Bioethics Discussion Blog: Patient Modesty: Volume 73





Wednesday, August 05, 2015

Patient Modesty: Volume 73

So the issue now with regard to patient modesty and patient dignity issues in the care of patients is whether there is "broken" trust in the doctor-patient relationship, particularly with regard to the patient not trusting their physician or nurses.  Or, one might argue, was there any trust from the very beginning of the relationship? If so, was the absence of trust because the physician or nurse did not offer evidence which would support trust by the patient or that patients enter or put into the relationship with the mindset that "all professionals in medicine are considered untrustworthy"? 
Whatever the origin, it is clear from the comments on the previous Volumes that trust is a missing element in medical care and is clearly a part of any discussion of patient modesty or dignity. ..Maurice.

Graphic: From Google Images.



At Wednesday, August 05, 2015 9:41:00 AM, Blogger Maurice Bernstein, M.D. said...

Volume 72 has yesterday exceeded the number of comments which has allowed with my response to Banterings going unpublished and so we start another Volume beginning with a repeat posting of Banterings initial comment to me about confidentiality in medicine and followed by my now publishable response. ..Maurice.
You do realize that confidentiality is a joke!

I respond here with:

Banterings, I was speaking about what I teach first and second year medical students and how they relate to their patients and the documents they write. All students from the first day know not to identify the patient's name on the writeup. Their writeups are read by no one but myself. The details of the history and physical are thus private. Obviously, later on their medical career, they will learn to be sure that the patient is aware of the distribution or restrictions to the patient's medical history. But for the first and second year students, declaration to the patient of privacy is the student's way to develop trust during the full hour or 90 minutes they spend with the patient. ..Maurice.

At Wednesday, August 05, 2015 10:56:00 AM, Blogger A. Banterings said...


I did not realize that you were referring to that part. I thought you were referring to what goes in to the medical record.

So that leads me to the question, at what point do they learn about the confidentiality that a physician claims to have with a patient?

The last time I had a blood draw (wife went to hold my hand of course), the "check in" clerk had me sign a little signature pad for what use to be sign at the "X". I think HIPAA, bill your insurance company, sharing results, etc. When I questioned one of the signatures, she eventually offered me a paper copy of what I was signing. I did not even see being in a cubicle and the large computer screen faced the clerk.

This has become business as usual. Here is the rub: the physician can only promise his confidentiality but not that of large mega-health corp he works for. So ethically, what responsibility does the physician have to the patient to tell how their info is used?

That is the loophole, the physician has an ethical responsibility but the corporate entity does NOT. But do you know who does? The Chief Medical Officer who is a physician and signs the license applications for the corporation to be licensed as a medical facility. I bet corporate ethics are NOT taught in med schools despite CMO are required to be physicians.

That leads me to a second question; At what point are medical students considered professionals and bound by professional medical ethics?

One final question; Are non-physician medical providers bound by the same ethics as physicians?

Are they bound to them as being an extension of the physician who is responsible for the Dx and Tx?


At Wednesday, August 05, 2015 2:20:00 PM, Blogger Maurice Bernstein, M.D. said...

Banterings et al, to get a fuller understanding of what is what and what is where in medical education, read this full page of description of medical school education with my current school University of Southern California Keck School of Medicine as an example. As you will read, professionalism, ethics, the law, attending to patients and their needs, attending to the business aspects of medicine, understanding the humanities and public health and much much more beyond the knowledge and skills of the medical specialties are described. My role is an instructor in ICM (Introduction to Clinical Medicine).

In answer to Banterings question about non-physician medical providers, they are bound by their licensing boards to the criteria of professionalism and laws and certainly physicians who work with them have a professional duty to observe and report deviations from appropriate ethical and legal behavior. ..Maurice.

At Thursday, August 06, 2015 5:05:00 AM, Anonymous Anonymous said...


I would suggest that the statement "have a professional duty to observe and report deviations from appropriate ethical and legal behavior" is great but exists entirely in a utopian world so everyone can wrap themselves in a cloak of professional superiority. While I'm sure at a personal level physicians are really good at maintaining prof stds - the nurses/receptionists are not - even though they exist under the physician's cloak of professional ethics and their own where applicable. Where I live the rec/nurses at the local doc clinic hung out together socially in a sports league. Over drinks they would discuss pts openly with names - "Mrs. Johnson and her" ....A few of us that overheard switched from this large (6 physician) practice to smaller ones. How do you complain about this and get results?

Interesting study:

"In sum, our findings demonstrate that men encounter prejudice when they behave atypically, and raise the possibility that men may avoid behaving modestly because they risk backlash for stereotype violation when they do."

I have always wondered why nurses claim 'most men are not modest'. While this study examines modesty as a personality trait (not self-promoting etc) I think it has cross-over to healthcare in terms of male behaviour when confronted with a humiliating situation. Males are 'punished' for weakness/lack of agency in society - I am sure some men react to this by taking control (strong) - exposing genitals etc instead of the nurse controlling (weak). The immediate conclusion for nurses is to judge the behaviour as 'immodest", or "wrong and indecent" without thinking that many are forced into this by social expectations. I mentioned in a previous post about how nurses need to control male exposure for their own comfort - to gain control of a situation which intimidates them....Kevin

At Thursday, August 06, 2015 5:17:00 AM, Anonymous Anonymous said...

Another article about how male modesty is perceived as weakness by...women...we are socially conditioned/punished for being modest; then women (that have reinforced this behaviour) draw the conclusion that men are not modest without realizing they themselves are largely responsible for conditioning this behaviour.


At Thursday, August 06, 2015 7:51:00 AM, Blogger Maurice Bernstein, M.D. said...

Jason K wrote the following today to the now closed Volume 72. My response follows his comment below.

Dr B - so you basically tell them to ask, then if the patient hasn't been whipped into submission and refuses, to just skip the questions / part of an exam. So.... no mention of body language or anything the patient might display if they really don't want to answer / consent but feel obligated to, or just as a sign of general embarrassment / discomfort?

Jason K.

Jason, no whipping. And yes, the students are taught to be aware of unspoken but behavioral rejection and yes, if the patient rejects despite further explanation, that activity is not performed but the students are to explain the absence in their writelups. Remember, every medical student and every physician should know, hopefully are aware that they are under the legal restriction from misbehavior termed assault and battery: threatening words or unwanted behavior mean assault and the unwanted "laying on of hands" define battery. ..Maurice.

At Thursday, August 06, 2015 3:55:00 PM, Anonymous Anonymous said...

Trust; here is a study of in-custody sexual abuse of youth in the US.

"Approximately 95% of all youth reporting staff sexual misconduct said they had been victimized by female facility staff (table 11). Among the estimated 2,730 adjudicated youths who had been victimized, 92% were males reporting sexual activity with female staff; an additional 2.5% were males reporting sexual activity with both female and male staff. In comparison, 91% of all adjudicated youth held in the sampled facilities were male. In 2008, 42% of staff in juvenile facilities under state jurisdiction were female."

These women are given positions of authority and control over youth (as are nurses) as they are gender neutral nurturing creatures. Its hard to implicitly trust any gender or 'professional' when gender politics sweeps these issues out of the media. Feminism is blind to this stuff; I wonder what their answer would be for these abused youth - that they were 'lucky'? As in the "vagina monologues" when speaking about the molestation of a 13 year old girl by an adult woman "if it was a rape, it was a good rape". Nice. I would never 'trust' anyone from the getgo just because they were professional. Trust is earned; given when a relationship is established and the client is satisfied with the demeanor/intent of the professional. Without some due diligence on the part of the client initial trust is just plain foolish...Kevin

At Thursday, August 06, 2015 4:48:00 PM, Blogger Maurice Bernstein, M.D. said...

Here is a unique and, I think, effective way of presenting issues of professionalism in medicine. It is a presentation of the Jefferson Medical College in Philadelphia Pa.
It consists of a series of short acted out video vignettes followed by a physician and also a student discussion of each subject in the series. The topics include: Commitment to Honesty with Patients
Commitment to Improving Access to Care
Commitment to Improving the Quality of Care
Commitment to Patient Confidentiality
Commitment to Professional Competence
Commitment to Professional Responsibilities
Principle of Patient Autonomy
Principle of Patient Welfare

I used 4 of these topics and links in a series of threads here in 2013 titled "A Medical Student and YOU" which is appropriate with regard to what has been discussed on this Patient Modesty thread.

Let us know what you think of these video scenarios. ..Maurice.

At Friday, August 07, 2015 7:04:00 AM, Anonymous Anonymous said...


Generally these videos present sober thought about day to day interactions amongst healthcare staff and how to analyze them. Perhaps the patient modesty video is missing from this collection? or perhaps not important? As there is the possibility for assault as you mentioned this is a glaring oversight. Also - would be nice to have a point of view from the patient in some of these scenarios - they count too right? The fact that the patient isn't represented is very telling IMHO....Kevin

At Friday, August 07, 2015 7:09:00 PM, Blogger Hexanchus said...

Dr. B,

I would agree that trust in medical professionals has eroded. There are likely a number of causes, but those I see as important factors are:

1. Disclosure of past or current practices where the privacy of patients was violated without their knowledge or consent - i.e. the practice of trainees performing pelvic exams on anesthetized patients without their knowledge or prior consent. This falls under the category of violating both informed consent and patient autonomy rights. Despite the fact paternalism is dead, there are still many medical professionals that fail to recognize that.

2. The common practice of physicians covering up for their peers wrongdoing, which leads to more patients being directly exposed to potential harm. The profession's track record of self policing is not very good and the public knows it and has lost trust in the physicians as a result. Even when one is caught red handed, there are many in the profession that will downplay the situation or try to put a spin on it. Until this is rectified and the bad apples are aggressively and permanently weeded out, I see no improvement in the situation.

3. Faster and more widespread disclosure of physicians physical or sexual abuse and/or misconduct with patients. With the advent of the internet and other news sources, what often wasn't quickly or widely disseminated becomes common knowledge on a national or global basis very quickly.

The most recent example of #3:
Now Dr. Binh Minh Chung's license has been suspended and the family practice doctor is behind bars, facing sexual assault and child pornography charges.

In a 28-count criminal complaint, he's accused of drugging patients in order to sexually assault them. The complaint lists at least 11 alleged victims, including a minor.

Certain occupations such as physicians and police officers have traditionally had an implied level of societal trust. To be entitled to this trust, they must be held to a higher standard of conduct that is beyond reproach. Sadly, I believe both professions have repeatedly failed to meet that requirement, and as a result their level of trust has been severely eroded.

If all these issues were forcefully and publicly addressed and corrected it might restore some of the level of trust, but I highly doubt it will ever go back to what it once was.

At Saturday, August 08, 2015 9:17:00 AM, Blogger A. Banterings said...


I totally agree. These are things that I brought up in my post about a "12 step program" for healthcare, but not as eloquent as you.

I am sure that most remember my citation of the following study on the NUH website:"Tomophobia, the phobic fear caused by an invasive medical procedure - an emerging anxiety disorder: a case report." This show the flaw in Beauchamp's and Childress's assumption of "the patient choosing health." It also showed that some people hold their dignity and quality of life in higher regard than length of life.

Keeping with this line of thinking, I present the paper, "Delayed diagnosis in an adolescent with a malignant testicular tumour ."

Feelings of embarrassment and fear in adolescents may contribute substantially to a delay in the diagnosis of malignant tumours arising from the genital region, with subsequent increase in morbidity and mortality. A case of a 15-year-old boy who had multiple visits to physicians with complaints of recurrent lower abdominal and back pain is presented in the current case report. He refused examination of his genital area during all visits, stating that there were no problems. The patient was admitted to the hospital with a working diagnosis of lymphoma after finding an abdominal mass and a neck mass. During bone marrow aspiration, while the patient was sedated, a large testicular mass was discovered. Each time the patient had been examined, he refused a genital examination and denied any change in the genital region.

Imagine what indignities that this boy suffered when younger with his pediatricians that led to his refusal of the exam to the point that he had to be sedated...

Screening for testicular cancer is no longer recommended for male adolescents and young adults due to low occurrence rates, high rate of curability, high rate of misdiagnosis, harms of false positives, harms to dignity/modesty, and other negatives.

(Source: Journal of Adolescent Health, "The Male Genital Examination: A Position Paper of the Society for Adolescent Health and Medicine")

(Note: The paper takes the position "Despite the lack of evidence supporting testicular cancer screen- ing, the male genital examination should be included as part of a routine physical examination...)

Voodoo in healthcare again!

The article, "Management of the Sexually Active Adolescent in the ED: Vaginitis, STDs, PID, and Emergency Contraception," stated:

An adolescent who feels unduly traumatized by the ED pelvic exam may be deterred from obtaining health care in the future, putting her at risk for cervical cancer and untreated PID...

I also wrestled with a similar issue myself last year. I was fully prepared to "roll the dice" and not get checked. Thankfully, I have an incredible doctor who I have established a 10 year relationship with. The way I deal with my healthcare phobia is to take charge of my own healthcare, and he has always respected that.

This ties back to the post that Hex's link to Las Vegas doctor faces sexual assault, child pornography charges.

Of course he may have just been doing medical research 10PM at night.


At Saturday, August 08, 2015 12:24:00 PM, Blogger Hexanchus said...


While sexual misconduct by physicians and other health care professionals is certainly part of the trust issue, the bigger trust issue is the covering up of professional incompetence.

For an example, google "Jayant Patel" and read some of the results, especially the wikipedia summary. This is a surgeon who despite repeated reprimands and practice restrictions, was allowed to practice for decades in the US and Australia, and his incompetence has been tied to at least 87 deaths in Australia alone. Even as he was put under practice restrictions, at the same time he was being praised by his surgical colleagues - what's with that?


At Sunday, August 09, 2015 9:08:00 AM, Anonymous Anonymous said...

Healthcare expects us to be trusting as in their mindset; in the old days the public was more likely to see providers in this light. My mother was of this mindset (LPN) and would speak excitedly if one of the demi-god physicians had actually conversed with her at work. Problem is there is an arrogance within medicine that is loath to admit failings: cases like Hex and Banterings have mentioned above are embarrassing to the establishment; reaction tends to be more a case of self-protection than humility and willingness to change.

Do I expect healthcare staff to be perfect? No - but when you put on the cape of a super being then errors become glaring and perhaps more shocking. Lawyers have not helped - they have made millions off of this growing mistrust. Had the medical profession been more willing to self-censure with humility I'm sure public trust would have remained higher. When docs are sworn to cause no harm but we know that many pts die each year from mistakes or are given diseases like MRSA and C. difficile while under care we lose trust. The numbers are staggering; every person hurt/killed by the system has a life and feelings but are treated much like collateral damage during a military briefing.

There is also a disconnect between the pt as a paying client and expectation of service - in Canada esp there is no real consequence for poor service as we have really no choice where to spend our $ - it gives the health system a sense of entitlement and dissociation from the paying client. If you suck at your job in the real world you get fired - in healthcare you are protected by co-workers/associations/lawyers etc.

A couple articles/papers on the erosion of trust:
“Patients with low levels of trust are less likely to seek or access healthcare, less likely to accept healthcare recommendations or maintain continuity of care, and more likely to avoid healthcare, including hospitals, entirely”
Note is only from physician view – no patient viewpoint

“The secret to the care of the patient…is in caring for the patient.” FW Peabody


At Monday, August 10, 2015 1:26:00 PM, Anonymous Anonymous said...

An article about butt covering by Canadian College of physicians/surgeons - note that the offender were allowed to continue practicing.

And another:

The colleges keep pretty tight lipped about the exact nature of the complaints. Seem to outsiders to be more interested in saving face/protecting members; action is taken only when they literally have no choice. I'd imagine there is a lot of heel-dragging on the way which likely makes many complainants not bother.

Maurice - self-policing is a very poor method of determining fault. Would you get a police force to investigate another one? Also..didn't see any criminal charges stemming from these...sexual assault is still a criminal offense so why are these abusers walking away with a wrist slap.

Without real consequences, investigation by third parties and full disclosure there will continue to be obfuscation and downplaying of cases where the perp should be brought into the light of day and judged by society - not his/her peers.

Want my trust? Show me you advocate for the victims fairly- not the offenders. Kevin

At Monday, August 10, 2015 2:01:00 PM, Blogger Maurice Bernstein, M.D. said...

Kevin, what do you define as "sexual assault"? Is it something other than "doctors who made sexual advances to their patients, fondled them, exposed themselves and had sexual intercourse in their offices with patients"? Is performing a history and asking questions about the patient's sexual experiences a sign of the physician making "sexual advances"? Is the doctor who examines a woman patient's breast or does a pelvic exam or genitalia and rectal in a man after the patients provides permission for the exams still considered "fondling"? If the physician's intent is to make a diagnosis and provide treatment for an illness and that the sexual history taking or the breast or genital exams are all part of that goal and the physician does all this with the assumption that the patient understands and is willing to be interviewed and examined, is all that "sexual assault"? Yes, battery may be a legal description of performing an examination without consent but to make it "sexual", shouldn't there be some evidence that questioning or laying on of hands on the patient was basically for the sexual interest of the physician and for no specific benefit for the patient.
I would say that it should be the responsibility of the patient to complain to authorities or take legal action if they believe that they were sexually assaulted. And it is equally the responsibility of professionals who have observed what they witness such an assault to speak up to authorities. And there should be consequences for any "authority" to ignore such reporting. ..Maurice.

At Monday, August 10, 2015 7:47:00 PM, Anonymous Anonymous said...

From Dr B patients provides permission for the exams still considered "fondling"? If the physician's intent is to make a diagnosis and provide treatment for an illness and that the sexual history taking or the breast or genital exams are all part of that goal and the physician does all this with the assumption that the patient understands and is willing to be interviewed and examined, is all that "sexual assault"? Yes, battery may be a legal description of performing an examination without consent but to make it "sexual", shouldn't there be some evidence that questioning or laying on of hands on the patient was basically for the sexual interest of the physician and for no specific benefit for the patient.

