients who are awake. This is exactly why patients cannot trust medical professionals to honor their wishes once they are under anesthesia. This is why I heavily emphasize that every patient should have a personal advocate not employed by the medical facility present with them at all times. The truth is patients often have more emotional damage than awake patients if they learn that their wishes were violated while they were under anesthesia.
Belinda’s points: For those who have had previous bad experiences an instance like that would keep that person from ever trusting the medical community again. The emotional damage would be so intense that it could be considered abuse if the medical team knew the patient's wishes ahead of time are excellent. One of my friends who has had many horrible experiences in medical settings shared with me that she never wanted to go to the doctor again. She was sexually abused by a male gynecologist when she was 14 or 15 years old. Then she was stripped naked for wisdom teeth extraction in a hospital when she was about 18. She had a horrible childbirth experience. She was supposed to have her baby with a midwife, but ended up having a C-Section because her son was breech. She got her wishes for a female OB/GYN, but this doctor ignored her wishes that she did not want any medical students to be present.
I really wish I could help this 16 year old boy who is concerned about his modesty during gallbladder surgery. I cannot find a way to answer his question. I am sad to see how many misguided answers he gets. He should be able to wear cotton underwear and shorts. There is no reason for a gallbladder surgery patient to be catheterized. I wish he could see the gallbladder surgery article I wrote. Can someone please check to see if there is a way to answer this guy’s questions?
Dr. Bernstein: I have some personal questions I’d like to ask you.
1.) If you were a patient undergoing surgery, would you like to know all of the people who would be involved in your surgery?
2.) How would you feel about your own medical students observing your surgery if it involved private parts?
3.) If your wife was a patient, would you like to know all of the people who would be involved in her surgery?
4.) Can you elaborate why you think patient’s modesty does not matter once he/she is under anesthesia?
Misty
I agree with APRC and Belinda...and I say that as a patient who doesn't have modesty issues, but rather has trust issues, following a traumatic experience with conscious sedation. I truly felt betrayed by my doctor who deliberately(?) kept information from me about the experience, but which I discovered later. When I confronted him, he arrogantly said, "Well, what's the difference between being unconscious and being having amnesia ?" as if there wasn't any. Whether conscious, unconscious, or sedated, I want to be informed now of everything that will happen, and EVERYONE who will either participate or merely observe my surgery or procedure.
By the way, I don't post here very often, but last time a couple of people confused me with "LL." I am "LJ."
There are two parts to informed consent. The first being informed, informed of course include options which would include the right to decline or not. If the form does not provide the right to decline or modify then consent is not informed consent, it is coerced consent. From what i understand many intake forms provide neither so the argument becomes a mute point from the begining.
But assuming we move past that, it comes back to the uniquenes of each and every patient. I was chastised here for saying I was less uncomfortable with the gender of my providers when I was out. I still stand by this, I did not say I was comfortable, just less uncomfortable and I feel it is trying to balance my concerns with the facilities needs for efficiency. I would prefer not to know or meet the team however but that is me. To me it becomes less truamatic if I am not experiencing it so to speak. Others feel different, some don't care, some care more if they are out. The relevant thing is providers do not and likely will not ask because it is easier and more efficient not to.
I agree the SOP of making patients strip completely for things such as eye surgery is ridiculous, the odds of having an issue are very very small, the odds of the time it takes to remove underwear would make a difference is even smaller, combined the odds are miniscule. The odds one of the providers will carry something in due to going from patient to patient in the same scrubs has to far outwiegh that.
So the long and short it is up to the individual, I have less concern when I am out, but do not feel that gives the provider the right to choose for me or anyone else. And the right to education does not in any way shape or form trump my right to choose for myself...don
As an answer to Misty's question, if I have surgery, as I have had in the past, I think my answer would be in keeping with the vast majority of patients (consistent with my own professional experience): I am only dependent on the trust I put in the surgeon and the surgeon's team to safely accomplish the goal set by the decision to operate. I really don't care or be concerned by any of the individuals in the operating room except that they do not interfere with the operation so that the surgery is complete and safe. And as I wrote, this view I think is the view of the majority and unless someone can prove otherwise, I will stick to this conclusion. Now,that doesn't mean that what I have learned by reading my blog thread over the years about patients who do not hold my view should be ignored about their concerns. Absolutely not. That's why I believe that full informed consent including consenting about the "viewers" as well as the "doers" of the surgery or procedure is to be encouraged whenever and wherever possible. But my own personal requirement is that I trust the "doers" to "do" the right thing and resolve my medical or surgical problem.
It is with this view in my mind that I have been shocked to read threats of some visitors here of abandoning their attempts to clear themselves of disease, even potentially fatal disease, if their modesty issues are not strictly followed. Obviously, these folks have to weigh the balance between concern about developing or exacerbating PTSD vs continued symptomatic illness or death. I will choose treatment regardless of gender but with trust in the medical or surgical provider. And, as I said, I think I am in the majority until proven otherwise. But, nevertheless, to my visitors here, go ahead and express your opinions and suggestions since that is all part of the title of this blog: DISCUSSION. And if the medical profession and system needs to be changed and yes I do agree about that: changed in ways to make the profession more ethical and even more safe and more available, I encourage all of us to talk about it and try to find ways and begin as advocates to achieve it. ..Maurice.
A Urologist posting about how to minimize embarrassment on KevinMD:
http://www.kevinmd.com/blog/2013/11/3-tips-overcome-embarrassment-doctorpatient-relationship.html
I encourage others to add their two cents!
Ed
Ed, thanks for the reference to the article but I think the urologist was writing about embarrassment in general and perhaps more about communicating "sensitive" history rather than the doctor touching "sensitive" areas of the patient's body. But the general recommendations are, of course, excellent and should be followed.
By the way, I did wonder why the doctor didn't get down to the "nitty gritty" of physical modesty that is being discussed here. That would have been very helpful. Maybe Dr. Shaw was "embarrassed" to direct attention to that issue OR as has been my professional experience over the years, patient's greatest source of embarrassment is to answer questions about their sexual history. That is why instructors in medical student history taking always have the student start out with something to the effect "I understand the questions I am about to ask may be very personal but I want you to know that your answers will remain private."
What do you think about the article? ..Maurice.
Dr Bernstein, I did address the nitty gritty issues but my comments are apparently awaiting moderation. I went to the website for his practice; he is the sole physician and his ancillary staff is all female!
By the way, I totally get med students needing to observe OR practices in real time. I respectfully disagree though with the measures taken to ensure true informed consent is obtained in all cases. Hospital staff assurances and "often the resident physician would inform the parents specifically about this and the implications" don't remotely meet reasonable assurances that the patients and their families gave true informed consent. That said, I recognize your unique situation since you're not an employee of the facility and can't afford to antagonize those who enable your educational mandate.
Ed
I also agree with APRC and Belinda's statements.
Due to several negative experiences that have severely eroded my trust in the medical industry I will never consent to general anesthesia, sedation, or the use of amnesia inducing drugs under any circumstances for any reason. If it can't be done with a local or regional block without sedation, then I won't consent and will forgo treatment - period!
I also will not consent to invasive airway support (intubation) or urinary catheterization under any circumstances for any reason.
Fortunately advances in regional anesthesia have significantly reduced the need for general anesthesia for most procedures - they're even doing open heart surgery on conscious, non-sedated and non-intubated patients using thoracic epidural anesthesia.
I maintain my opinion that the wide use of general anesthesia and sedation is primarily for the benefit of the providers, not for the safety or benefit of the patient.
Dr. Bernstein: While it is true that you and some other patients do not have any modesty concerns, there are many patients indeed who have concerns about modesty. Many patients just won’t speak up. I can understand your concerns about some patients refusing medical care. Sadly, some patients no longer trust the medical profession because they had bad experiences. Many of those patients would still seek medical care if they could be ensured their wishes for modesty were honored.