Unless the patient also has a medical degree and knows what is or isn't medically necessary, and is able to say "no, you don't need to check that for the symptoms I'm displaying", then yes, it should be assumed that a breast / genital / rectal exam is for the sexual gratification of the doctor, regardless of consent, if the exam is medically unnecessary. Think Doctor A does a breast exam every visit for a patient complaining of lower abdomen pain.... Patient is fed up with lack of results and goes to Dr B, and as she's taking off her top, Dr B asks what she's doing... so she explains what Dr A did every single visit, and Dr B KNOWS there was no reason what so ever for it. Sure, she gave consent, but was effectively lied to for the reason.

Jason K

At Monday, August 10, 2015 8:47:00 PM, Anonymous Anonymous said...

Yes there is a definite gray area with respect to what legally constitutes sexual assault vs battery. What is the intent/meaning of the physician? How do you know what they are thinking? How does the pt feel? We err on the side of trusting professionals - but how do we know the physician isn't aroused? Putting on a white lab coat does not 'dehumanize' the wearer (read the blog post 'the other side of the speculum'). I realize providers are put in a very difficult position here. But the default of 'proving' they did something for sexual reasons is very problematic and they (the abusers) know this. What was that extra touch during the pelvic exam/breast exam? How do you prove anything? MD says necessary and consensual exam - pt says was abused. The nurse who took my BP pre-op blushed and looked down when the cuff was too small - minutes later I was nude on the OR table - what am I supposed to think? She had a natural human reaction - attraction.

To somehow say you can switch off attraction doesn't fool anyone with common sense. We are humans all; replete with faults. Touting this falsity does not create trust. Some pt's are attracted to their doc's and this is a recognized ethical issue - but the opposite doesn't happen?

The colleges of physicians/surgeons are not very forthcoming with the details of the cases I sent you. They have their reasons but from my side of the fence (patient) it reeks of 'handling' or 'damage control'. As an outsider this does not foster trust. What if that was me/spouse/family? Would I just get 'handled' and swept away? Many cases where physicians remain in practice while there were some pretty serious allegations. How is the public to trust you to self-police?

I am in no way accusing all providers with anything. But there needs to be a balance where pts feel engaged/heard/empowered; and that there are serious consequences for those who would abuse this trust, and transparency in the process. Am pretty sure a close family member was accidentally killed by a transfusion of incorrectly typed blood in hospital. How can my trust be rebuilt? My cousin (plastic surgeon) once told me tongue in cheek - "stay away from doc's - they'll kill you".

At Monday, August 10, 2015 9:45:00 PM, Blogger Maurice Bernstein, M.D. said...

So Kevin and Jason K, what is the solution to this dilemma of trust/distrust and what the medical profession is all about: to diagnose and treat and to attend to the patient in a civil, empathetic and humanistic way where the physician's primary concern is for the peace of mind and physical betterment of the patient??

Should the practice of medicine now in this age of robots and computers be relegated to robots and computers? Surely the issue of the healthcare provider becoming sexually aroused and acting on that arousal will be moot... well, at least for a while.

I think we have to trust the airline pilot to complete his or her job to our benefit and safety and we have to do the same for our physicians. Otherwise, all members of society will have to study to become pilots or physicians and then practice their skills upon themselves. What is the alternative? ..Maurice.

At Tuesday, August 11, 2015 7:15:00 AM, Anonymous Anonymous said...

As a start:

1. patient education - (esp for women) - what is a normal exam, how to tell when its not, what to do about it, addressing modesty concerns, being able to say "STOP", creating a transparent process so that pt concerns are addressed and they feel empowered in the transaction. Knowledgeable and empowered pts will greatly increase the likelihood of abusive providers getting caught. For every victim that complains - how many do not? 1/2, 1/10, 1/100? This should be taught in school as part of health ed.

2. AMA/colleges recognizing the problem and dealing with it proactively. Some humility would go a long way here. Creating an atmosphere where all health prof's can talk about/address these issues without stigma. Perhaps a course "when you are sexually attracted to pts" (notice no 'if').

3. Introduction of a more balanced approach to the currently provido-centric viewpoint when discussing doc/pt interaction - the vids you linked to never really provide the pt perspective - we are treated like an object in the interaction. This seems pretty obvious to me. Docs should walk a mile in pt shoes.

4. Prof assn's reinforcing the separation of duties vs remuneration. We are increasingly materialistic and unhappy with our lot it seems. Medicine is big business and increasingly about performance/ROI and this directly undermines care. Docs have the licenses; therefore should control the process more. A little solidarity here and direction would do wonders. My own assn is so interwoven with employers that any idea of autonomy is in reality utopian but nor realistic. Docs have all the power here - time you got your sh** together and used it.

Note in study above that US ranks #3 in satisfaction of doc care but #23 in trust of docs. Whats wrong with this picture?

Robots? Actually no. We are social beings and the effects of caring touch are highly undervalued in medicine. Its all about balance, empowering pts and ejecting the miscreants.

At Tuesday, August 11, 2015 9:36:00 AM, Blogger A. Banterings said...


Here is what needs to change; Despite what the physician says about an exam NOT being sexual, when ever someone touches MY genitals, it feels very sexual to me. Note I said "it feels," and I can NOT control how my body feels. That is what men are told about erections during genital exams.)

What I can do is convince my mind that it is not sexual, but it will still FEEL that way. Teaching providers that these procedures ARE sexual (from the patient's point of view), and acknowledging them as such is the first step. Telling a patient that it is not sexual is exactly what erodes trust. As the patient, I know that what I am experiencing (feeling) is in direct conflict with what the provider is telling me, so the provider is either lying OR incompetent.

The next step is to err on the side of the patient's dignity. The literature supports that many providers omit the genital exam (obviously they are not necessary), yet there are those militant providers that insist on them. Here is an example: No genital exam, no football.

Then we come to find after an evidence based review, these things provide no benefit and are a matter of ritual (women's pelvic exam and sports hernia check). Give the patient the option of skipping these. Explicitly ask, right one is about to preform a GE if the patient wants to skip it. The problem is that they know they can skip them, the first clue is that other providers skip them.

The next issue is dealing with the past and present transgressions. The whole pelvic exams under anesthesia (without direct, explicit consent from the patient); if you don't know this is wrong then you should NOT be practicing medicine let alone ever allowed to touch another human being.

"Medically necessary" can no longer excuse assault and battery.

Go back and look at this case that I cite (ad nauseum); Dr. Stanley Bo-Shui Chung.

Maurice, what is your opinion on Dr. Bo-Shui Chung?


At Tuesday, August 11, 2015 11:07:00 AM, Anonymous Anonymous said...

What can be done?

1) allow patients to bring their own chaperones with video / audio recordings to prove what they saw the doc do. ( I trust my girlfriend a tad more than some random hospital employee to be on my side)

2) A step by step layout of what each procedure entailes available online so both patient and chaperone have a chance of knowing when a line is crossed. Procedures will have to be cleared in advance. (or wait 30 seconds while pt or chaperone google it on their smart phone.... and no, bleeding out during a surgical mistake is not what I'm talking about and you know this, so don't use that as an anti-example)

3) severe criminal penalties for ALL medical staff involved in wrong doing...

**Dr. Twana Sparks molests males while they're under... EVERYONE in the room should face jail time. The doctor herself all the way down to some orderly minding their own business off in the corner prepping gauze or something. THAT is the only way they'll start to keep each other in line.

3) hearings are decided by a jury of non-medical people, preferably made up of at least half by those who have been wronged by the medical profession since they know what it's like to be the victim, and aren't of the mind set "they have a white coat, they must be trusted and can do no wrong".

Jason K

At Wednesday, August 12, 2015 11:20:00 PM, Anonymous Anonymous said...

Etiquette in the OR under general discussion, Allnurses.

According to the nurse the strapping fireman had a micro penis
and the surgical tech started laughing and was going to tell

I'm not sure what a micro penis is but this sounds more than a
etiquette issue. Furthermore, not sure what she expects to
accomplish by running to tell everyone. Is there such a thing
as micro breasts and if there were male mammographers would
it be just be poor etiquette to run and tell everyone about a
patients micro breasts.

This kind of behavior is commonplace in healthcare. I'll tell you
this this happens to almost every patient that under goes


At Thursday, August 13, 2015 2:33:00 PM, Blogger Maurice Bernstein, M.D. said...

So.. on Tuesday August 18, I will be meeting with my 6 first year medical students for a brief 45 minute introductory session (my learning about them and them learning about me and then a general introductory session of what this Introduction to Clinical Medicine course is all about for our group). (As you may recall this ICM course instructs students about how to take a history and in the second semester starting to learn about performing a physical exam.) Virtually all the students are, as yet, not indoctrinated by teachers about medical professionalism or how it is practiced or how it should not be practiced. So they are fresh but ready to learn.

I figure with what else we have to do in the 45 minutes, I would like to speak out a 5 minute presentation of the issues presented on this blog thread: trust, patient dignity and patient physical modesty.

In the remaining days until Tuesday, I would like to read here from my visitors a 5 minute "script" of what I should actually say to them. Remember, even though these students are yet "bare" in the "practice of medicine", each must already have their ideas, concerns and such based on their own personal or family experiences. And, by the way, all 32 groups of 6 are profoundly multi-cultural from all parts of the world and each will have their own cultural backgrounds and fixations.

So here is your chance to directly contribute to medical education (and not by having a medical student performing a genital exam while you are asleep!). Your 5 minute script will be most appreciated by me and certainly will be incorporated if not in whole then in part for my session with the students on Tuesday. ..Maurice.

At Thursday, August 13, 2015 3:58:00 PM, Anonymous Anonymous said...

"a 5 minute "script" of what I should actually say to them. "

Try to always keep in mind that just because you've went through medial school and are trained to see strangers in various states of undress, those people likely never went to school to be trained to be seen naked by strangers. Just because you got used to it has no bearing on their point of view.

Jason K

At Thursday, August 13, 2015 7:25:00 PM, Blogger Maurice Bernstein, M.D. said...

Jason K, excellent point. The state of patient "undress" may be observed by the medical student and later the physician without emotional discomfort since they understand the "diagnostic necessity" and repetitive experiences. However, the undressed patient may be at the same time "uncomfortable" as a reaction to the patient's own modesty and possibly wrongly educated as to methods. What I mean is that the patient has seen on TV like we all have seen physicians examining patients through full layers of clothing as though this was a standard and accepted procedure. But that "covered exam" may be necessary when the patient is being photographed on TV but is not to be considered as an acceptable and productive standard of clinical practice. And this kind of ridiculous "diagnose through clothing" is not what we teach our students. But again, Jason, you brought up a point worth emphasizing to the student group. ..Maurice.

At Friday, August 14, 2015 7:43:00 AM, Blogger A. Banterings said...

First, do NO harm!

That does not only mean to the physical body, but to the psyche and to the dignity of the patient. That includes a patient's choice of the gender of their providers, calling a patient your age by their first name (without them telling you to), and not telling the truth. Perhaps the most common lie told to patients about students is introducing them as " (student) doctor."

Part of human dignity is the patient's modesty. Because one has examined hundreds or thousands of exposed bodies, you may only be the fourth or fifth person your patient has ever exposed their body to.

Imagine if the Supreme Court ruling that not only decided gender was a bona fide occupational qualification (BFOQ), but gave the patient the right to choose the gender of their was EXPANDED to allow the patients to VERIFY the gender of their providers. Would a provider be comfortable being exposed to every patient who simply asked to verify their (phenotype) gender?

Then why would any provider assume that a patient would have no problem being exposed to any provider who simply asked? Even with justification?

Point of view is everything. When you are the only one in the room without any clothes (only a gown), being FELT, POKED, and PRODDED; you are NAKED. When you are one of the ones wearing clothes, you EXAMINE the EXPOSED areas of the DRAPED patient.

How different would procedures be if the physician had to perform them in the same state of undress as the patient?

Silence, does NOT mean consent!

It is not a matter of what we know, it is what we don't know. When evidence is reviewed, things that we thought to be medically necessary are just ritual and provide NO benefit, some cause HARM to patients. Too many guidelines say "...despite lack of evidence, [insert name of the alphabet soup of organizations here], recommends that patients receive [insert ritualistic procedure here]...

"Do no harm" and the physician's fiduciary duty may require and justify the omission of procedures (even when appropriate), and despite the physician not feeling "thorough," to preserve the patient's dignity and mental well being.

No genital exam is ever routine or to be normalized (despite what the AAP says). Evidence only proves the opposite.

Is student learning medically necessary to the patient's current condition?

The people who speak on the Bioethics Discussion Blog are NOT against physicians, quite the opposite, they want to see them be the best that they can be....


At Friday, August 14, 2015 8:10:00 AM, Blogger Maurice Bernstein, M.D. said...

Banterings, although I won't use your specific words, I certainly will incorporate and elaborate on two of your titles "First, do no harm" and "Silence does not mean consent". I can pose the last question to the students since some may have that very question in mind as they start out, each student migrating from only a potential patient status themselves to one who treats patients:"Is student learning necessary to the patient's current condition?" The answer, for the first two years of learning is generally NO but with some occasional exceptions. For the last two years, some of the responsibilities given to the students may well be needed fpr the patient's current condition. However, that's why each student should never be called or considered as a "student doctor" but only as a "medical student" and their status in the hospital or clinic environment should always be initially explained to the patient and await the patient's consent. ..Maurice.

At Friday, August 14, 2015 9:51:00 AM, Blogger Maurice Bernstein, M.D. said...

I want you all to read this article in "The Atlantic". It will present to you the patho-physiology of most of the physician "disinterest" in the feelings of the patient as you all have amply described. And as you will see from the article, what I begin to tell my 6 first year medical students starting in 4 days may be highly significant in how they will personally consider and behave in the future. One interesting concept brought up in the article is the consideration of PTSD affecting the student as a consequence of what teaching and experience that is occurring.

Let us know what you think about the article and how you think it applies to what you all have been describing here. ..Maurice.

At Friday, August 14, 2015 10:03:00 AM, Blogger A. Banterings said...


I would hope that you post your "speech" either here or under a new topic.

As to the "medically necessary" issue, see the latest news: New York City Hospitals to End Filming Without Consent.

The Greater New York Hospital Association, an umbrella organization that represents all of New York City’s hospitals, has asked its member institutions to put an end to filming patients for entertainment purposes without getting their permission. The move came in response to an issue raised by a ProPublica story published with The New York Times earlier this year.

..."When you go into a hospital, you deserve to know that your sensitive moments are not going to end up on primetime.”

...“People don’t go to the hospital to be on reality television,” Caplan said. “It’s exploitation and it shouldn’t be happening anywhere in a hospital, a nursing home, or any other healthcare setting.”

See related: New York Legislation Would Make It a Felony to Film Patients Without Prior Consent

...Joel Geiderman, co-chair of the emergency medicine department at Cedars-Sinai Medical Center in Los Angeles and chairman of the ethics committee of the American College of Emergency Physicians, opposes filming of patients without prior permission.

“It’s sad that someone would have to pass a law to prevent hospitals from allowing something that is so clearly morally wrong,” he wrote in an email. “But at this point, that may be one of the only choices left.”

Here is the bill pending in the NY State Assembly:

The AMA takes up the issue in the current issue of JAMA (August 2015) in the article; Navigating the Minefields of Medicine and Journalism. It addresses the issue of patient privacy on camera (Sanjay Guptain Haiti), but it avoids the most blatant abuse of this, ER reality shows.

The AMA did take up the issue in JAMA in 2002: Commercial Filming of Patient Care Activities in Hospitals. Even though it concluded:

Although some argue that filming patient encounters is justified because, on balance, there is a societal benefit, appeals to public beneficence fail to adequately account for principles of fairness or justice. Under an egalitarian conception of justice, the relative social benefits and burdens of a policy or program should be distributed fairly and should not confer morally arbitrary advantages on some persons at the expense of others.77 Extrapolating this notion of fairness to commercial filming in health care, the principle of justice would presume that public education should not be at the expense of those who, through no real fault of their own, find themselves exposed before a camera. Since acutely ill and injured individuals are generally not responsible for their plight, they should not be exploited, exposed, or denied their rights to privacy as a result of their illness. Thus, justice would favor the privacy rights of patients over the interests of nonpatients to be informed, and filming without prior and appropriate consent would be proscribed.

The AMA still gave guidelines for filming in a hospital. The only logical conclusion that can be reached is that the AMA and other similar organizations are USELESS. Despite the facts, law,evidence, and common sense, they will continue to publish guidelines that are in the self-interest of physicians and NOT patients.


At Friday, August 14, 2015 12:11:00 PM, Anonymous Anonymous said...

From Dr B I want you all to read this article in "The Atlantic".

That's actually not a bad idea. Imagine how much more empathy there'd be if they found family willing to sit in DURING the dissection.

Another way to instill empathy for patients would be to have the doctors go through any non-surgical procedure themselves. Let them all take turns being "sequentially exposed" in front of each other and receive complete physicals from fellow med students before they make the assumption that a single "real" patient should go through it. It;s for the students benefit after all.

Sure, the DRE, pelvic / testicular exam likely won't be anything other than a practice run, but it will let the student know what the patient is going through, provide all the students doing it a baseline to "normal", and who knows... you might actually find something and save a students life through early detection.

Unless of course med students aren't mature enough to see each other naked and act like adults about it...

Might be an idea to ask them if they'd be willing to be "patients" for the class, and if not, why not... and why should the general public allow them to practice on them if they themselves are against it when it's the students that benefit from it, not the patient. a paragraph or two reply to that as a homework assignment might be some interesting reading.

Jason K

At Friday, August 14, 2015 1:19:00 PM, Blogger Maurice Bernstein, M.D. said...

Jaspm K, I have already gone through the discussion which you brought up in your last posting on a number of Volumes in the past. The students are "undressed" (but never naked) in the physical exam practice on each other and as I have previously written, genitalia exams are not performed on themselves but performed directly on teachers whose job (paid profession) is to instruct each student practicing on that teacher and then monitor and provide immediate feedback with regard to the student's ongoing performance.

I am sure that many students have been undressed as part of their own personal life experiences with medical care and fully remember their being the "object" of a physical exam and how they felt about it. No need to repeat such an experience as an academic requirement.


At Friday, August 14, 2015 2:22:00 PM, Blogger A. Banterings said...


I recognize the point that you make to Jason K, and that is probably more applicable a discussion in reference to 2nd/3rd year. Still I believe that there is some merit in the point that he brings up. In a 2000 article in Academic Medicine; journal of the Association of American Medical Colleges titled, "Are Medical Students Comfortable with Practicing Physical Examinations on Each Other?," the issue of practicing peer physical examinations (PPEs) on fellow classmates is examined. This paper noted:

Almost all respondents agreed or strongly agreed that PPEs are both an appropriate part of medical training (98%) and a valuable learning experience (97%). Most of the students (91%) did not feel that PPEs strain classmate relationships. No student indicated that PPEs were “unprofessional.”

But when it came to intimate areas:

The majority (56%) agreed that performing peer breast, genital, and rectal examinations is not an appropriate part of medical training, and 68% would not consider volunteering for such examinations.

Note that there is scientific evidence and a history of performing PPEs, including intimate exams:

eer physical examinations (PPEs) may also help develop student camaraderie, which has been identified as an important element of medical school learning.

...In the past, many medical students were required to perform full examinations on each other, including female breast, male genital, and rectal examinations.

So what does this teach Medical students?

- An "us and them" mentality where there are 2 sets of rules.
- Providers are superior to patients.
- "It is no big deal as long as I keep my clothes on."
- Professionalism is meaningless, it is what you tell patients to justify what you do.
- It teaches students to lie.
- It teaches students to objectify patients.
- Their dignity, modesty, and autonomy is absolute, the patient's is NOT.

Please note (before you crucify me), that I am not advocating for PPEs, I am just pointing out that there is a validity to his point. Professionalism and the rules must apply to all evenly, both patients and providers.

As to your students; I would assign them to read this 2011 article about Sir William Osler, M.D. on NIH: "Can Osler teach us about 21st-century medical ethics?"

It is important to note that Osler is not always the saint that he is made out to be. He did advocate and practice ritualistic procedures (like bloodletting) and was very paternalistic in many of his practices (a contradiction to most of his views). Osler also hid the addiction of a fellow physician. He also established residency (and to some extent clerkship) which have been the source of some of the most egregious abuses of patients.

Still, many of his words that advocate patient dignity have gone (mostly) unheeded to this day...

The motto of each of you as you undertake the examination and treatment of a case should be “put yourself in his place: realize, so far as you can, the mental state of the patient, enter into his feelings… Scan gently his faults. The kindly word, the cheerful greeting, the sympathetic look.

There is a tendency among young men about hospitals to study the cases, not the patients, and in the interest they take in the disease lose sight of the individual. Strive against this.

To serve the art of medicine as it should be served, one must love his fellow man.

Keep a looking glass in your own heart, and the more carefully you scan your own frailties, the more tender you are for those of your fellow creatures.


At Friday, August 14, 2015 2:32:00 PM, Anonymous Anonymous said...

I think you missed the point(s) I was getting at...

Sure, some of them have likely been "exposed" to doctors before... but how many of them have been exposed to students ?

And I suggested asking them if they'd be willing, and if not why not. if they put some thought into their answer, it might help them keep in mind what a patients objections might be.


At Saturday, August 15, 2015 2:02:00 PM, Blogger Maurice Bernstein, M.D. said...

I have been currently involved in an active discussion on a medical education listserv to which I subscribe about PPE (peer physical examination). So far there is consensus that the students should be aware of their real patient's modesty/dignity needs even there is no accepted or practical way to simulate the issue in a classroom PE session. And no.. we don't teach physical examination with a nude student just as we don't encourage physical examination of a nude patient. (and as I have written many times in the past, fully nude examination by some dermatologists should be discouraged and should be replaced by segmental skin exposure for inspection.)

I wrote the following to the listserv:

I think we should declare to the students that at no time, except for a life-threatening emergency, should physicians assume that patient's self- modesty or dignity is trumped by the need and value of an effectively performed physical examination.

So you see, what you are writing here is being distributed by me to the medical education profession. ..Maurice.

At Saturday, August 15, 2015 2:38:00 PM, Anonymous Anonymous said...

From Dr B I have been currently involved in an active discussion on a medical education listserv to which I subscribe about PPE (peer physical examination). So far there is consensus that the students should be aware of their real patient's modesty/dignity needs even there is no accepted or practical way to simulate the issue in a classroom PE session.

I know it's beating a dead horse with you about this at this point, but meh... what's a couple more swings at it?

A practical way to simulate it would be to have the students do genital exams on each other. Just saying.....

As for "accepted"... please don't use that word in conjunction with protecting a doctor or students modesty when you're talking about an industry that saw NO problem with raping sedated women for the same purpose as what they're avoiding themselves. NOTHING is the "accepted" practice until it is. By that, I mean a "new thing" has never been done, then done once or twice... if it doesn't work, it's abandoned, if it does work then it's spread and adopted by more and more people... then guess what? eventually it's the "accepted practice".

I'm curious what the folks on your listserv are suggesting for how to make students aware of modesty concerns, especially if the concept is as alien to them as it is (or was) to you. By that, I mean that you've said you've NEVER experienced a patient being uncomfortable being undressed / exposed / whatever... so how could you explain what to look for or how to deal with it, other than in a memorize and recite from a textbook speech? It'd be like someone who's never driven a car being the one to teach someone else how to drive.


At Saturday, August 15, 2015 4:31:00 PM, Anonymous Anonymous said...


Somewhat off topic but pertinent to your upcoming medical students. While not specifically addressing modesty concerns he talks about mistakes he's made. Important here is his attitude now from making his own mistakes and the actual admission that doc's make mistakes (stating the obvious but still nice to hear). He seems authentically sincere and humble. Refreshing.

Brian Goldman is a Canadian doc who cuts through the bs to address some hard to talk about concerns on his show 'white coat black arts'.


At Saturday, August 15, 2015 4:53:00 PM, Blogger Hexanchus said...

Dr. B,

You wrote:
"I think we should declare to the students that at no time, except for a life-threatening emergency, should physicians assume that patient's self- modesty or dignity is trumped by the need and value of an effectively performed physical examination. "

This is far as it goes. What's missing is that even in a life-threatening emergency, an alert and oriented patient still has the absolute right to refuse any exam, treatment or procedure. The emergency exception to the requirement of consent only legally applies if the patient is unable to give consent, such as if they are unconscious.

Regardless of the situation, if a patient has the capacity to make a medical decision (which only requires that they understand the potential consequences and are able to express that), then any provider that ignores their refusal is committing a battery against that patient.

This is something that all medical students need to clearly understand......and it wouldn't hurt a lot of physicians to be reminded of this either.


At Saturday, August 15, 2015 7:24:00 PM, Anonymous Medical Patient Modesty said...

I’ve been busy preparing for a fundraiser event for Medical Patient Modesty. But I wanted to share some thoughts about teaching medical students about patient modesty.

I do not think it is a good idea to push medical students into having unnecessary intimate exams at all. I feel this could desensitize them. For example, should everyone be bullied at school in order to understand why they should not bully people? I personally want to see medical & nursing students, medical professionals, and people who are not in the medical profession to have their modesty in medical settings protected as much as possible.

I feel medical schools have played a role in desensitizing many medical & nursing students and I feel this is why we see so many patient modesty violation cases today. I think it is ridiculous that medical schools require medical students who are going into specific specialties such as ENT, podiatry, orthopedic surgery, etc. to learn how to do intimate procedures. A female doctor who is going in OB/GYN will never do rectal or genital exams on male patients so why should she have to participate in genital exams on male patients? Check out some of my comments on medical schools cutting out unnecessary intimate exams on Dr. Sherman’s blog.

Check out this article:
“What Your Doctor Won’t Tell You About Surgery”
. A medical student talked about how mortified she/he to discover that many medical professionals probably saw her/him naked during appendectomy. But then she/he got desensitized to this in medical school. Most patients do not know the truth about how exposed they are in operating room once they are under anesthesia. I have bolded the section about the medical student below.

We all see you naked, but we don’t care
When I had my appendectomy in college, I was absolutely mortified when I discovered the next day that the surgeon, residents, nurses, assistants, techs, aides, and probably several dozen other people all saw me au naturel. It hadn’t even occurred to me beforehand that this was even a possibility. Several years later during the first operation that I witnessed as a medical student, I immediately realized that no one in there cares. We’ve all seen it a million times, and trust me, despite what you may believe, yours is no different than anyone else’s. I’ve had many patients who have been apprehensive about disrobing before surgery, but there is nothing remotely titillating in the operating room. Nothing.

I have come across some nursing students who were very upset about the idea of doing opposite sex intimate procedures. In fact, I knew a male nursing student who was very upset about the idea of doing breast exams on female students in his class because he had a moral conviction it was wrong for him to see women’s breasts. But some people including his mom told him it was important for him to do that in order to pass the class. A few years later, he got so desensitized to patient modesty that he did not really want to acknowledge that patient modesty was an issue.


At Saturday, August 15, 2015 7:29:00 PM, Anonymous Medical Patient Modesty said...


I really appreciate your great points below:

What's missing is that even in a life-threatening emergency, an alert and oriented patient still has the absolute right to refuse any exam, treatment or procedure.

Regardless of the situation, if a patient has the capacity to make a medical decision (which only requires that they understand the potential consequences and are able to express that), then any provider that ignores their refusal is committing a battery against that patient.

Patients definitely have the right to decide what exams or procedures they can have. It really frustrates me that some doctors and nurses insert catheters in patients who have life threatening illnesses or injuries without their consent. Urinary catheter is overly used. It is not just patient modesty you have to be concerned about, but urinary catheters have caused a lot of complications.


At Saturday, August 15, 2015 9:40:00 PM, Anonymous Anonymous said...

From Misty's post -- We all see you naked, but we don’t care
When I had my appendectomy in college, I was absolutely mortified when I discovered the next day that the surgeon, residents, nurses, assistants, techs, aides, and probably several dozen other people all saw me au naturel. It hadn’t even occurred to me beforehand that this was even a possibility. Several years later during the first operation that I witnessed as a medical student, I immediately realized that no one in there cares. We’ve all seen it a million times, and trust me, despite what you may believe, yours is no different than anyone else’s. I’ve had many patients who have been apprehensive about disrobing before surgery, but there is nothing remotely titillating in the operating room. Nothing.

It's this attitude that disgusts me, and is 95% of the problem.

First, it's easy to say that as they're not the ones naked (notice the med student uses the word "naked", not "exposed".... )

Second, that statement is looking at it from the wrong frame.... it has nothing to do with how many naked people the clothed person has seen... it's how used to being seen naked the person expected to undress is. You really think a nude model or porn star would be as uncomfortable being seen naked by a group of (dressed) virgins as a virgin would be being seen naked by a group of (dressed) nude models or porn stars?

This dismissive attitude is almost as bad as their sense of entitlement.


At Saturday, August 15, 2015 10:42:00 PM, Anonymous Anonymous said...

Regarding the comments from Misty's post.

"but there is nothing remotely titillating in the operating room. Nothing."

Folks, obviously these comments were written by someone whose goal is simply to dismiss the countless unprofessional
behaviors that occur in the operating rooms. Dr Twana Sparks would know, ask her.


At Saturday, August 15, 2015 10:46:00 PM, Anonymous Medical Patient Modesty said...

Dr. Bernstein,

You mentioned that you will be meeting with 6 first year medical students. Is this their first semester of medical school? I think it is important to reach out to medical and nursing students when they first start medical / nursing g schools about patient modesty. Several nurses told me that they were never taught about patient modesty at the local community college that has a nursing program.

As you can see, we have some tips for medical students / residents on MPM’s web site. I would love for you to use some information from this link to share with your medical students.

If I had to come up with a paragraph I wanted you to share with your medical students, here’s what I would say to them:

Be considerate of patients' wishes regarding patient modesty. Many people don't feel comfortable having certain parts of their body exposed to the opposite sex except for their spouse. Always work to respect patients’ wishes for modesty. The number one priority should be the patient and the number two priority should be the patient's family. Keep in mind that their wishes for modesty are very important.


At Sunday, August 16, 2015 9:05:00 AM, Anonymous Anonymous said...


This article states:
“Lack of respect poisons the well of collegiality and cooperation,” the authors of the articles wrote. The poisoning-of-the-well metaphor is apt. Like pornography, we know it when we see it. Ask a nurse or an intern or a medical student, and they can tell you with pinpoint accuracy which areas of the hospital are toxic to work in, and which are not. Now think of the patients who have the misfortune to be stuck in one of those toxic areas. It’s not just unpalatable; it’s unsafe.”

She quotes this study of disrespect in medicine:,_Part_1___The.10.aspx

“Humiliating, degrading, or shaming behavior is a threat to patient safety because it can have both immediate and long-term negative effects on the recipient”

“Malpractice suits are more common against physicians who intimidate or insult patients”

“If the physician is not a constructive team player, team efforts fail, and patients suffer the consequences.”

“But the most serious effect on students comes from within. Disrespect is learned behavior, and students learn it from their role models, the faculty.”

“Even when they have minor ailments, virtually all patients have some fear and anxiety when interacting with the health care system. Doctors and nurses have the power to reduce this distress substantially by being sympathetic and understanding.”

“Doctors who have suffered bad experiences, such as bullying, during their formative years may be so traumatized that imitative behavior becomes ingrained in their unconscious. Their reaction to stress is to bully, reflecting their earlier experiences.”

“Disrespectful behavior is pervasive in health care and takes many forms. “

You will launch your students into a culture where disrespect causes many negative outcomes – one being lack of concern for patient modesty. You cannot change the downstream system but you can help foster a mindset in your students that helps them navigate through without turning into stressed disrespectful clones.

At Sunday, August 16, 2015 11:31:00 AM, Blogger Maurice Bernstein, M.D. said...

Kevin, you quote “But the most serious effect on students comes from within. Disrespect is learned behavior, and students learn it from their role models, the faculty.”

But, I can tell you all, this attitude if it affects the behavior of some students certainly does not come from instructors for the first two years like me or my colleagues. Respect for the patient is emphasized throughout those years and we actually tell the students that if they witness any disrespect in their later years as part of the "hidden curriculum" they should make their observations known to the faculty trusted to handle these unprofessional issues. This is what they are taught and this is another point I will inform my group of 6 first year students in a couple of days. ..Maurice.

At Sunday, August 16, 2015 5:07:00 PM, Anonymous Anonymous said...


Your commitment to this blog leads me to believe you do care and want to make the system better. Most of us responding here have either had bad experiences in health care or like me have reasons to avoid. Unfortunately you are on point for the greater whole of medicine where it is not always so 'ideal'. I am sure you cringe like us lay people when you read accounts of what some folks are put through by the miscreants in the system - but at the same time are proud of your profession; what you have done as a doc and the great things that have been accomplished by medicine in general. Were it not for modern surgery techniques I would have likely died at 10 from appendicitis/peritonitis so I get this in a very empirical sense.

I have no doubt that your students will be given a great foundation in humanistic treatment of their pts - what they do with it is up to them. I hope that these new students are the seeds of change; that they can help to initiate a shift in the system from within. Banging on the doors of fortress medicine doesn't get one very far (I know this from personal experience); the only thing that gets heard is lawsuit filings. This is stupid, unproductive and serves only to enrich leech lawyers and polarize the parties. We need to initiate a conversation in healthcare without acrimony, pride and defensive posturing getting in the way. Being a mentor is an extremely important and honorable undertaking - I think your students are fortunate.


At Sunday, August 16, 2015 6:39:00 PM, Blogger Maurice Bernstein, M.D. said...

Thanks for your personal supportive comments but I want to emphasize that, based on student feedback and the discussions in our faculty meetings, that it is virtually all the instructors teaching "Introduction to Clinical Medicine" to these first and second year medical students who are engaged in teaching medical professionalism from the view of that "its not all about ourselves but it is all about our patients."

And, by the way, even though over the years here I have been restating that I never was told, never heard, from my patients anything about how they wanted to be treated or how they were being treated (good or bad) from a physical modesty point of view..never.. this doesn't mean that during the 25 years I have been participating as an instructor in this course that I abandoned instructing the students the necessity for developing a relationship with the patient beyond diagnosis or treatment. A relationship which should include listening to the patient as we hope they would listen to us and proceed with our attention to patient informed consent. In a few words on Tuesday but to be repeated in further detail as the year goes on, this will be my definition to include into what makes up the goal of becoming a medical professional. ..Maurice.

At Sunday, August 16, 2015 7:04:00 PM, Blogger Maurice Bernstein, M.D. said...

To amplify what I wrote about in the last posting, I would like to reproduce here a posting I put on my blog here in July 2004. It was a poem I wrote about a real case that I had just experienced and emphasizes paying attention to the patient as a person and not just a disease. (For those who know the difference, I used the wrong expression: referring to "translation" and "translator". Actually, correct term for my assistance was "Interpretation" and "Interpreter". Translators work with the written word Those who work with people are really termed interpreters.) ..Maurice.

Unspoken Translation
by Maurice Bernstein, M.D.

“I have this”
She talked through a translator with a language I don’t know
“And it burns”
She pulls up her shirt and points to her kidney
“I am worried”
Why? I ask through a translator
“I am unmarried and have a small child”
Are you worried about your kidney? The translator speaks for me
Tears fill her eyes and move down her cheeks and
I don’t need a translator to tell me more

At Sunday, August 16, 2015 8:18:00 PM, Anonymous Anonymous said...