A majority of the people who have come to this blog have had bad experiences or seen their families or friends have bad experiences. One of my friends has had a lot of horrible experiences. First of all, she was abused by a male gynecologist when she was 14 or 15. Then she was stripped naked unnecessarily for wisdom teeth extraction in a Connecticut hospital. Then she had a horrible childbirth experience. She was supposed to have her baby with a midwife, but she ended up having a C-Section because her baby was breech. She got her wishes for a female OB/GYN, but this doctor ignored her wishes that no medical students could be present. As a result of this experience, she decided to not have any more children. She told me that she avoids doctors. This is sad. I wish that she could have not had those bad experiences. I was really shocked about how she was stripped naked for wisdom teeth extraction because I personally got to keep all of my street clothes on when I had my wisdom teeth removed.
Ed: I commented on the article you mentioned. I thought your comments were excellent. It really bothered me that Dr. Shaw has an all-female staff according to the staff page for his practice. His practice is located in Austin, TX which is just over an hour away from the all-male urology clinic in San Antonio . I wish there were more all-female urology clinics for women only and all-male urology clinics for men only. It’s sad about how many urologists do not take into consideration about how important male patient modesty is. Also, many men do not feel comfortable talking to front desk staff about male problems they may be having.
I received a letter from a man who supports Medical Patient Modesty today who talked about male patient modesty. He has boldly stood up for his rights. He has refused female nurses and doctors on numerous occasions. One female doctor tried to do a prostate exam on him, but he refused and asked for a male doctor. The female doctor said okay, but made fun of him. It is sad about the callous treatment men receive when they speak up about their wishes for modesty.
Misty
Misty wrote: " I can understand your concerns about some patients refusing medical care. Sadly, some patients no longer trust the medical profession because they had bad experiences. Many of those patients would still seek medical care if they could be ensured their wishes for modesty were honored. "
Short of the medical profession simply ignoring those "wishes" by the patient which I hope no members do, however, instead of appearing as "wishes" to them, if they appear as "orders" then there will be a problem with compliance.
And the problem will be mostly based not on lack of concern for the emotions of the patient (if the patient even has described their hidden emotions) but the at times complex logistics of following such orders at the time of the request.
Thinking about this further, perhaps the patient is offering the provider even more than an "order" but a "challenge". It would go beyond simply saying "this is what I want" but it might also appear as "If I don't get what I want, I will sacrifice my health specifically because of your unwillingness to follow my request." Wow! Is this really what we are discussing here? I am not sure that most doctors or others in the healthcare profession will readily accept such a challenge.
And the result? Well, in these days of patient autonomy for their own medical decision making what is there left for the healthcare provider to say or do? An explanation of the refusal to the patient and then "your decision is up to you."
I say, as Misty used the term "wish" and its dictionary definition "a desire or hope for something to happen", let us keep it only a "wish" and not an "order" or challenge and I am sure most doctors will listen and attempt to bring that wish to fruition if possible. I know I would. ..Maurice.
Please note, in my above posting, I didn't use the word "threat" in place of "challenge". Do you think that some healthcare providers might consider the patient's refusal of medical care if their "wishes" are not followed a threat? ..Maurice.
Dr. B.,
"Short of the medical profession simply ignoring those "wishes" by the patient which I hope no members do"
Unfortunately all to often that is exactly what happens. The staff will pay lip service to the patient's "wishes" and then promptly ignore them without making any significant attempt to accommodate them - you need only look at some of the situations described by contributors to this blog to see this.
The problem is that the majority of medical staff have little or no respect for "wishes" or "preferences" of the patient and don't take them seriously. In fairness, the time pressures of their jobs may have a big influence on this.
In the face of this, I believe it is justifiable for the patient to assert their rights in order to have their "wishes" or "preferences" taken seriously - whack them up the side of their head with a 2x4 to get their attention.