So then assuming that you and your cohort are all on the same page as to ensuring the students are "all about your patients";

Are students given any psychological testing for vocational suitability prior to admission? Attitudes, personalities, empathy etc.

Is there any tracking of students in the system to gauge their future performance or perhaps changes in attitudes after they leave your charge? It would be interesting to track them and any changes in attitudes/personality/behaviours as they move through to the MD. I think it would reveal major changes when sleep deprived; pressured and perhaps bullied. I read that many med students deal with depression and contemplate/commit suicide and develop PTSD during this phase.


At Sunday, August 16, 2015 8:52:00 PM, Blogger Maurice Bernstein, M.D. said...

Kevin, I truly can't speak about medical school admission practices since I don't participate but only on rare occasions of a "problem" student do I wonder.

If you check the literature, you will find that long term followup of students, comparing their years later outcomes and problems (including unprofessional or criminal) with their behaviors, at the time of their medical school experience is really rather limited. A well known, first study is available at this link

Yes, the mental illnesses you wrote about are realistic and are noted in our faculty meetings and there is opportunity to identify and treat those symptomatic students at our medical school. ..Mauric.


At Sunday, August 16, 2015 9:24:00 PM, Blogger A. Banterings said...


You said in response mainly to Jason:

"And, by the way, even though over the years here I have been restating that I never was told, never heard, from my patients anything about how they wanted to be treated or how they were being treated (good or bad) from a physical modesty point of view..never..."

I find this worrisome because I can point to an instance of this that you experienced. Remember the student with the colostomy bag who did not want the other students examining this feature about him? The fact that you can not bring that up to counter Jason is disconcerting.

Perhaps you need to ask yourself if you recognize this discomfort in patients. Please not I am not accusing you of any malice or shortcomings, but as has been pointed out on this thread, have you been desensitized to patient dignity and modesty? I am sure that after pointing this out, you will have multiple examples of you experiencing this discomfort in patients. So what is medical education lacking and potentially what is not being taught to medical students?

Another point that you made was"

"...But, I can tell you all, this attitude if it affects the behavior of some students certainly does not come from instructors for the first two years like me or my colleagues. Respect for the patient is emphasized throughout those years and we actually tell the students that if they witness any disrespect in their later years as part of the "hidden curriculum" they should make their observations known to the faculty trusted to handle these unprofessional issues..."

I understand that it is not your problem if the teachers "poison" your students in the 3rd and 4th years, AND you don't know what their attitudes and behaviors are because after that they are off to residency. But then how can you say that you ARE adequately trained your students if you have no data to back the assertion? Is this the ritual that exists in medicine?

Furthermore to many it seems to epitomize the Edmund Burke quote, "The only thing necessary for the triumph of evil is for good men to do nothing."

Evidence has changed your view on what people have said here over the past 9 years. All the assumptions made about outliers have been proven false and the problems shown to be systematic. So let's start looking at the system from the beginning. Is it working and if it is, where is the evidence?

I am sorry if this seems like a personal attack, it is not meant to be. I would hope that you know by now that I am not like that. I am looking at this issue scientifically. I hold that I may be missing some pertinent facts that show my assertions that I put forth to be in error, and I would prefer to be wrong in this situation.


At Sunday, August 16, 2015 9:37:00 PM, Anonymous Anonymous said...

Physician bullying nurses
Nurses bullying Physicians
Physicians bullying patients
Nurses bullying patients
Round and round it goes
Where it stops, nobody knows.


At Sunday, August 16, 2015 9:56:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, I am not sure that your link got to the topic you wanted to present.

Banterings, what I have been stating about my patients is quite true. I am not sure what that has to do with the isolated case of a medical student in my group who did not want to expose his abdomen to his colleagues in the abdominal exam workshop because of his colostomy. Yes, I was quite appreciative of his concern and in view of his rejection of my suggestion that viewing the colostomy itself would be of teaching value to the other students, I told him that he could examine his colleagues but didn't have to be examined himself. But. again, this has nothing to do with my experiences with my patients since if they were concerned the didn't speak up.

Banterings, I have no personal upsets about your comments since I see you are trying to understand and learn about the important behaviors of the medical profession in relation to their patients..and, of course, vice versa. ..Maurice.

At Monday, August 17, 2015 8:17:00 AM, Blogger Maurice Bernstein, M.D. said...

Below is a posting by A. Banterings last evening that was erroneously not published at the time.


Just as I call providers out when they are wrong, I am pointing out an instance that can refute Jason's assertion of you not recognizing "distress in a patient." Although he was your student, you were also his physician, even if just in (if you will) a role play situation for the purposes of learning. You also handled that situation in a very compassionate manner even though (by your own assertion) your students would have benefitted greatly if he had allowed the examination.

Perhaps even greater was the lesson of the physician's fiduciary duty of not being thorough....

I also asked why you have not used this as a rebuttal to Jason's arguments?

As to the question of proof, you defend your teaching, and I agree that (from your description of your teaching and the obvious love that you have for your students and profession) that you cover patient dignity/modesty thoroughly. But I question the results? Is there any data, proof, tracking, etc. that shows the curriculum is doing enough?

One may see a logical connection between oral contraceptives and PEs, but the evidence (and guidelines) does not support it. I simply pose the possibility that this may be the situation not only with your school's curriculum, but the entire medical school curriculum.

The passing of the boards is more about technical skill than patient dignity.


..and my comment to Banterings:

I was not looking myself as a physician nor was I presenting to the student as his physician in terms of his concern about exposing his abdomen. I was his instructor in the practice of medicine and my permitting him to avoid exposure to his colleagues was my decision as an instructor. Taking on the role and responsibility as an individual's physician is, as you would agree bears different responsibilities.

With regard to the medical boards, different than when I took the boards years ago, there is the use of standardized patients to test not for just technical skills but how the developing professional demonstrates skills attending to the patient with humanistic skills. ..Maurice.

At Monday, August 17, 2015 9:11:00 AM, Anonymous Anonymous said...

Here's a female pediatrician who wrote this blog about the need for teen boys to "get em checked". Hmm, valid argument, right? Thing is she wanted to do a genital exam on teen boy with mom present and was surprised when he didn't comply. Her view is so entitled and provido-centric that she just can't understand why the boy had a problem. She added a new posting about a boy with an un-distended testicle which had been missed as no one checked him. She says girls seem to have gotten over this..lets see, female (same gender) doc. By this justification we could do all kinds of exams on underage pts in their own best interest.

Can one get a concussion/brain trauma from too much face-palming?


At Monday, August 17, 2015 10:13:00 AM, Anonymous Anonymous said...

Bad Blood: Doctor-nurse behavior problem impact patient care.

Bullying in healthcare


At Monday, August 17, 2015 6:57:00 PM, Anonymous Medical Patient Modesty said...


The web site link you provided would not work. Can you please check again to see what the actual web site link is?


At Monday, August 17, 2015 8:24:00 PM, Blogger A. Banterings said...


I know that post very well. I had posted a comment in a very respectful tone backed by evidence (as I do here) and it was deleted by Dr. Berman. This shows that along with the issues you cited, Dr. Berman disregards evidence and practices voodoo medicine.

Also note the graphic that she uses of the clueless, adolescent, stoner. Reminds me of Jeff Spicoli (Sean Penn) in the 1982 movie, "Fast Times at Ridgemont High."

I personally find this article degrading to males. Why should a teen male object to a stranger (who happens to be wearing a magic white coat) examining his genitals?

Her assertion in "fail[ing] Communication 101 with Dan at explaining the importance of a complete body check..." is based on the fallacy that just because one wears a magic white coat, it is appropriate and no one SHOULD object to that person examining their genitals.

At least she did NOT fail at informed consent 101...


At Monday, August 17, 2015 9:34:00 PM, Anonymous Anonymous said...


For me the fact that his mom was in the room, she's a female doc and he was a teen boy speaks volumes to me about the doc's mindset. Especially a pediatrician who of all docs should know the psychology of adolescent males. Kudos to mom for backing him though - if she wasn't there the good doc would likely have brow beat him into compliance and one more male would likely stay away from care due to humiliation/lack of trust. Then she and those like her will write more articles about how stupid males are to avoid care.

My comment pretty much stated this (politely); and wouldn't you know it - it got deleted. Funny - hers is the only comment on the blog..? Opinions are great as long as they match hers I guess, but not one (aside from hers) has in five years? Hard to have conversations with folks in the business when they plug their ears and sing. This is why the conversation needs to take place within medicine. Only so much we can do from outside.


At Tuesday, August 18, 2015 9:09:00 AM, Blogger A. Banterings said...


Agreed 100%.

Still, there was something else bothering me about this post and I could not figure it out until last night. It’s the title: "To Teen Guys: Yes, We Really Need To Check ‘Em."

There is an old saying, the only thing we NEED to do is PAY TAXES and DIE. So where is the honesty? If the truth be told, the title would be, "To Teen Guys: Yes, I would like to To Check ‘Em." But why would this professional lie?

There are many reasons. The first being that this makes her sound really creepy (creepier than she already is). By saying "NEED," the physician is an instrument of some greater power and (like the patient) does NOT have a choice in the matter and must comply (cited in Joan Emerson’s Behaviour in Private Places). This also makes the patient to have a mental disorder when they refuse (cited in Joan Emerson’s Behaviour in Private Places).

Unless there is a genital complaint, (and even then) there (may be) is no reason to perform a genital exam. Does performing the GE make a diagnosis easier? Yes, but it is much less convenient. This blog has repetedly demonstrated that healthcare is all about the convenience of the providers.

The next (invalid) argument is that the physician WANTS to give the best care. In order to give the best care, she NEEDS to preform a GE. The problem is that the term, "the best care" is subjective. What are the goals of the patient are not necessarily the goals of the physician. That is why paternalism has been replaced with patient autonomy. (See: PubMed, "Supporting Patient Autonomy")

It is well known that physicians will order unnecessary tests just to CYA.

Here is the Science Based Medicine article, "Why Doctors Order Too Many Tests" that cites the 1979 New England Journal of Medicine article written by Joseph E. Hardison, MD which examines the excuses given to justify unnecessary tests and procedures.

Healthcare tells lies until they become truths. Why else would there be guidelines that say, "despite lack of evidence…"?

A recent article, published in the journal Mayo Clinic Proceedings, provides chilling evidence that many well-established medical practices are wrong. Researchers from the National Institutes of Health looked at 10 years of clinical investigations from the New England Journal of Medicine. Over the past decade (2000-2010), they found 363 published studies that evaluated an established therapy.

In 146 of the 363 studies (40%), the scientific evidence caused a reversal of established medical practice. That’s a sterile way of saying that nearly half the time the prevailing wisdom was wrong. It is worth going over some examples. Not one branch of Medicine was spared a reversal. (Source: journal Mayo Clinic Proceedings)

Then providers refuse to acknowledge the real truth and continue to cling to the lies as truth. (See: Changing the culture of American Medicine — Start by removing hubris )

So what are we left with? A system of Voodoo, convenience, and lies.


At Tuesday, August 18, 2015 10:29:00 PM, Anonymous Anonymous said...

Let's reverse the roles

The male pediatrician posts a blog with a pic of a young teen
womans shocked look and the caption

To teen girls: yes, we really need to check'em, your breasts.

With the young womans father in the room.

You can always appreciate the double standard when you
reverse the roles. I really don't think a male pediatrician would
post such a blog. With the creep factor and all but I suppose
this female pediatrician thought it's ok and that she can just
do so and fly under the radar.


At Wednesday, August 19, 2015 7:58:00 PM, Blogger Maurice Bernstein, M.D. said...

Here are my notes for yesterday's few minute introduction for my 6 first year medical students to the issue of patient modesty and dignity and the need for the student's awareness to consent and patient discomfort with what is occurring. This was just a beginning. I will have more time to discuss this in greater detail and also provide feedback after actually observing them with patients.

Attention to the patient not as a disease (NOT "the gallbladder in room 214") but as a whole person.
Students and physicians should attend to obtain informed consent for taking a history or performing a physical examination.
Be aware and attentive to the patient's modesty and dignity issues and observe the patient for discomfort during the taking of a history or performing a physical examination. Have the patient "speak up" if you sense discomfort.


At Wednesday, August 19, 2015 8:28:00 PM, Anonymous Anonymous said...

Part 2

To quote Donmd again: “We know that girls in our society grow up being taught it's OK if they bathe the baby boy or babysit. We have no problem with a 5th or 6th grade girl helping bathe a 4 year old boy or change a 3 year old's diaper. But would we feel that comfortable with a 5th or 6th grade boy helping bathe the 4 year old girl? We tend to protect the female toddler, but let any little girl see the baby boy. “
I grew up where as a young boy I was not allowed to wear a swimsuit where girls were always covered. Women feel they have an inherent right to men’s bodies but not the reverse. This has created a sense of entitlement in women.
Note Dr. Berman’s attitude in previous link that she has a ‘right’ to examine a teen males genitals and uses her white coat to argue her position. Never once did she question his reaction – only her own – what if he was sexually abused by a female? Didn’t seem to enter her stream of consciousness. Modesty is a learned trait – affected by social conditioning/trauma.
Lara Stemple on the results of the National Crime Victimization Survey ; The experience of men and women is “a lot closer than any of us would expect,” “In asking 40,000 households about rape and sexual violence, the survey uncovered that 38 percent of incidents were against men.

I dated a female MD once and asked her – if I was your pt and you didn’t know me – would you have been sexually attracted? Answer? Yes.

Do I hate women? No – just am not stupid enough to accept the lie I get fed by feminism and healthcare.


At Thursday, August 20, 2015 9:08:00 AM, Blogger A. Banterings said...


I spoke of (and referenced) the use of correct terms such as “need” and "want.” Now I want to examine something you stated:

"Students and physicians should attend to obtain informed consent for taking a history or performing a physical examination.

You use the term “SHOULD” when you must use the term ”MUST."

"First, your return to shore was not part of our negotiations nor our agreement, so I must do nothing. And secondly, you must be a pirate for the Pirate's Code to apply, and you're not. And thirdly, the Code is more what you'd call guidelines than actual rules. Welcome aboard the Black Pearl, Miss Turner.” ―Hector Barbossa, Pirates of the Caribbean: The Curse of the Black Pearl (2003)

This is part of the problem with informed consent that I pointed out back in Volume 69 (I believe). To have any exceptions to informed consent is a slippery slope. I initially took issue with it in “emergency situations” and with it in terms of “medically necessary.” The latter making a criminal act only an ethical violation. There are other situations where it is permissible to lie to a patient, not require consent, coerce the patient, or ignore the patients wishes.

Patient consent must be absolute! I believe that we should go to a system not of patient autonomy but that of patient paternalism (the opposite of traditional paternalism). You have defended against this saying that physicians are at risk of censure, loosing their license, lawsuits, etc. Patients are risking something much greater, their lives. Again, the slippery slope. Here is what it leads to:

Dr. Sean Orr, Accused of MS Misdiagnosis Scheme, Back in Business.

It is the same for only wearing a gown for surgery. Instead of the inconvenience of determining which patients need to only wear a gown, educating them, explaining why you can only wear a gown this time when last time you had your own clothes, etc., just require everyone wear a gown.

Catheters are the same way. Why help a patient to the toilet or have to wait for a urinal (and clean any spills), just catheterize everyone. No one can argue this point, just look at what Medicare requires of a hospital’s catheterization program.

In my discussion about the PPE (peer physical examination) above, I said it teaches students:

- An "us and them" mentality where there are 2 sets of rules.
- Providers are superior to patients.
- "It is no big deal as long as I keep my clothes on."
- Professionalism is meaningless, it is what you tell patients to justify what you do.
- It teaches students to lie.
- It teaches students to objectify patients.
- Their dignity, modesty, and autonomy is absolute, the patient's is NOT.

That is reflective if the views of (almost) all providers. They are against “patient paternalism,” PPEs, and other things that patients have been subjected to for hundreds of years. Why the double standard? If the system is can be applied to patients, then why not providers?

It is the same with the clothing argument; all the people wearing clothes have no problem with the patient’s body or state of undress.
The patient must be an outlier or mentally disturbed…


At Thursday, August 20, 2015 9:43:00 AM, Anonymous Anonymous said...

Here's Part 1 of my last post - guess it got lost...

There is a cortical blindness when it comes to women and sexuality. Feminism has sold the trope than men are sexual and women benign – which plays directly into the gender neutral crap we get fed as users of healthcare; and of course with the overwhelming female presence in medical roles this is problematic.

To quote Donmd – (a male doc who visited a modesty discussion on Allnurses commenting on a man who was being catheterized by a female RN with two other RN’s standing there watching). Not long before this he was driving to work – now he was naked with three strange women present: “The patient did what most men in the patient role do. Assumed this was how it is, and if he objected he'd be a bad patient. So he did one of the two options men have. Either "man up" and tough it out and maintain control, or freak out and be aggressive and loud and be seen as an ass. He stayed quiet.” Proving again men are not modest, right?

The youtube vid (below) is with Michele Elliott of 'Kidscape', in an interview recorded in 2004, and provides an insight into women who sexually abuse children and covers how some Gender Feminists (among others) have attempted to suppress the reality of the high prevalence of female abusers. Note that at 6:43 she refers to jobs female paedophiles seek – teachers, nurses etc. When we are blind to this we leave our children at risk; and it calls into question the very foundation of gender neutrality; and allows female abusers easy access and excuse. Talk about fox in the henhouse. Is it a good idea to give women carte blanche access to children or any dependent patient? My grade 3 (female) teacher would watch all the boys in my class urinate to “control misbehaviour” – no one gave it a second thought. Reverse genders? Remember these woman abuse boys too.

In the book/film “The world according to Garp”, a nurse decides to become pregnant from a dying patient who was perpetually tumescent. Fiction but we don’t bat an eye at the thought. Reverse genders? Male nurse having sex with a semi-conscious female pt? Cortical blindness. Many examples of how we accept this behaviour in fiction and in real life due to our societal view of the female. Not only is a teen boy ‘lucky’ when an adult woman sexually predates upon him – he is legally responsible for any child that arises from the statutory rape in many states. Not sure if Garp’s mom sued the soldier’s estate for child support…? Kevin

At Thursday, August 20, 2015 10:44:00 AM, Anonymous Anonymous said...

Maurice: "Be aware and attentive to the patient's modesty and dignity issues and observe the patient for discomfort during the taking of a history or performing a physical examination."

This relies on the student recognizing psychological behaviours in someone he/she has likely never seen before. The pt may be anxious just being there (white coat hypertension). Why not cut to the chase and ask them if they have any modesty concerns? Great time to address them isn't it/ takes the guesswork out. Kevin

At Thursday, August 20, 2015 12:06:00 PM, Blogger Maurice Bernstein, M.D. said...

Banterings, between "should" and "must", there are very few "musts" in medicine except "must not" as related to criminal behavior or acts. Otherwise, "should" is a proper way of expressing to medical students a directive. In some life-threatening situations where the patient has no capacity for decision making (unconscious) and there are no patient surrogates available, the word "should" is appropriate since it reminds the medical staff to obtain consent through an advance directive, POLST or search for a legal surrogate before examination or treatment but that attempt to save a life is not denied because no time is available to carry out the requirement set by a "must".

Kevin, for the student to "be aware" does require direct feedback from the patient when the patient is informed of what is to be done. (Remember, creating an "informed" patient is more than presenting the patient with information but also establishing whether the patient understands. This should then give the patient an opportunity to "inform" the physician.} But, you know, even with informed consent, if a patient shows or expresses signs of discomfort during the history or physical, the student should also be "aware and attentive". ..Maurice.

At Thursday, August 20, 2015 12:19:00 PM, Blogger Maurice Bernstein, M.D. said...

By the way, though I may have mentioned this once in recent Volumes, I want to congratulate all my visitors who are commenting nowadays for expressing their views utilizing specific references and links and not just "telling" some view or views of others without specific documentation, the latter being a common observation through many, many of the early Volumes on this thread.
P.S.- Just take care to be sure that the links that you post are currently active and will provide the reader with the specific information you want to document and not just some advertisement or error message.

At Thursday, August 20, 2015 2:03:00 PM, Blogger A. Banterings said...


In your example of an unconscious patient, “must” is better than "should.” It is easier in that situation to say “the patient can’t consent” and proceed. Saying “must” reenforces the notion to seek consent beyond just the patient.

It still sounds optional. All patients sign a consent to treat, so is that good enough? It just is too, “should have,” “would have,” “could have...”

The other problem that I alluded to with the Pirates of the Caribbean quote was that ethicals and guidelines mean nothing in healthcare. Legal and ethical are 2 different things, only legal is enforceable. Medical Boards are useless in self-regulation:

The Washington Post, Medical Boards Let Physicians Practice Despite Drug Abuse

The Bad Doctor Database

Note that this 2014 LA Times article (The M.D.: Silence on bad doctors) stated:

Some doctors simply don't believe that reporting is always the right thing to do. In fact, only 64% of physicians surveyed in the JAMA study completely agreed that they have a professional commitment to report a colleague who may be endangering patients or not adequately performing his or her job.

This is an incredibly good PubMed article on the topic: When Good Doctors Go Bad.

To bolster proof that this is a common problem with healthcare, read this article from Great Britian: The pervert will see you now: Doctors with convictions for child PORN allowed to practice.

Even the Hippocratic Oath is not standardized.

Nearly all medical schools incorporate some form of professional medical oath into their graduation ceremonies. The oldest and most popular of these oaths is the Hippocratic Oath, composed more than 2,400 years ago. In modern times, especially during the twentieth century, the Hippocratic Oath has had its content changed and its authorship challenged. (Source: Albert Einstein College of Medicine)

See also: The Hippocratic Oath Today.

How many guidelines have been referenced saying “despite lack of evidence…”? There are so many conflicting guidelines that a physician can do whatever he/she chooses and still be following guidelines. (See: Why Many Doctors Don't Follow 'Best Practices')

Patient paternalism is the solution. Why are we constantly asked to sympathize with those who hold more power than us, and have been known to often wield it irresponsibly? Physicians have long held a privileged position within society where their authority has traditionally been unquestioned and respected. Now health insurance companies, healthcare corporations, ACA, and EHR have usurped a lot of their power, which makes the position a lot less appealing. People don't often surrender power willingly, right?

Just like with self regulation, if the system does not start using the correct terms like “want” and “must,” then regulations will continue to remove the power that the system refuses to give away.


At Thursday, August 20, 2015 3:32:00 PM, Anonymous Anonymous said...

Part 1
So what exactly is a ‘modesty/anxiety issue?’ Somehow people go from a naked newborn who doesn’t give a whit about nudity to having modesty issues or feeling anxious about a medical exam. Why does this occur? While it may be immediately obvious that a person has issues due to religious beliefs– why all the others?

Using the accepted numbers that 1 in 4 women and 1 n 6 men have been sexually abused by age 18; assuming an equal gender split in pts fully 20% or 1 in 5 of the pts your student will see have been sexually abused by this age. Knowing how males are less likely to access healthcare it will likely be higher than that as the balance tips to the females. That’s a significant morbidity rate. I would suggest that you use an algorithm to specifically rule out this history when consulting patients. You would ask if I’ve had diseases which affect a significantly smaller % of the population than this so why the reluctance to ask? I don’t get it. It directly affects outcomes – from psychological outcomes to pain perception, PTSD to not re-accessing healthcare or following up afterward.

“Many men find it difficult to admit they have been sexually abused. Our culture encourages males to believe they should be in charge of every aspect of their lives, so when boys are abused, they often think they should have been able to stop the abuser. Later, as adults, they may blame themselves for having allowed the offender to have power over them.”

A few poignant notes from this handbook on sensitive care of abuse survivors:

Survivor participants also spoke about dissociating during interactions with health care providers.

Many survivors spoke at length about their tremendous fear and anxiety during health care encounters. The experiences of waiting, being in close contact with authority figures, and not knowing what is to come all resonated with past abuse.

Conditioning to be passive. Abuse can teach children to avoid speaking up or questioning authority figures. In adulthood, survivors may then have difficulty expressing their needs to a health care practitioner who is perceived as an authority figure

Few issues highlight survivors’ difficulties in health care settings as much as the need for removal of clothing. While practitioners often take for granted the need to disrobe and to don an examination gown, undressing for someone in a position of authority transports many survivors.,,, cont'd

At Thursday, August 20, 2015 3:40:00 PM, Anonymous Anonymous said...

This blog thread has turned serious and constructive which is good. Occasionally it's worthwhile to see that someone [me in this case] has learned something from reading the thread.
At the risk of a Pyrrhic victory, I decided to request the male scribe when making the appointment for my annual dermatological checkup. The male scribe was a condition of accepting this MD in the first place [via letter and face-to-face conversation with a staffer]. The male scribe had been present at past appointments, but I knew a specific request would be pushing the envelope. Sure enough, a female scribe accompanied the MD. It was an opportunity for a pleasant conversation [per the advice of previous posters] with the MD in the presence of the female scribe. Among other points, I asked him if the letter addressed to him was in my file [of course not]. Now I have to find a new MD or accept wrong appointment dates and times, double wait times in the office, and other negatives beyond my creativity which is inferior to petty functionaries with power and the need to prove, to themselves, that they are in control.

At Thursday, August 20, 2015 4:22:00 PM, Anonymous Anonymous said...

…..Part 2
Health care providers should recognize that, while asking for this information may seem safer than talking about past abuse, survivors may still experience it as difficult. If an individual’s nonverbal cues indicate tension or anxiety, the practitioner may need to ask very specific questions such as, “Do you have any discomfort having your blood pressure taken?” or “Do you have difficulty when someone touches your knees?” Survivor participants urged clinicians to pick up on obvious things: “You seem very anxious, is there something that you are uncomfortable with or is there something I should know?”(Man survivor)

Touch is difficult, but if I feel safe, then I can tolerate more. (Man survivor)

The practitioner who helps the survivor to feel some sense of control during treatment can allay abuse-related fears and increase the likelihood of greater cooperation during treatment.

Feeling out of touch with their bodies can make self-care difficult for childhood sexual abuse survivors.

A person who has been triggered or has dissociated may not retain or recall important information

Some survivors who want to disclose find the topic too difficult to initiate on their own and are relieved when a practitioner broaches the topic:It was a huge relief to have my doctor ask, “Were you ever abused?”(Man survivor) It’s very important that these pts are made to feel in control – at the very least a partner in the exam – being treated as an object is highly triggering.

It would have helped me immensely if someone would have taken the time or had the intuition to ask me that question.

20% of your patients is a huge demographic Maurice. Ask.


At Saturday, August 22, 2015 11:00:00 AM, Anonymous Medical Patient Modesty said...


I understand your frustration with how society seems to think that females cannot abuse men. The truth is most abuse cases are never reported because many men feel that people won’t believe them. I believe there is a high rate of female nurses or doctors abusing male patients. We just almost never hear about it. When men do report abuse, they are often not taken seriously.

Were you the same Kevin who submitted this case on MPM’s web site? I have appreciated your contributions to this blog.
I was very disturbed this week to learn about this article, that discusses the importance of parents preparing their children for genital exams. It was one of the most misguided articles I’ve read. There is honestly no reason for healthy kids with no genital problems to require genital exams. This statement in the article: "The genitals are part of the body like the ears and the nose and eyes. ... Children should know they are healthy all over." was very disturbing. What are your thoughts?


At Saturday, August 22, 2015 6:40:00 PM, Anonymous Anonymous said...


Yes. I am one and the same. We need to erase all the preconceived notions about gender and behaviour and treat everyone equally. This applies to healthcare especially as no where else do we routinely give strangers access to our 'private parts'. I find the constant message that women are caring. nurturing etc to be insulting and effectively silences anyone affected by their abuse. Feminism has a lot to answer for. Even if one child was abused due to my political views I could not live with it.

Here's a link which shows how nurses provided Brit pedo Jimmy Saville with fresh young girls to molest - even picking out the 'chosen one'. These were children entrusted to the care of these nurses. Nurturing, loving, gentle?...not really. As a kid I was forced to 'make nice' to an abusive alcoholic uncle - this takes away a child's sense of self-determination - makes them a prime target for a pedo. In a perfect world everyone is nice. We just don't have one of those. How would you feel if it was your daughter who was the lucky 'chosen one' like the brain damaged girl?

As to your link; its about time we took control back from medicine. Teaching children to accept genital exams just 'because' someone has a white coat is problematic. We need to ensure our kids are empowered enough to say no. What's wrong with educating kids/ourselves what to look for? If your car breaks down - there are a few basic things to check to find the fault. Medical folks will tell us we are not qualified to look after ourselves - we need to get 'towed in' for everything. In this light we are treated like ignorant children who need their help. As part of sex ed basic health info should be included - what's normal - when to see a doc, make sense? Teach genital health checks to both boys and girls.

Ears nose and eyes? Then why will I be arrested for exposing these items in public? Why do some people get gratification from touching them? Until I can expose my genitals in public without ramification or have someone get gratification from them then they are not ears. Case closed.

As a kid I was forced to 'make nice' to an abusive alcoholic uncle - this takes away a child's sense of self-determination - makes them a prime target for a pedo. Forcing a child to grant access when they are reluctant to sends a dangerous message - that they are not in control of their genitals and bodily autonomy. The child has to feel in control - they are 'granting' access - access isn't a forced thing demanded by an authority figure. In a perfect world everyone is nice. We justdon't have one of those.

I am in no way saying avoid medical folks - just don't be passive about it. Get educated, pay attention to changes,do your own research, ask questions. Tell the medical system what you want out of it. We are not just slabs of meat to be poked, prodded, sliced up and medicated. We are people with feelings; we have families/friends that care about us. Children should be taught early that they are in control.

Doctor knows best? - not long ago thalidomide was the bees knees.


At Saturday, August 22, 2015 8:46:00 PM, Anonymous Anonymous said...

Part 1
The feminization of healthcare?

A piece in Kevinmd written by a female doctor claiming that basically medicine is better now because it has/is being feminized. She presents the utopian ideal of feminism’s view - how the world would be better if it were run by women alone. More co-operation – teamwork. You name it. And of course she doesn’t stop there - shaming all of the bad ‘male’ behaviours – heroism, independence and competition….horrible stuff…ruinous to healthcare., right?

There have been several studies on bullying/violence within nursing, hmmm… but that’s mostly females right? What gives? Teamwork? Co-operation? Eating their young? Doesn’t the overwhelming female presence already make it ‘feminized’?

Here’s a nice example of a social experiment which highlights how men and women cope in gender isolation. It’s a Dutch version of survivor – two tribes on the show were divided on gender lines. After some jostling for position the men got it together and accomplished stuff. The females? Hmmm..they couldn’t achieve any teamwork but dissolved into two factions that bickered. They built nothing; ate all their supplies etc. and basically sat around like it was a vacation. The producers had to do a ‘merge’ to keep things going. The clip starts with a man landing on the women’s island. They had a list of stuff for him to do ‘cause he’s a man and a utility to be taken advantage of. I realize this is a selected group of women but the difference in the two groups is striking.

Same thing but with brit women, maybe a pattern?

Will a feminized surgical team stand around arguing to find a consensus while I am bleeding out? Or maybe they’ll split into factions and disagree so that my surgery isn’t even done? No one want to lead? There has been much harm done to patients over nurses bullying each other – passive aggressive, not sharing information. Why do we have to tolerate that? We need gender balance; optimizing each others' traits for the benefit of the pt…...cont’d

At Saturday, August 22, 2015 8:47:00 PM, Anonymous Anonymous said...

Part 2 This vid discusses ‘horizontal violence’ (bullying) and the impact on patients.

Ever increasing #’s of female MD’s graduating coupled with the predominantly female nursing side means medicine is getting even more feminized. Now that males are finally getting a taste of ‘bodily autonomy’ (no mandatory nude school/YMCA swimming/nude group military physicals, private shower stalls etc) I think this will lead to rejection of female entitlement to the male body. How will that affect healthcare? How will men be treated or access feminized healthcare in the future? Seem like women do pretty well in the current system. Men not so much – and I think it will get worse before it gets better.

Of course women have used the excuse of “oppression”’ - to invade our locker rooms, men’s clubs and washrooms and it’s causing a backlash. Why does a woman feel she has a right to walk into my washroom when I am using a urinal? Just because hers is busy it gives her the right to walk into a designated private male space without permission? In the same way a female nurse isn’t bothered by my nudity when she exposes me unnecessarily I guess – hope I didn’t offend the washroom trespasser either. Personally; I discuss a lot of business at the urinal with other guys and want to keep the women out of it.

Dr. Berman’s argumentative teen male (previous post) is I think representative of this new generation of males. They won’t be browbeaten into accepting the crap double standards my generation (and earlier ones) of men have put up with. They haven’t had all the forced nudity and purposeful exposure to females; they have had bodily autonomy. We need to start a new conversation in medical care. One that empowers the patient; balances the gender ratio of providers and gives us choice for gender…. Kevin

At Sunday, August 23, 2015 2:06:00 PM, Blogger Maurice Bernstein, M.D. said...

Here are examples of the "hidden curriculum" which is presented to students in the 3rd and 4th year clerkships and beyond. These published examples, which though anonymous, are most likely true present strong reasons why both students and physicians should "speak up" after witnessing such events. And, certainly, this is what I am going to teach my new first year medical students.

From Annals of Internal Medicine

From Better Health


At Sunday, August 23, 2015 5:46:00 PM, Anonymous Anonymous said...

From the second link Dr B posted.... but I knew that if I confronted him head-on it could trigger an investigation and in the end I had no hard evidence to prove that he had done anything wrong. It would wind up being a “he said, she said” scenario ..... I wonder if he is still out there violating his patients, and if anyone has ever confronted him. ...... I guess you could say that in my medical training, I witnessed a child rape.

Since this doc was comfortable enough to do this infront of a co-worker he's likely been doing it a long time, in front of many many people, and (up until that point at least) nobody had bothered reporting him....

Let that sink in for a minute... this guy... this "future doctor".... witnessed what he considered a child being raped... right in front of him.... and did nothing because he didn't think it'd be worth the hassle.

So there "may only be" a handful of "bad docs"... but all the support staff are just as guilty as far as I'm concerned, and in all reality, how can you honestly expect us to trust ANY member of the medical community? we have no way of knowing what they do when we're out.... I'm not religious, and I don't work on "faith".


At Sunday, August 23, 2015 7:51:00 PM, Anonymous Anonymous said...


Thanks for posting those links. Although sickened by the events described I think it very important to bring situations like these into the light of day and talk about them. Yes Jason - hard to read and we all feel violated and un-trustful of healthcare - I feel sick to my stomach for that poor little girl. Anyone who would violate a little child like that....well..jail is too good for them.

Unfortunately we need confessions like these to get discussion going and change the mindset of those in healthcare so it can be stopped and the sociopaths committing these acts weeded out/charged. No more sweeping it under the carpet. Med students need to feel OK in reporting those with authority above them - and need to be protected from any backlash. Its the only way to make it right. Its easy to look from the outside in and criticize the writer in the second link. He had no way of proving what happened and his future was in jeopardy if he did. A no win situation that has been played out umpteen times I'm sure. He is obviously haunted to this day by it.