If there is some reason the patient's wishes or preferences can't be accommodated, then they need to explain that to the patient and why and try to come to some kind of negotiated agreement, then stick to what was agreed on.
There is never a justification for ignoring a patient's expressed wish for no unnecessary personnel, including medical student and any other observers being present for any surgical procedure, whether or not the patient is conscious. If they are not part of the surgical team, they have no business being there without the prior informed consent of the patient. IMHO this requires more than "they know this is a teaching hospital" or the fine print buried in the admission forms. You need to specifically ask them ahead of time if it's OK. If asked respectfully, the vast majority of patients will likely have little or no problem with it. For those that do, respect and comply with their wishes and move on.
The bad feelings arise when a patient finds out after the fact and is offended because they weren't specifically asked and feel that they were misled or lied to, then when they complain and ask why they get blown off. Now you have someone that will never trust the medical system again.
You also wrote:"Please note, in my above posting, I didn't use the word "threat" in place of "challenge". Do you think that some healthcare providers might consider the patient's refusal of medical care if their "wishes" are not followed a threat?"
By definition, a threat is:"a statement of an intention to inflict pain, injury, damage, or other hostile action on someone in retribution for something done or not done" Refusing care if one's wishes aren't respected doesn't fit the definition. It would only be a threat if the statement of intent to harm was directed at the healthcare provider. Refusing consent to treatment if the patient's preferences won't be accommodated is simply the patient exercising their rights under portions of the 1st, 4th, 5th, 9th and 14th amendments to the constitution and as supported by case law.
Hexanchus, of course patients have a legal right to express their preferences and that has nothing to do with "threat" to others unless it is implied that without the healthcare provider following their preferences, the patient will allow harm to come to themselves with the inference that the harm will be the result and responsibility of the healthcare provider. To me, that could be interpreted as a "threat".
I fully agree with you on the need for "negotiated agreement" with attention to the word "negotiated". That's how the process should be carried out when the healthcare provider may be limited from providing fully the wishes of the patient. On the other hand, it does also require the patient to "speak up". And that is what may be missing. And as strongly suggested by many here "speaking up" is the necessary first step for that negotiation, the first step to which I fully agree. ..Maurice.
Maurice,
The proper word for this discussion is requirement. Legally, if the patient has medical/psychological challenges, the hospital has no option but to find a way to comply.
Ignoring a requirement is a breach of agreement with the patient. If ignoring the requirement inflicts pain (physical or emotional), or, creates an unsafe environment for the patient, there's liability.
If the requirement cannot be met, then there is liability for the hospital medically if the patient refuses care because they won't meet the requirement. So, in the end, the patient is holding all the cards with the support of his/her doctors and the explicit need to meet the requirement.
For some, it has to do with this modesty issue, but this is painted with a broader paintbrush. It's all about patient safety, what's needed medically and emotionally.
The law now states that insurance companies cannot discriminate between mental and physical health with regard to coverage. So, implementation of the law in the medical setting would infer that psychological needs have the same importance as physical ones.
belinda
So now we have gone from "wish" to "order" to "challenge" to "threat" and now to "requirement". They each have their own connotations though the last makes the decision appear to be based on some established, perhaps legal, criteria. But, if as Belinda states, "requirement" is part of a doctor-patient agreement, then first an agreement between the two parties has to be reached. And this is where both parties must find common ground with the limitations each carry for the essential common trust to be established. ..Maurice.
Maurice, The word requirement is both legal and medical. If doctors who support the patient deem whatever a requirement, then it becomes part of the procedure protocol due to medical necessity.
It further takes away the idea of patient demand, puts the onus on the physician and gives the patient the guarantee that everything possible will be done. For me, there is no broker. It's what I need as a requirement, or it's a no go. This works well for elective surgery but realize this might be a problem for an emergency. Then it's up to the patient to give direction and it's up to the facility to honor the competent patient.