We know already this stuff takes place; having medical folks admit it is a huge and necessary step to make it better and regain our trust. Did I like hearing about Twana Sparks? No, but it needed to be brought into daylight so we can process it and make it better.. Kevin

At Monday, August 24, 2015 10:05:00 AM, Anonymous Anonymous said...

From Kevin Unfortunately we need confessions like these to get discussion going and change the mindset of those in healthcare so it can be stopped and the sociopaths committing these acts weeded out/charged. No more sweeping it under the carpet. Med students need to feel OK in reporting those with authority above them - and need to be protected from any backlash. Its the only way to make it right.

Yeah, they need to be protected..... IF THEY REPORT IT. If they do like the guy from the article and say nothing, and someone else reports it or it comes out some other way, then they should face SEVERE jail time, lose their license, and be put on the registered sex offender list.

Even if he had no way to prove it, and nothing came of that specific incident.... if every other time a med student works with "Dr Bob", they report him for being a child rapist.... eventually the powers that be should clue in that "hey... we've had 30 students in the last 2 years tell us this is happening.... Dr Bob might just be a bloody sex predator", and they can act on it. (police can talk to victims, have a doc pose as a new intern to witness, or any number of other methods to look into it)


At Monday, August 24, 2015 12:50:00 PM, Anonymous Anonymous said...


Unfortunately if from the get-go we talk about punishing observers who didn't report - no one will come forward and it gets swept aside and nothing changes, ever. Can we help past victims? Not really - but we can help those who have yet to be affected. To me that is a real crime - and we are all complicit if we don't make the effort to end this - whatever it takes. Observers have to feel secure enough to come forward. Is the observer guilty of something? Yes. But unless given some protection they will remain silent. We need them.

Should the rapist in the second link be punished? Absolutely. But using a club on the doc who wrote the email will not get his compliance in identifying the perp or his witness against him. This is the price of getting change unfortunately. I believe he bears a cross on his conscience for his inaction. I'm sure whenever he sees a teen girl he remembers - especially if he has a daughter himself. We need to get this dialogue going. Setting the 'new' rules and telling observers they will be protected when they report and considered complicit if they do not is where this has to go.


At Monday, August 24, 2015 1:48:00 PM, Anonymous Medical Patient Modesty said...


I think you have made excellent points about observers. I believe the reason many medical students won’t report the senior doctor or medical school professor when they do something wrong is because they fear they will be treated horribly in medical school. Many nurses who have watched doctors doing things wrongly won’t report them because they are afraid they will lose their jobs or get treated horribly. The medical industry is very powerful. Look at this link about a stressed medical student who quit medical school. She questioned unnecessary intimate exams and look at how she got treated.

I also appreciated your great points about how genitals are not like other body parts. It is strange that some medical professionals try to get you to believe that genitals are like other body parts such as ears that you can show in the public.

I am not sure if you read about the mean female CNA who talked about how she could not wait to get her CNA II training next so she could shove a catheter in a man. This shows that there are indeed female medical professionals who like to abuse men. Our society wants to pretend that women are always nurturing and not capable of abusing men. Most men won’t speak up when they are abused so that’s why we do not hear much about men being abused by female medical professionals.


At Monday, August 24, 2015 9:09:00 PM, Anonymous Anonymous said...

Part 1

I have no doubt there are some women who derive pleasure in having power over men and humiliating them. If 1/4 women are sexually abused by men then I am sure many will not be able or willing to treat male patients well at all. Misandry is culturally accepted in North America - watch the youtube video of 'The Talk' where the panel and audience (women) laugh at the Katherine Kieu male genital mutilation case. Are women really finding this funny? Although I always do wonder when in one breath women will decry FGM then state a preference for "cut" men. Lets circumcise all male babies to please women. Is it only me that finds these attitudes abhorrent? Wonder why I do not blindly trust female nurses? Sometimes I feel women do not see men as sentient beings; rather utilities devoid of emotion.

Are women violent? Interesting to note that the terms 'DV' and 'abused women' are used interchangeably - but when you examine studies into lesbian DV "35.4 percent of women living with a same-sex partner experienced intimate-partner physical violence in their lifetimes". Wait, women are violent after all? The rate is 21.7 in hetero relationships. The rate of rape is 11% in lesbian relationships, 4% in hetero. Something is rotten in Denmark. scroll down to "Gay and lesbian vs. other opposite-sex intimate partner relationships"

I like to think I am an 'egalitarian' - that all folks irregardless of gender, race, politics or sexuality are potential douchebags. It may look like I am always against women - I would point out that many men are perps too but this subject is always on the table so not a lot of point.


At Monday, August 24, 2015 9:10:00 PM, Anonymous Anonymous said...

Part 2

Here's a case where a male nurse uncovered widespread child sexual abuse (15 cases) in a small remote northern Canadian town and was dismissed when he tried to advocate for the kids.

"In early December 2010, a meeting was held between Schultz (nurse) and representatives from the health authority and social services to discuss the many reported cases of child sexual abuse in the community. Schultz understood he was not to take any further sexual abuse statements from young children because the resources weren't available to adequately help them, nor to get any disclosures from children under 12, nor to do any kind of preventative work or have any discussion with community members around sexual abuse."

Politics trumping children's rights to not be sexually abused. Is this the "see no evil, hear no evil' defense? How can these people sleep at night?


At Tuesday, August 25, 2015 10:47:00 AM, Anonymous Medical Patient Modesty said...

I wanted to let you all know that Outpatient Surgery published an article that included the link to the essay about misbehavior of surgeon today. The title of this article is Surgery's Darkest Secret.

What bothers me so much is that many patients have been abused under anesthesia and have no idea they were abused. This is exactly why it is important for each patient to be able to have a personal advocate such as a spouse be present in OR at all times.


At Wednesday, August 26, 2015 2:50:00 PM, Anonymous Anonymous said...

From Mistys link "Although we wish it were otherwise, most physicians at some point find themselves in the midst of situations where a colleague acts in a manner that is disrespectful to a patient," write the physician editors of Annals of Internal Medicine

So... since doctors are the ones saying this now... wouldn't that make the "good docs" the outliers, instead of people like us who you used to call outliers?

I don't mean this as rhetorical... I'm actually asking you... Dr. B ... since the physician editors of Annals of Internal Medicine have said "most" docs WILL find themselves in this situation... does that not mean that the doctors who actually respect patients modesty / autonomy / dignity are the outliers?


At Wednesday, August 26, 2015 3:45:00 PM, Blogger Maurice Bernstein, M.D. said...

Oh Jason, I don't think the editors of the journal were saying those students or physicians who failed to "speak up" to those who were disrespectful in their behavior to patients were themselves disrespectful of patient's modesty/autonomy/dignity. It is that these physicians who observe had personal fear of some sort of retribution. I doubt they are "outliers", I think most doctors have such fears which is because the system fails to give them the support and protection so they feel safe "speak up". ..Maurice.

At Wednesday, August 26, 2015 5:45:00 PM, Anonymous Anonymous said...

I don't think the editors of the journal were saying those students or physicians who failed to "speak up" to those who were disrespectful in their behavior to patients were themselves disrespectful of patient's modesty/autonomy/dignity.

If it's such a common occurrence that "most will" encounter it, then it's obviously pretty wide spread. And really... would it matter to you if there were 7 people in a room but only 2 of them were abusing you when you were out, or would it matter more to you that it happened at all?

What it seems like you're getting at is that there's 3 types of people in the medical world... Those who stand up to the "bad docs" (and are apparently the outliers).... those who don't partake in the abuse, but do NOTHING to stop it, so they're part of the problem as well...... and those who abuse patients, which seems likely to be a majority of the medical field, otherwise an encounter with them wouldn't be all but guaranteed.

"All that is necessary for the triumph of evil is that good men do nothing." (Edmund Burke)


At Wednesday, August 26, 2015 7:10:00 PM, Blogger A. Banterings said...


I have to agree with Jason, that if one observes these actions and say nothing, then it can be taken as a sign of approval. One can assume that they are free to repeat the offense.

Saying that they feared retribution is no excuse. That was no excuse at Nuremberg, that is no excuse in healthcare.

Legally, if the offending party was committing a felony (assault, rape, murder, etc.), and an observer did not report it, they are guilty of the crime of conspiracy or in some cases equally as guilty for the crime itself. Failure to report a crime is also a crime in and of itself.


At Thursday, August 27, 2015 8:13:00 PM, Blogger Hexanchus said...


You stated:
"Legally, if the offending party was committing a felony (assault, rape, murder, etc.), and an observer did not report it, they are guilty of the crime of conspiracy or in some cases equally as guilty for the crime itself. Failure to report a crime is also a crime in and of itself."

Actually that is not uniformly true.

Most states have mandatory reporting laws that apply to specific professions as mandatory reporters for specific categories of suspected crimes - usually physical or sexual abuse. beyond that, Joe citizen is not required to report a crime.

“Misprision of felony” is a crime that occurs when someone knows a felony has been committed, but fails to inform the authorities about it. The crime originated in English common law and required that citizens report crimes or face criminal prosecution.

Due to the harshness of imprisoning people merely for failing to report a crime, most states chose not to include misprision of felony in their criminal laws. Instead, conduct that would fit the misprision definition is covered by other laws, such as those dealing with accomplice liability. Uniformly these other laws require some active form of cover up such as lying to the police about what you know when asked, covering up evidence or actively helping the perpetrator in some way.

At the federal level it usually requires some typical act of concealment such as making false statements, hiding evidence, and harboring the felon.

For example, if a person knows that their neighbor is running a meth lab, they would not be guilty of federal misprison for simply remaining silent, but if they lie to the police when directly asked about it, then they have committed misprison.


At Thursday, August 27, 2015 10:50:00 PM, Blogger A. Banterings said...


You are correct in your assessment of misprision. States that do not have specific statutes making misprision a felony, it still may be a felony (although not defined) like in the State of Virginia.

Because health records are electronic today with remade forms, and all members of a surgical team must at the very least sign off on a report if not file their own individual report, failure to mention the patient abuse (checking the “procedure normal” box) may constutite covering up a crime.

One can also show actively concealment if professional ethics require reporting (even though there are no legal requirement). Professional ethics create a duty to report.

The point that is missed here is that most physicians will witness a patient being abused and do nothing about it.

Would anyone accept the excuse of SS officers who knew about the atrocities and dis nothing? Remember the Oskar Groening Trial: 'Accountant of Auschwitz' trial?

While Groening had spoken openly in interviews about his time as an SS guard at Hitler's infamous death camp in occupied Poland, he insisted he only witnessed atrocities and did not commit any crimes.

On his first day in court in April, Groening said he felt morally guilty for his work at Auschwitz but that it was up to the court to determine if he was legally guilty.

…but Groening did not want to get fired from his job or confront his superiors (he was only a staff accountant).

Yes this sarcastic, but how is Groening any less culpable than the physicians in the articles.

This only furthers the idea that the profession is morally bankrupt. Why do physicians have such a high rate of suicide? I would argue that trying to live with yourself taking an oath to “first do no harm,” and witnessing acts such as this and doing nothing about it can drive one to that.

If this is how most physicians want this to be their profession, then they can not complain when they are all perceived negatively.


At Saturday, August 29, 2015 8:18:00 PM, Anonymous Anonymous said...

Here is a quote from the blog Canadian Family Physician about the hidden curriculum:

“the difficult professional challenges of dealing with unprofessional colleagues; and about behaviour that imperils patients. We need to add “Above all be not silent” (Primum non tacere)17 to “First do no harm” as tenets to live by, and we must emphasize to students that what they are like as physicians is just as important as what they know.”

A couple of studies which illustrate the problems with the hidden curriculum and med students:

“The response rate was 71%. The students reported that exposures to unethical behavior started early and continued to increase with each year in school. For example, 35% of the first-year students reported observing unethical conduct by residents or attending physicians. This percentage rose to 90% of the fourth-year students. The authors found no significant relationship between demographic variables other than the year in school and the ethical dilemma variables.”

“Of the 665 students (36%) who responded, 58% reported having done something they believed was unethical, and 52% reported having misled a patient; 80% reported at least one of these two behaviors. In addition, 98% had heard physicians refer derogatorily to patients; 61% had witnessed what they believed to be unethical behavior by other medical team members, and of these students, 54% felt like accomplices. Many students reported dissatisfaction with their actions and ethical development: 67% had felt bad or guilty about something they had done as clinical clerks; 62% believed that at least some of their ethical principles had been eroded or lost. Controlling for other factors, students who had witnessed an episode of unethical behavior were more likely to have acted improperly themselves for fear of poor evaluation [odds ratio, OR, 1.37 (95% CI, 1.18-1.60)] or to fit in with the team [OR 1.45 (1.25-1.69)]. Moreover, students were twice as likely to report erosion of their ethical principles if they had behaved unethically for fear of poor evaluation [OR 2.25 (1.47-3.45)] or to fit in with the team [OR 1.78 (1.18-2.71)].”

How many studies do we need? What will it take for the medical “profession” to do something about this?


At Saturday, August 29, 2015 8:59:00 PM, Blogger Maurice Bernstein, M.D. said...

But Kevin, these studies were 20 years ago, in a different ethics and educational age. There has been much more emphasis on teaching the ethics of medical practice since then. There is much more understanding of the "hidden curriculum" and the need to provide an outlet for students who witness "bad behavior" in their clerkship years to feel free to present their observations to faculty not attending physicians, who are supportive of the students concerns and able to investigate. I don't recall that the these outlets for student observation and concern were available 20 years ago.

Kevin, did you find any more recent studies for comparison? ..Maurice.

At Saturday, August 29, 2015 9:16:00 PM, Blogger Maurice Bernstein, M.D. said...

Interestingly, I noted that there was a disclaimer after the article in the "Canadian Family Physician". The article warned the reader not to ignore the "hidden curriculum" and emphasized the need for changes in the medical education and medical system to resolve the dangers within that curriculum. And the disclaimer: "The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada." This disclaimer points the seat of the problem, the unwillingness of the system to take responsibility. The College could have easily accepted what was written as part of their professional ethics but no.. they end up with a common disclaimer. Shame. ..Maurice.

At Thursday, September 03, 2015 9:32:00 AM, Anonymous Anonymous said...

A scheme concocted by a male and a female TSA agent to purposely grope male passengers at a Denver airport unfolded
recently. www. TSA administration responded by saying " we hold our agents to the highest standards.
This reminds me of healthcare and all the propaganda that's said. Lies.


At Friday, September 04, 2015 4:22:00 AM, Anonymous Anonymous said...

Here’s a 2011 study of burnout/hidden curriculum in residents. The more I read – the more I feel that many of the problems we discuss – (poor recognition of patient modesty concerns/bullying etc) arise from the mental health and outlook of medical staff. While a bit of a chicken and egg discussion (ie does burnout happen due to hidden curriculum or vice versa) – the effects on patient care and outcomes are direct and measurable.

“This learning environment may also impact residents' personal well-being. Burnout, operationally defined as a syndrome of emotional depletion and maladaptive detachment after prolonged occupational distress, has an estimated prevalence of 50% to 76% among residents. It is associated with lower empathy, poorer patient care, and increased perceived medical error. Medical student burnout has been associated with more unprofessional behavior. Perceived mistreatment is also common; residents may feel abused, belittled, and humiliated by those in authority. These experiences, as well as observations of unprofessional conduct and cynicism, may contribute to the indifference and emotional fatigue characteristic of burnout.”
“Respondents reported exposure to unprofessional conduct by faculty, peers, and staff: more than two-thirds felt humiliated by nurses and by patients and witnessed residents being disrespectful to patients. A third witnessed faculty demean another service or specialty on 4 or more occasions.”

“Our data demonstrate an association between the hidden curriculum—that is, exposure to unprofessional behaviors—and measures of resident burnout and cynicism. We found that cynicism and burnout were also significantly associated and may be measures of similar but not necessarily identical behavioral responses to the challenges posed by residency....These instruments may serve as a first step toward reforming institutional culture and preventing the development of disillusioned, detached, and unprofessional residents.“


At Friday, September 04, 2015 7:37:00 AM, Blogger A. Banterings said...


This is just another example of “abuse of power” that is rampant in our society. Power is protecting their own interests, not the common person. Thankfully we live in a society that was founded on self reliance. The citizens of Ferguson, MO and at military recruitment centers in response to a lack of protection by our Federal, State, and local governments. Even Kim Davis’ husband alluded to the 2nd Amendment in the wake of death threats against his family.

Then there is innovation, another form of self reliance. Perhaps the best example of this is Skype in it’s efforts to take on long distance phone companies. One may argue the success of Skype, because shortly after, most phone companies eliminated long distance charges with in the US.

Alternative medicine, “opting out,” and making many previously prescribed medications OTC have been responses to traditional medicine.

That also provides me a segue into my next comment. The Department of Health and Human Services (HHS)Issues anti-discrimination rules for transgender people on Thursday.

One has to ask, if healthcare is filled with such compassionate physicians, nurses, and other providers, then why does HHS have to issue such a ruling?

The answer is because the treatment of transgender patients in healthcare (other than trans-specific issues) essentially amounts to <a href="”>torture</a>.

If providers want to solve the problems they face today, the first step is honesty; admitting to past and current abuses of the system. Then they need to apologize and change these. Until that happens, the public is NOT going to trust healthcare. After all, nobody is forcing them to do this. Providers are free to continue in their current state of misery…


At Thursday, September 10, 2015 4:50:00 PM, Anonymous Medical Patient Modesty said...

I wanted to let everyone here know that a new article about patient modesty has been published on Medscape. The title of the article is What if Your Patients Don't Want to Take Their Clothes Off?. Dr. Sherman shared some insights in this article. It was encouraging to see some other doctors admit that patient modesty is an important issue. You are required to have a Medscape account to access this article. You can sign up for a free account to access this article and other articles on Medscape.


At Monday, September 14, 2015 10:07:00 PM, Blogger A. Banterings said...