I think this covers all the corners and is just a peek at the work I've been doing for patient advocacy on this subject.
Just to let you all know, I'm working on a collaborative project with a health ph.D on speaking presentations.
belinda
Hexandus: I was well aware that many surgeries can be done under regional anesthesia today. I personally think it is ridiculous for hand surgery patients to be put under anesthesia. I certainly had no idea that they could do open heart surgery on conscious patients. Can you please email me some research you’ve unveiled about open heart surgery?
Dr. Bernstein: It really does not matter which term we use. Medical professionals should work to accommodate patients’ wishes (also known as requirements) for same gender medical personnel or alternative procedures to protect their modesty better. A patient is a paying customer so her/his requirements should be accommodated. I find it strange that many medical professionals think that it is important for a restaurant to honor a customer’s specifications for food. For example, if you went to McDonald’s and asked for a plain cheeseburger and you got a cheeseburger with ketchup. You could return it and say no you have to make my cheeseburger plain. Patients have to refuse medical care if their wishes are not being honored.
I got a letter from a man who made a small donation to Medical Patient Modesty yesterday who shared about how he had to stand up for his wishes many times. He said that some female nurses and a female doctor gave him a hard time. In fact, one female doctor made fun of him when he asked for a male doctor to do his prostate exam. He has felt strongly about patient modesty since he was 12 and he is in his 60’s now.
It is very obvious we cannot trust the medical profession. One of the goals of MPM is to educate patients about steps they have to take to ensure that their wishes are honored. The only way that a surgery patient’s requirements for modesty can be 100 guaranteed is for her/him to have a personal advocate not employed by the medical facility present for pre-op, surgery, and post-op.
If a medical facility is not willing to accommodate a patient’s requirements for modesty, the best thing a patient can do is to go to another medical facility that is more accommodating. There are some medical facilities that do not have same gender medical personnel available. For example, one of my friends who lives in a small town with a hospital that only has male doctors drove over 30 minutes to take her teenage daughter to another medical facility with female NPs. It was certainly worth the drive. I really appreciate her protecting her daughter. Too many teenage girls have been traumatized or abused by male doctors. Patients should even cancel surgeries at the last minute if they see their requirements won’t be honored. The truth is most surgeries are scheduled so most patients’ lives are not in danger.
It is not just patient modesty that I am concerned about. I am also concerned about deaths and infections that have been caused by negligent medical professionals. My paternal grandmother had an elective surgery 14 years ago and passed away unexpectedly because an inexperienced doctor let her bleed to death. A much more experienced doctor was supposed to operate on her, but somehow plans changed. A nurse who was present told my aunt what happened, but she would not testify. This is another reason why every patient should have a personal advocate present for surgeries.
Belinda: Thank you for your persistence! I am excited that you are going to do some speaking engagements.
Misty
Misty,
Just google "awake open heart surgery".
This technique was pioneered around 2000 and there is a group in India that has successfully performed over 1000 of these procedures. A number of studies have shown it as a viable alternative to GA with less anesthesia associated risk for the patient.
Sorry for digressing from the blog topic Dr. B.
Hex
An interesting article -- look especially at number 3 on this list. The main piece of advice we've been giving here, as I see it, is for patients to speak up. They may pay a price for speaking up, but there is a much higher price people pay for not speaking up.
http://www.karenstan.net/2013/11/11/nurse-reveals-top-5-regrets-people-make-deathbed/
www.centerforurology.com/staff.html
They call this a urology center for men and women.
Look at their staff, then you decide.
PT
Actually, PT, that urology site looks interesting. Yes, you're right. They have an all-female staff with no males. That's not good. But here's where the patient needs to take some responsibility. You'll find the following statements under these categories on their website:
"PATIENT RIGHT AND RESPONSIBILITIES
The patient has the right to considerate and respectful care; cultural, psychosocial, spiritual, personal values,
beliefs, and preferences will be respected. Patients with vision, speech, hearing, language and cognitive impairments have the right to effective communication.
The patient has the right to every consideration of his/her privacy concerning his/her medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly.
PATIENT LEARNING ASSESSMENT
Do you have any cultural or religious practice/beliefs
that may affect your care or treatment?"
So, you see, PT and all -- this practice can't have it both ways. Patients need to read this stuff and then use it to make their cases. It's pretty clear to me, pretty broad, open to everything we're talking about on this thread. The patient needs to download and copy these forms from this practice's website, make an appointment, the request same gender care and use these documents as evidence that the practice has, in effect, made a committment to honoring this kind of request. Frankly, I'd like to hear how they would argue against it.
Hexandus:
Thank you for the information! Some of the articles I found are:
Eyes Wide Open: Patient has open-heart surgery while he is awake
Doctors Perform Open-Heart Surgery on 'Wide-Awake' Patient
Patient Awake During Heart Surgery
PT:
I looked at
http://www.centerforurology.com/staff.htm and it bothered me that they only have one male doctor and the rest of the staff are female. I am sure that the female medical assistants often participate in appointments with male patients. I wonder if the male doctor allows male patients to have procedures with him alone. It is also disturbing the female front desk staff could ask male patients personal questions that they may be uncomfortable answering. I got a letter from a man who supports Medical Patient Modesty the other day who shared about how upset he was to go to a clinic many years ago for a prostate exam. He said that the female front desk staff asked him some personal questions he did not want to answer. Then he went into the examining room shocked when a female doctor came in. This man spoke up and told the female doctor he wanted a male doctor. The female doctor said ok, but she laughed at him.
Doug’s suggestions are very helpful. I wonder if any men have challenged this particular practice you are referring to.
Misty
That urology clinic is a joke. One male physician
and the rest are female, all 11 of them. Yet, it
really dosen't matter how many male physicians
they have. What counts is there are no male
nursing assistants.
What I believe to be the biggest joke about that
clinic is the comment about one of their physician
assistants. Since when does a physician assistant
become an expert in pelvic floor disorders. Since
when does a physician assistant become an expert
in anything.
Do you think she will publish articles in the
American journal of medicine. Would she be
asked to speak at a urology conference. Would I
want to follow up with a physician assistant as a
post-op patient, HELL NO!
Someone should ask her how many urological
surgeries she has done. That would be ZERO! Their
disclaimers do nothing but blow smoke up your
rectum. I wouldn't visit this clinic even if I were
a female.
PT
Misty commented "...one of my friends who lives in a small town with a hospital that only has male doctors drove over 30 minutes to take her teenage daughter to another medical facility with female NPs. It was certainly worth the drive. I really appreciate her protecting her daughter. Too many teenage girls have been traumatized or abused by male doctors." Misty, you imply that most male physicians are perverts. Surely you must know that the number is extremely low. Gerald
Gerald,
It was for a personal issue. Many teenage girls are traumatized by male doctors doing intimate examinations on them. Sexual abuse by male doctors of female patients is very common. You should check out http://www.sexualmisconductbydoctors.com. Look at the tips about how to prevent sexual abuse for teenage girls.
I have gone to a male doctor for non-intimate things so I am not against male doctors. In fact, my dad was always with me for my appts. at a school infirmary when I was a kid. The male doctor never did anything inappropriate to me. I always kept on all of my clothes. He was very reserved about how he touched me. However, I heard that he abused some girls whose parents were not there with him.
One time when I had strep throat infection, I asked a male doctor in ER to keep the doors open and that he could only do a strep throat test on me. He complied.
Misty
I wanted to ask you all what you think about doctors’ offices having locks on the doors of examining rooms. I’ve been thinking some about this because of what happened to Belinda recently. I am sure that Belinda would probably have found it useful to lock the door to prevent that male from coming in.
What are your thoughts? Dr. Bernstein: I am especially interested in hearing your thoughts.