In light of Caitlyn Jenner, gay marriage, etc., there has been a movement of LGBT rights as the modern civil rights movement. One area is inappropriate questions posed to transgender individuals by healthcare providers (asking about genital anatomy for a sore throat visit) and by the general public.

Although the following 2 articles are about questions asked by the general public of trans individual, it can also apply to questions asked of trans individuals by healthcare providers and how most patients feel in general.

Off Limits: My Transgender Teen's Body Is Not Up for Discussion

Note in this article: I find the blatant inquisitiveness about trans bodies, particularly trans women's bodies, to be downright invasive, in part because the questions are often cloaked within polite conversation and are therefore so unexpected. Janet Mock brilliantly exposed the absurdity of this troubling pattern when she flipped the script on a cisgender interviewer, firing intensely personal questions of the kind that she routinely encounters herself, such as "Do you have a vagina?"

Notes on the Tension Between Privacy and Surveillance in Nursing, is a great example.

Going back to the original post of this volume, privacy and what is necessary...

Here are my references as to how trans individuals are treated:
--12 Tips For Nurses And Doctors Treating Transgender Patients Note question #10
--Court Rules That Transgender Patient Tortured By Doctors Is Protected Under Obamacare
--Understanding the TranssexualPatient: Culturally Sensitive Care in Emergency Nursing Practice
--How health IT fails transgender patients. This is just another example of how patients’ dignity and identity are disrespected in healthcare settings.


At Thursday, September 17, 2015 7:37:00 PM, Blogger Maurice Bernstein, M.D. said...

I have a blog thread here that may interest visitors to this "Patient Modesty" thread.
It is called "Being Hugged By Your Doctor: Invasion of Privacy vs Sign of Compassion?"
It started in November 2007 with 44 Comments, the most recent today. One of the early comments was from a surgeon. I thought you might be interested to read that view here.

In my medical role I have to violate all sorts of physical/social boundaries (I am a surgeon). People frequently feel extremely vulnerable, and I don't want to make anyone any more uncomfortable.

I feel the same way about hugging as I do about prayer (not to open up another ethical discussion that you've probably already had). If a patient wants to hold my hands and pray in the preop area, then that is fine with me. I don't feel it would be appropriate for me to propose a prayer (or a hug). What if they say yes, but they wanted to say no? What if they say no, then worry about how that would affect their care?

I make a point of shaking hands when meeting a patient, and of touching their shoulder/etc when rounding. I have no problem hugging a patient, but I let them initiate it. It feels more respectful.

There is a lot of interesting examples and conversation on that thread. You might want to take a look. ..Maurice.

At Friday, September 18, 2015 7:54:00 AM, Blogger A. Banterings said...


For as hard as I appear to some, especially in regards to dignity and bodily integrity, I welcome such things. It makes me feel like a person. I believe that this truly shows compassion, especially when someone is afraid. Never underestimate the power of a compassionate touch, whether that be a hug or a hand on the shoulder. That says I am here with you.


At Friday, September 18, 2015 8:07:00 PM, Blogger Hexanchus said...

Interesting discussion regarding hugs - responses are all over the map as might be expected.

Unlike Banterings, I am not comfortable with invasion of my personal space without my explicit permission. A hand-shake is fine, but anything beyond that is not and I would not allow it. You can be kind, caring and compassionate without being "touchy-feely".


At Monday, September 28, 2015 6:14:00 AM, Anonymous Anonymous said...

Humans are social animals. Touch is an important part of our interaction. When we comfort an injured/sad child the normal instinct is to hold them. Life experience has taught me that we never really grow up - we (esp men) just learn 'adult' ways of masking our emotional needs. So we soldier on and keep our adult dignity intact - avoiding situations where we might need the very support we cannot ask for. On one hand the social conditioning of men has been to emotionally isolate us from birth so we can be strong; then we are ridiculed when we avoid the very situations when we feel vulnerable (and then admonish us to man up and be vulnerable - thanks ladies!).

Anyone else see the irony in having a healthcare provider unable to comfort us with hand holding or a hug but then having access to our most private body areas? Lets not allow caring touch - then bring in support animals (dogs etc) to provide this for our emotionally isolated pts. Outcome and emotional state are deeply intertwined. Happy people feel less pain than sad people and recover more quickly. Yes there is a risk of improper attachment by vulnerable pts and providers but at the same time some folks fall in love with a person through media without ever meeting in the flesh.

Due to my own life experience I have always avoided touch - except from my kids and intimate partners. Yet when faced with the anxiety of dealing with surgery etc. it would have been extremely helpful. But first I need to trust the providers.


At Monday, September 28, 2015 7:48:00 AM, Blogger Maurice Bernstein, M.D. said...

Kevin, beautiful! I agree. But is what we teach the medical students.

The initial introductory handshake represents simply a look or test into the trust of the upcoming relationship.

It is only when trust by the patient develops as the student proceeds taking the history that then the patient allows the further "laying on of hands" upon the patient's body. ..Maurice.

At Monday, September 28, 2015 2:24:00 PM, Anonymous Anonymous said...


On 8/13, you solicited a “5 minute ‘script’ of what [you] should say to” first-year medical students. Unfortunately, I was not participating on your blog at the time and did not add my two cents. I’d like to do so now with the hope that you might find my contribution useful in the future.

Responses to your request and your final exhortations to students appeared to be founded on the assumption that an appeal to the finest qualities in students – their compassion and empathic proclivities – is the best way to approach them. More broadly, the assumption was that human beings are inherently good and, therefore, willing to protect the dignity of others. However, there are as many or more people who believe that human beings are inherently selfish and acquisitive. They are therefore largely uninterested in protecting the dignity of others unless it is to their advantage to do so. Medical students, in particular, are believed by these cynics to be interested only in what benefits them; they could care less about catering to what they believe to be the puerile and callow demands of patients that their bodily integrity be protected. Indeed, this is a concern of a friend of mine who teaches patho-physiology at an osteopathic school. He tells me that with increasing frequency, cupidity drives students more than a desire to help others; he claims the school has been experiencing a precipitous increase in the number of students who want to become physicians because of the status it brings and because it is a path to affluence rather than because it is a medium for helping others.

If my friend is correct and if his concern can be generalized across medical schools, then an appeal to medical students’ less admirable instincts may capture their attention more readily than an appeal to altruism. A twenty second preface to five minutes or more of elaboration might be in order. The preface may take something like the following form:

Take what I am going to say to heart. There is nothing more sacrosanct than the human body. Make no mistake, if you forget this during your practice as a physician, you invite the scrutiny and intrusion of the media, of government, of attorneys, and of social critics. We can ill afford such intrusion for it will eventually whittle down our authority and autonomy, erode the public trust in medicine and our therapeutic relationships with patients, and, ultimately, diminish medicine as a profession.


At Monday, September 28, 2015 8:22:00 PM, Anonymous Anonymous said...

Maurice, would you please share with us your syllabus for Introduction to Clinical Medicine?


At Monday, September 28, 2015 9:18:00 PM, Blogger Maurice Bernstein, M.D. said...

Ray, this explanation of USC Keck School of Medicine ICM course sets the basis for everything and how we teach. Yes, each instructor will provide their own approach but what you read below is what is expected of the instructors and the learning and experience by their students. ..Maurice. CONTINUED ON NEXT POSTING

At Monday, September 28, 2015 9:21:00 PM, Blogger Maurice Bernstein, M.D. said...

Introduction to Clinical Medicine

Introduction to Clinical Medicine expresses the strongly patient-centered orientation of the medical school curriculum. The student is introduced to patients and is involved in patient care activities from day one. Students are introduced to the principles of patient care and management and examine what it means to be a physician and how one becomes a physician.
The major content areas of the course include communication in the setting of illness, the unified concept of health and disease (the biopsychosocial model), basic clinical skills and the correlation of basic science with clinical medicine.
ICM emphasizes the systematic acquisition of the clinical skills of interviewing, history taking, physical examination, elementary clinical problem solving, and medical record keeping. Throughout the Year I-II continuum, the ICM clinical skills curriculum is integrated with basic science instruction. Students can therefore learn and apply basic science knowledge in the clinical setting. By encouraging a thorough understanding of the direct applications of basic science research to modern clinical medicine, instructors motivate the student to learn, use and retain more of the content and concepts presented in the basic science portions of the curriculum.
A group of five or six students spends from four to eight hours each week with an instructor from the clinical faculty who remains with the group for one to two years. As the group deals with basic medical themes (death, pain and helplessness) and issues (patient responsibility, learning to live with ambiguity and uncertainty), instructors help students to cope with their own feelings. This format opens the door for student-faculty interaction and improvement of student-faculty communication.
Instructors encourage students to take advantage of the learning experiences provided by their roles as helping and therapeutic persons. Students develop their ability to communicate with patients in the setting of illness and are guided by patient concerns to enhance their own growing knowledge, skills, abilities and responsibilities. Students are expected to acquire skills and habits of self-education and self-instruction which will prepare them for lifelong learning.
The unified concept of health and disease presented in this course enables the student to comprehend the human organism in all its complexity. Using their clinical experiences as a teaching model, students are taught to consider the patient as an integrated whole and to view the patient's illness or disease as more than simply a disruption of physiologic processes or a collection of physical findings.
Additional learning experiences occur through workshops and focus experiences. ICM workshops provide standardized instruction in history taking and physical examination, as well as integrated instruction in areas which cross disciplines. These include adolescent health, use of interpreters, patient education, and ethics. Through focus experiences, students are encouraged to explore a variety of practice environments as well as community-based health and social services. For example, students may visit outpatient clinical settings, a geriatrics long-term care facility, a hospice care facility, or homeless services organizations.

At Tuesday, September 29, 2015 11:37:00 AM, Blogger A. Banterings said...


Welcome back! As usual you apply what we have learned from Zimbardo, Bandura, Foucault, and others to practical solutions.

I very much like your “introduction.” Perhaps you can also comment on the following as well...

That also leads me to another paper that I recently read which in support of what you propose from your osteopath friends’s observation, helps explain why people we assume to be compassionate would do such horrible things to patients: The Role of Moral Disengagement
in the Execution Process (Law and Human Behavior, Vol. 29, No. 4, August 2005)

This research is conducted within the social cognitive theory of moral agency (Bandura, 1986, 1991). In the exercise of a moral self, individuals adopt standards of right and wrong that serve as guides and deterrents for their conduct. In this self-regulatory process, individuals engage a number of cognitive functions by monitoring their conduct and the conditions under which it occurs, judging their actions in relation to their moral standards and perceived circumstances, and regulating their actions anticipatorily by the consequences they would apply to themselves. They do things that give them satisfaction and a sense of self-worth, and refrain from behaving in ways that violate their moral standards because such conduct will bring self-censure.

What this means is being a “good doctor” to achieve the (perceived) status of a (successful) good doctor.

It goes on to show how Moral Disengagement is achieved:

Operating at the behavior locus are three separate disengagement mechanisms that convert the construal of injurious conduct into righteous conduct. In moral justification, worthy ends are used to vindicate injurious means (Bandura, 2003; Reich, 1990). Second, by the use of sanitizing euphemistic language, injurious conduct is rendered benign (Bolinger, 1980; Gambino, 1973). Exonerative comparison with even more flagrant inhumanities is a third mechanism for cloaking injurious behavior in an aura of benevolence. This advantageous contrast relies heavily on moral justification by utilitarian standards. It affirms that injurious conduct will prevent more human suffering than it causes (Bandura, 2003). This trio of mechanisms is especially effective in disengaging moral self-sanctions.

But there is a danger that once one learns to “switch off their conscience,” they can do it any time it becomes troublesome:

The facilitative role of moral disengagement has been verified in diverse forms of injurious conduct. They range from antisocial pursuits (Bandura, Caprara, Barbaranelli, Pastorelli, & Regalia, 2001) to international terrorism and support of military force in international conflicts (Bandura, 2003; McAlister, Bandura, & Owen, 2004a).

A bit of my dark humor that I share with close friends, is when they are discussing a moral dilemma, I will say, “I had my conscience surgically removed.” Although humorous, it does highlight the conundrum as being that of a moral/ethical dilemma and point to the obvious solution.

Just as Joan Emerson noted in Behaviour in Private Places about sanitized/technical/scientific lingo:

Moral qualms are eased when execution is viewed in the abstract under the sanitized label of “capital punishment.” People favor the death penalty in the abstract but are more hesitant to impose it when given information that personalizes the murderer (Ellsworth, 1978).


At Tuesday, September 29, 2015 12:39:00 PM, Blogger Maurice Bernstein, M.D. said...

If this piece posted today in Michigan State University Bioethics by Tom Tomlinson, a well known ethicist, doesn't rile up my visitors here, then I don't know what will (or maybe I still do). ..Maurice

At Tuesday, September 29, 2015 11:05:00 PM, Anonymous Anonymous said...

Thanks, Maurice, for the Keck reference. I’ll have something to write about it tomorrow.

Regarding my recommendation about what to communicate to students, a no response could be construed as an indicator that the reader/listener, for whatever reason, is not taking “to heart” or taking seriously the message that is being communicated. It is pertinent to earlier contributions having to do with the diminishing public trust allocated to physicians as an aggregate, especially among lower income respondents. Do you have any response or, more specifically, any questions about what I have written, Maurice?

I read Tom Tomlinson’s piece with interest. I’ve an acquaintance who has spent much of his professional career studying humor. Some of it is pertinent to what Tomlinson wrote. I’ll try to write about it tomorrow

Thanks for the “welcome back,” Banterings. I’ll read the article you referenced soon. It looks interesting. The authors’ conceptualization and measurement of moral disengagement is similar to how Matza’s “techniques of neutralization” has been conceptualized and measured. Zimbardo has made a habit of unknowingly reinventing the wheel, probably because he confines his attention to the works of social psychologists rather than expand his studies far afield.


At Wednesday, September 30, 2015 2:23:00 PM, Blogger A. Banterings said...


I believe that this will ruffle more feathers here than Tomlinson:

Terrible Doctors Are Uploading Selfies Taken Next to Women's Vaginas During Childbirth

I have nothing to say. The story speaks for itself…


At Wednesday, September 30, 2015 8:31:00 PM, Anonymous Anonymous said...

Maurice: I read everything I could find on line about the Keck model. It is notable by what is missing. All I could find were broad descriptive statements about intent including, inter alia, the mission statement, the vision statement, and the description of Introduction to Clinical Medicine.

I could find no list of objectives for the course, the methods used to achieve objectives, and how the extent to which objectives are achieved is measured. In the 38 years I spent in higher education, I and my colleagues were required to include these elements in some document, usually our syllabi, and were expected to provide a copy of these documents to students and to whomever asked. It is this detail for which I have searched.

Surely somewhere there must be a list of goals/objectives/methods/measures for this course. Will you point me in the right direction?


At Wednesday, September 30, 2015 9:31:00 PM, Blogger Maurice Bernstein, M.D. said...

Ray, yes there is an ICM Student Manual as well as one for the faculty, in both, which is highly detailed as to the subjects covered and approaches to teaching and learning.

I would strongly advise you to review again this website

of the medical school and directly contact the school for access to further details and perhaps the Manuals themselves, if they are available to the public.

I can say about ICM, beyond the Manual, specific workshops and the periodic faculty meetings all instructors in this course are free to devise their own approaches to the teaching of interacting with patients, obtaining a history and performing a physical examination.

Again, go to the website and there are many contact resources listed. Here is one which may be appropriate for your concerns:

MD Program Office of Curriculum
Keck School of Medicine
University of Southern California
1975 Zonal Avenue
Keith Administration (KAM) 200
Los Angeles, CA 90089-9023

(323) 442-1763 Phone
(323) 442-2318 Fax

I hope this helps with your research. ..Maurice.

At Thursday, October 01, 2015 2:48:00 PM, Blogger Maurice Bernstein, M.D. said...

So today I wrote a Comment to the MSU Bioethics website in response to Dr.Tomlinson's article on the practice of physicians and their expressing of "dark humor" with the patient as the object.

Here is what I wrote:

Maurice Bernstein M.D. says:
October 1, 2015 at 5:15 pm
So.. I teach first and second year medical students in the “Introduction to Clinical Medicine” course how to interact with patients, take a history and perform a physical examination. We have never advised students to make “jokes” about their patients to others (colleagues or others) and certainly not back to the patients themselves. I stress to my students that a patient should be looked as a subject of an illness (a person with a name who is sick) and not an object (their anatomy or their pathology or their hospital room number for identification).

Should I warn my students that the upcoming “hidden curriculum” is going to find them observing “dark humor” told about a patient while watching a procedure or later, Should I tell them when they hear or see this to stop paying attention, walk away or even stand and speak up to the one making the joke (if they have the courage) and not just standby smirking, a little smile and with a little giggle.

I feel that if “dark humor” is so valuable as a professional form of therapeutic emotional ventilation, why not joke about the medical system itself or your colleagues? Or might some find joking about those “objects” objectionable?

And this response to the professionals in my attempt to change the system and preserve patient dignity (which I never have challenged in my practice.) ..Maurice.

At Friday, October 02, 2015 8:32:00 AM, Anonymous Anonymous said...


Dark humour is a natural human response to normalize what is difficult for us to bear and allows us to distance ourselves. I would draw a distinction though in how it is used. The doc taking selfies with birthing women's vagina's is just in poor taste and mocking the pt. This has nothing to do with him coping with a stressful event - especially when you take into consideration his comments about adjusting women's anatomy post delivery.

I am 'one of the guys' with a group of firemen/first responders/ paramedics - I for sure have heard this dark humour. I have never heard them use it it a way that was demeaning to an accident victim though. The paramedic attending a car accident that almost stepped on a human heart without realizing; having to look for part of someone's head blown off in an industrial accident are traumatizing and it is important to process these events to ensure mental health/avoid PTSD. Humour helps.