There are some pros and cons of having locks on doors of examining rooms. I realize that some male doctors could lock the doors to sexually abuse female patients or have sex with them. But at the same time, I think locks could be useful to prevent unnecessary people from coming in.
Have anyone ever seen any doors to examining rooms that had locks? I cannot recall seeing any.
Misty
Misty, I would not ever recommend locks to closed examination room doors to prevent entry. A sign "Knock, Await a Response before Entry" would be sufficient as long as the stsff's criteria for employment was that they were able to read English.
I think it is ridiculous to argue against locked doors on the rationale of preventing sexual abuse by "male doctors". This is like arguing against taking a commercial airline flight because fear that any particular flight will crash. Medical practice never is and will never be a sexual experience for the healthcare provider regardless of all the propositions to the contrary here and all without statistical verification. In fact, medical practice makes every effort to make the examination and procedures asexual. Any professionals who are exceptions are statistical outliers and should be removed from practice.
I totally reject the idea that doctor's offices and operating rooms are dens of sexual perversion. As I don't believe that most patients are looking froward to the doctor visit as a sexual experience good or bad, I don't think virtually every doctor is anticipating the visit as a sexual experience. Anyway, Misty those are my thoughts. ..Maurice.
My friend delivered her child at a hospital where floor nurses had the authority to put up a sign outside post partum patient rooms that directed everyone to see the nurse before entering the room. This could be if a bedside procedure was being done, if she was doing patient education on breastfeeding or even if Mom/Dad and Baby needed some rest/sleep. I thought it was a good policy that afforded Mom some time to be alone with her baby and rest/bond/learn to breastfeed in peace and quiet etc.
Misty, you are using anecdotal information and some websites where certain groups "of a common feather gather." I do not believe anyone can find scientific data that shows more than a very few male physicians being perverts. We must always rely upon scientific data as opposed to anecdotal stories.
I am sorry you were traumatized but you are trying to confer your feelings upon others by using scare tactics. I believe you are doing a dis-service to others by instilling fear in them.
I have had some physicians with locks on their doors. Just a week ago, I was receiving a hip injection when a female clerk came in to access the printer. So this happens both ways. As Doctor Bernstein said, a knock and a wait for a response should suffice. I did NOT request that the door be locked after this. What if I had fallen and broke a hip? It would be more difficult for someone to help. One medical assistant would be of little use by herself in that situation. Gerald
When I had my dreadful experience in the late 1980s it was a free for all with personnel wandering in and out and my being in stirrups with a speculum stuck up me and being left like that at one stage. I was just a kid and it breaks my heart to think about the impact this had on my own sexuality and mental health (and that wasn't the worse of it). He also felt he had the right to slap me across the backside, imply I was a slut and insert tampons into me - still in that position. The doctor is still practising in London and is apparently 'widely respected'. He was 'cautioned' for inappropriate behaviour towards women in 2000 as I have recently discovered on the internet. Maurice, I think it doesn't matter what a healthcare practitioner's motive is - safeguarding is safeguarding point. Whatever measures need to be taken, so be it and stop throwing up smoke screens by saying that all professionals have a blanket consensus attitude. I was a professional and I say a wide range of behaviours within my industry towards clients.
Anonymous from 1:43 AM today, I suggest you shouldn't assign that "wide range of behaviors" towards "clients" to the medical profession. The medical profession and accepted behavior in medicine is different than any other profession: the activity is intimate both from the perspective of the patient exposing the patient's personal history and intimate from the perspective of the patient exposing their own body. What other profession bears responsibility for their behavior within that extent of "client intimacy"? ..Maurice.
As a pragmatist, I am going to go with the knock and wait for reply sign. It seems like a low cost solution. Also, I would think it would be beneficial for a provider because if you were in the middle of some type of procedure or exam I would think you would want to focus your attention and not be interrupted or distracted. I don't like it when I am working and concentrating and someone interrupts me to ask me a question that could wait for later. I am not a doctor, but if I were intently listening to someone's heart and really trying to zero in on something I was afraid sounded wrong and someone knocked on a door to use a printer I would be highly irritated. People really should not be interrupting providers when they are with patients for any reason other than a true emergency. If I am with a doctor, I want his full undivided attention during the entire appointment. Given the ridiculously small amount of time docs spend with patients now due to insurance company reimbursements and hospital administrator mandates I am totally unwilling to share that time with anyone unless someone is absolutely about to die. Selfish? Maybe, but I want his full attention. I realize this is off topic, but it still goes to the no interruptions issue. Also, the best solution to many of the modesty issues is TRUST. How am I supposed to trust you with my health/mind/body when I have to compete for your attention during the 8 minutes I get so see you? Interrupting providers when they are with patients is just bad all around. Maybe it's just me, but if I were meeting with a client getting him prepped for a deposition and someone knocked on the door and walked in to use a printer, I would be seriously irritated. I also think it would be disrespectful to my client to be barged in on like that when I was trying to counsel him. How is he supposed to remember anything I am telling him when his train of thought gets derailed?
APRC
To anonymous about the urology center "for men and women" with all women on the staff, with the exception of one male doctor:
This would be a pretty good setup for women who need to see a urologist. However, as physiology would have it, more men see urologists than women. I'd have to wonder about a man choosing to see a female urologist just as I would a woman choosing to see a male gynaecologist.
Now, granted, some of the female staff on that page were receptionists, billing clerks, and administrators who don't participate in patient care.
It's fine to say that the patient shares some responsibility in obtaining same-gender care, but when insurance companies dictate which practices you can see, it may be difficult to impossible to obtain it with your insurance.
The answer in many cases is to forgo care, while in others patients are (almost) forced to accept intimate care from someone that is inappropriate for them. Neither of those makes for good, positive outcomes.
Here are some comments from a person who read comments Dr. Bernstein & Gerald made:
I have read the comments on Bernstein’s blog. I was appalled at some of the statements, especially in regards to the claim that it is “ridiculous” to want locked doors to keep out unwanted prying eyes. I have no desire to comment on Bernstein’s blog. There is a culture of dismissal, negativity, and a refusal/inability to acknowledge the issue of sexual abuse within the medical community that prevails. It is this type of prevalent attitude of denial and dismissal that is so dangerous because it perpetuates the abuse.
To comment on Bernstein’s blog feels similar to what it might feel like for a Jewish person to enter Auschwitz and expect to be treated as a human being. It just is not going to happen.
OK, let's talk statistics.
Referring to the book:
Sex Offenders : Identification, Risk Assessment, Treatment, and Legal Issues ...
edited by Fabian M. Saleh M.D. Assistant Professor of Psychiatry Harvard Medical School, Albert J. Grudzinskas M.D. Assistant Professor of Psychiatry in Law University of Massachusetts Medical School, Division of Forensic Psychiatry University of Ottawa John M. Bradford M.D. Professor and Head, Toronto Daniel J. Brodsky LL.B. Criminal Defense Lawyer, Canada University of Ottawa
"In the 1980's an attempt was made to estimate the lifetime prevalence of misconduct among various professional groups. A questionnaire study of psychiatrists found that 16% of responders acknowledged at least one sexual contact with a patient (Herman, Gartrell, Olarte, Feldstein & Localio - 1987)."
"Similar studies found that the frequency of self report of sexual misconduct ranged between 8% and 16%, a range that has also been found among most physician groups (Gartrell, Millikan, Goodson, Thiemann & LO - 1992)."
"During the early 1990's, physicians in family medicine, OBGYN and psychiatry were the most common brought board attention for sexual misconduct in Oregon (Erbonn & Thomas- 1997)."
"Both forensic and questionnaire data agree that approximately 90% of offending professionals are male."
NOTICE: AS OF TODAY NOEMBER 27, 2013 "PATIENT MODESTY: VOLUME 59" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 60. ..Maurice.
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