I have never once heard them refer to someone's anatomy or belittle a victim. I think a good self-check for anyone involved would be to assume the pt heard your joke - how would they feel? Anything which depersonalizes/belittles pts is a step towards the them/us dichotomy so rampant in your field. The nurse remarking to colleagues on a person's genitals; the surgeon grabbing an obese woman's fat and jiggling it; the doc saying she wanted to punch the sedated pt in the face to man him up; these are not for healing - they are passive aggressive bullying.


At Friday, October 02, 2015 9:26:00 AM, Blogger Maurice Bernstein, M.D. said...

Kevin et al, so.. what would you suggest is what to teach my first year students on how to behave when they see or hear their superiors do or say something "dark" and knows, if they were the patient themselves and aware, they wouldn't tolerate it? Remember, it could be about superiors and not necessarily their student colleague and remember superiors have some special academic power over their inferiors. ..Maurice.

At Friday, October 02, 2015 2:37:00 PM, Blogger A. Banterings said...


As long as all this continues, there will be lawsuits and criminal investigations. Big corporations will continue to gobble up partnership practices that can no longer afford med-map insurance. Providers will be relagated to the same ranks of Walmart employees.

The cries of burnout and disgust for the profession will fall on deaf ears. Since the profession could not police itself, society will settle for healthcare corporations holding the leash, keeping the profession in check with pay and bonuses tied to patient satisfaction surveys.

Even now, patient satisfaction surveys show that what patients want from providers is not JUST good healthcare. Society’s definition of good healthcare is different from that of most physicians.

This points back to one of the first things I had to get you to understand, that a patient WOULD refuse life saving treatment for legitimate reasons that are NOT mental illness. Healthcare has taken the “trauma” view, save a life at any cost and nothing else matters.


At Friday, October 02, 2015 4:43:00 PM, Anonymous Anonymous said...

Maurice: I’m curious as to why you believe Tom Tomlinson’s piece would “rile up [your] visitors.” What riles me are a few of the thoughtless responses to his piece including 1) gallows humor is justifiable among physicians because attorneys do it too. It is also justifiable because 2) it is due to human nature, because 3) it helps physicians cope with their stressful jobs, and it is justifiable 4) unless they are told “with the intent to harm” or “affect the quality of service to the patient.” I have frequently gotten the same feedback from physicians, nurses, and nursing students. All three of these justifications are specious and founded in some cases on logical fallacies.*
I agree with Tomlinson when he suggests that gallows humor can be placed on an ethical to unethical continuum. He writes, “. . . while some [dark humor] will be utterly objectionable, some of it will be ethically acceptable. The trick is how to tell the difference.” The respondents seemed, for whatever reason, not to make this distinction.

* I’ll not introduce arguments for how these justifications are specious unless asked to do so.


At Friday, October 02, 2015 4:44:00 PM, Anonymous Anonymous said...


Tomlinson’s use of Wikipedia’s definition and conceptualization of dark humor seems apropos, as far as I am concerned. He moves from this understanding of dark humor to what he believes to be innocuous examples of gallows humor that do not violate ethical conventions. My assessments of his first and third examples of innocuous dark humor are exactly the same as his. However, I take exception to his analysis of the second example. While attending to an elderly dying patient another patient falls “out of bed, stone cold dead.” Tomlinson classifies this anecdote as ethically acceptable because “the laughter was triggered by the sudden ironic incongruity presented by the situation” not by the unexpected death itself. Similar examples can be found in “Nuring 2000” in a list of “Bone Ticklers” found in its column entitled “Grin & Share It.” Here are how these bone ticklers read:
“As an orthopedic nurse, I heard many stories about how patients broke their bones. Here are a few of my favorites.
• One woman fractured her hip while stomping down a cereal box that ‘got away’ from her.
• Another woman fractured her hip when she somersaulted over the rail of her balcony while shaking out throw rugs.
• While dancing, a young woman’s boyfriend tripped and fell on her, fracturing her hip.
• While mowing his yard, a man slipped on the dewy grass, slid down a hill, and hit a fence, breaking both ankles.
• During a demonstration at a department store on how to lay floor tile, a shopper tripped into the exhibition – tile, glue, and all. She arrived at the hospital stuck to a long board. The health care team used solvents to remove her from the board. When she arrived in the orthopedic unit, she was still tacky.”*

* I can imagine the laughter by providers precipitated by the incongruity inherent in the woeful tale of a woman who became glued to a toilet seat in a Home Depot.



At Friday, October 02, 2015 4:46:00 PM, Anonymous Anonymous said...


Aside from the fact I found none of these bone ticklers bone tickling, I can understand how the incongruity inherent in them (an activity generally regarded as safe leading to injury) could elicit laughter from some, if not all (excepting yours truly), “Nursing 2000” readers. The problem with considering the bone ticklers and Tomlinson’s second example ethically acceptable lies in Tomlinson’s explanation; viz., they are ethically acceptable because of their ironic incongruities. Incongruity transcends gallows humor in the sense that it can be found in all kinds of humor. Furthermore, it may be an inherent quality in gallows humor that exists at the ethically unacceptable end as well as the ethically acceptable end of an ethical continuum. This argument is implicit in John Macionis’ (“Society,” 2011, p.108) recognition that “humor arises from the contradictions, ambiguities, incongruities, and double meanings found in differing definitions of the same situations” whether it violates ethical guidelines or not. If this is so, then it makes no sense to defend the ethics of gallows humor by pointing to a quality that transcends gallows humor and is, at the same time, part of gallows humor, whether ethically acceptable or not. I find these examples ethically suspect because they make light of human misery by their very nature of drawing attention away from human misery and onto the incongruity.*

* Maybe jokes of the nature described here can be placed somewhere in the middle of the ethical/unethical continuum rather than at the bottom.



At Friday, October 02, 2015 4:47:00 PM, Anonymous Anonymous said...


I cannot think of a specific example of an ethically-told joke about patients shared by health care providers that constitutes gallows humor because of its inherent incongruity. But there are some out there. Here is an example of gallows humor that elicits laughter because of an incongruity. It is told by James Vander Zanden in a textbook on racial and ethnic relations. It seems that in the early ‘50s an African American man was stopped in the Deep South by a patrol officer for running a red light. The officer approached the vehicle with pen and pad in hand.
“Why’d you go through that read light?” he asked.
“Well, sir,” replies the driver, “I saw all those white folk going through the green light, so I went on through the red light because I supposed it was for us black folk.”
“You get on home. And, from now on, you go through green lights just like white folk do.”
At first blush this anecdote might be construed as an ethically questionable racist joke. In fact, it was used to illustrate how humor can be employed by minorities as a form of protest designed to bring about social change. The context here may be construed as changing the definition of the situation from ethically questionable to ethically acceptable.
I also believe I can safely say that the same joke may be classified as being ethically acceptable in one situation but not in another. For example, the characteristics of the joke teller may determine the ethical acceptability of gallows humor. To illustrate, I have a good friend who has Parkinson’s disease. I was eating lunch with him one day and noticed that his tremors were particularly violent. “Marvin,” I said, “I see why you’re so thin; you’re exercising all the time.” Pretty thoughtless of me, wasn’t it? Of course I never said such a thing nor did I have the wit to even think of it. But he did.
“Ray,” he said, “do you know why I’m so thin?”
“No,” says I.
“It’s because I’m exercising all the time.”
Another example comes from the film “The Doctor,” a dramatized account of a of a physician turned patient. In the film, a patient expresses her concern to him that ever since she had a mastectomy her husband found her unattractive. Dr. Jack thoughtlessly dismisses her with something to the effect, “Just tell your husband that you’re a pin-up girl. You have the staples to prove it.” That response rendered her mum post haste. Had the woman self-effacingly made this same comment about herself, then one might suppose it would move up the ethical acceptability ladder.



At Friday, October 02, 2015 4:48:00 PM, Anonymous Anonymous said...


I agree with Tomlinson’s belief that use of “400 pounder” and “Wacko” rank low on the ethical acceptability scale. So too do many other “humorous” pejorative descriptors that have been used at one time or another by physicians and nurses including, but not limited to, big G., boarder, crispy critter, crock, dirtball, dud, F.L.K., Galen warrior, garbageman, gome, gomer, gomere, gonzo, L.O.L in N.A.D., M.U.O., N.A.T., N.T.B., O.T.D., P.I.A., toasted toddler, and worm (see, Melvin Konner. 1988. “Becoming a Doctor: A Journey of Initiation in Medical School).
I have questioned eight healthcare providers who I have heard use some of these expressions (in particular, gomer, F.L.K., crispy critter, toasted toddler, and crock). To the person, their response has been “I don’t mean anything by it” or some variant thereof. To test the credibility of this proclamation, I followed with the question “Would you use this concept in front of patients or their families?” which was always followed by a negative. In fact, one respondent proclaimed with unmasked irony, “I wouldn’t be so cruel as to do that.” Another followed with, “What kind of person do you think I am?” I so wanted to answer the question but bit my tongue.
Some providers become livid when their use of patient pejoratives is challenged. Witness, for example, Dr. Peter Gott’s* effort to defend himself against attacks for using the term “crazies” when referring to those unfortunate people who are tortured by mental, emotional, and personality anomalies. He raked his accusers over the coals for taking offense at a term not meant to be offensive and for having “no sense of humor.”
In one small town with which I am familiar, some nurses at the local hospital nicknamed male patients according to the shapes and sizes of their genitalia – Mr. Big Balls, Mr. Right Angle, Mr. Little Guy, Mr. Big, Mr. Uptight, etc. They openly broadcasted their “humor” in public places and shared the joke with their friends outside of health care. When Mr. Big Balls found out about this, he reportedly complained to the hospital’s administrator only to receive the admonition that “Our nurses don’t act that way; they are professionals.”
Some health care providers take umbrage at the use of language that denigrates patients but soon learn that, as one nurse-educator suggested, it is part of a culture and, as such, is difficult to dislodge. For example, a nursing student working in a hospital’s surgery department reported to me that she had lodged a complaint with the hospital’s administration against physicians who regularly made sexually explicit statements and engaged in offensive humor directed at surgery patients. According to her, she received no response from the administration and the offensive behaviors did not dwindle in frequency.

* “Ask Dr. Gott” was a syndicated column in thousands of newspapers around the country until he retired his column in 2011.



At Friday, October 02, 2015 4:51:00 PM, Anonymous Anonymous said...


Other health care providers and students see humor in events that shame or show disrespect for patients. For example, not long ago I spoke to a nursing legal/ethics class. The students responded with peals of laughter at two actual cases presented for discussion, the first by me and the second by the instructor. According to the instructor, she was helping prep an anesthetized patient for surgery when, to the delight of other nurses and student nurses present, she lifted the man’s penis, commented on its length and size, and then pretended the penis was giving a lecture as she maneuvered the meatus as though it were speaking. I asked the professor if she reported the incident to authorities to which she sheepishly answered “No.” But she did admonish the students for thinking the incident was funny, pointing out that what the nurse did was a criminal battery. Apparently, however, the students didn’t take her seriously for their reaction was the same to the following anecdote I communicated to them.

A B.S. nursing student doing a clinical in the local hospital was called to “observe a catheterization.” When she entered the patient’s room, she saw a physician, nurse and several medical students. To her amusement, the patient, who was anesthetized, was a male instructor whose class she was attending that semester. When she went home that evening, she reported what she saw to her roommate, “laughing,” according to her roommate, “the entire time.” “There he was, just hanging there,” she allegedly said to her roommate. After commenting on how small his penis was, she reportedly added that when she went to his class it would be difficult not to imagine him with his clothes off and even more difficult to keep from “bursting out laughing in class.” The roommate, who was not majoring in a health care discipline, said that she was “appalled” and “shocked” at her roommate’s behavior and “perverted sense of humor.”

Another example of gallows humor that denigrated patients occurred during a presentation by nursing students about an overseas trip they took. One student described her participation in the circumcisions of twelve-to eighteen-year-old boys. She indicated that she and her nursing student colleague assisted in the first circumcision after which they were allowed to actually circumcise the young men. As she spoke, a picture of gowned adult participants including the surgeon and a boy of about fourteen, discreetly covered and with an arm over his eyes, was projected on the wall. Her description elicited peals of laughter from the mostly nurse and nursing student audience. Her description was as follows:

Most people would say that their most exciting experience . . . was in delivering babies. For me, I enjoyed circumcision the most (audience laughter). I might sound cruel, but it was a lot of fun (laughter). . . I really enjoyed suturing. That’s what I like about it. . . I’ve got to find something where I can do some suturing (laughter). There’s a funny story that goes along with this. It’s not exactly the caring process [a nursing model perfected by Jean Watson] we’ve been taught (laughter). But, the little boys are awake while this is going on but can’t feel anything. Our little boy . . . he keeps moaning, everything we do. Even if he can’t feel it, he’s seeing it, so he’s making all these moaning noises. So, when [the other nursing student] goes to make the cut, our surgeon friend just screams out so loud – AH! Like that – and we just all start laughing so hard because he’s kind of mocking this little boy. But after that, the little boy was quiet; he was fine (laughter). And [the other nursing student] was afraid that she was going to ruin that part of his life (laughter). . . And all the doctors and nurses were, like, telling the little boys they were lucky because they were circumcised by an American female (laughter).



At Friday, October 02, 2015 4:52:00 PM, Anonymous Anonymous said...


Each year nursing students return to the States from their overseas trip and make presentations about their experiences. The listener can usually count on gallows humor being part of the presentation. For example, a nursing student, with the approval of faculty, projected on a screen a photograph of herself suturing a boy’s circumcised penis. The second photograph showed her rearing back with her hands in the air as though she made a terrible mistake followed by a re-showing of the first picture, an antic that again elicited laughter from the audience. There was no evidence that the student who took the photograph was given permission by the patient or legal representative to do so. Even had the patient consented, it is highly doubtful that he also consented to using the photograph in the manner in which it was used. And, even had he consented to the latter, one would wonder why such an ethnocentric and insensitive display of a people’s cultural practice would be approved by adult faculty members whom I know in other settings verbally discourage expressions of ethnocentrism from their students. Yet in both the present case and the case described in the last paragraph, not only were the students’ displays approved by nursing mentors, but they were lauded by the nursing faculty present for their presentation.
In the same vein, Konner writes about one professor of medicine who was chosen as professor of the year by medical students. His idea “and not surprisingly, that of some of his colleagues – of how to relieve the sheer boredom of the lectures, was to make fun of patients and their illnesses. . . Vulgar jokes about patients are a ubiquitous feature of medical social life, excused as a ‘necessary defense mechanism’ in the fact of illness and death. But he was not an intern shooting the breeze; he was a physician and scientist talking to a large class of first-year medical students who had not yet had any official experience with patients.” Konner also describes a young woman who, with the encouragement of the professor, presented a vulgar poem to the class that ridiculed a patient with syphilis. The professor later gave a lecture on “the plague” while projecting a picture of a syphilis victim’s face on a screen that “was grotesquely misshapen, bulbous, swollen, and deep purple in color.” He then “proceeded to make lame jokes about the patient that drew peals of laughter from the audience.”
An especially disturbing example of questionably ethical behavior by health care providers was communicated to me by a colleague. It seems that his father had a coronary infarction in his home which took his life. As two paramedics tried to resuscitate him, they joked and made light of the tragedy. This behavior so disturbed the man’s grandchildren that one asked his father, “Why did they joke about Grandpa when he was dying?” When my colleague filed a complaint, the paramedics denied everything and their supervisor supported their protestations of innocence. Upon hearing this, I could only wonder at the level of inanity it would take for a supervisor to believe that it served the interests of a college professor to lie about the behavior of people who tried to save his father’s life, but was not in the interests of the paramedics to lie about their behavior.



At Friday, October 02, 2015 4:54:00 PM, Anonymous Anonymous said...


According to Tomlinson, when the unethical use of dark humor “becomes a routine way of talking,” it “institutionalizes* an attitude or perspective about patients.” What is that attitude or perspective? Conrad tells us what it is when he writes, “Crude jokes and gallows humor about patients become part of the everyday scene of medicine. Although making fun of patients may release stress, it also sets doctors farther apart from their patients. . . The situation of the medical students, and later [the physician], does not lend itself to caring for and about patients. Quite the opposite is the case; the situation often encourages the definition of the patient as an adversary or even as an ‘enemy.’” The situation also fosters a perspective of the patient as an object, a non-person, an inferior which, in turn, increases the likelihood that patients will be dehumanized, depersonalized, and objectified -- all this in spite of first year medical school faculty’s efforts at the medical school where Dr. Bernstein practices to guide students away from the inevitable.
Both theory and empirical evidence tell us what the social costs are of providers getting comedic relief from stress at the expense of patients – an increased likelihood of public distrust, civil lawsuits, delay of needed treatment, and so on ad infinitum. The relationship between unethical use of gallows humor and social costs is not only indirect, it is sometimes direct. For example, the earliest case I know of in which a person filed suit against physicians because they used her as the brunt of their jokes and jabs while she lay helpless on a hospital gurney occurred in the 1930s. The most recent case was, I believe, cited earlier in this blog. **

* When something is institutionalized it is made culturally acceptable or normal. Patterns of behaviors (e.g., the unethical communication of gallows humor) and attitudes/perspectives toward patients (e.g., as sub-human, non-human, inferiors, objects, enemies) are said to be institutionalized in health care settings.
** It is highly unlikely that the $500,000 award will remain intact following an appeal of the decision. -- FINIS


At Friday, October 02, 2015 8:56:00 PM, Blogger Maurice Bernstein, M.D. said...

Ray, WOW GREAT dissertation. As I had my first year medical student group read your September 28th comment and was later discussed in a group session, I intend to present your current writing to them. I do think it is important for the students to gain insight into what is a simple acceptable joke and what jokes only degrade the profession of medicine. ..Maurice.

p.s.- Banterings, I am not ignoring your valuable documentations and views.

At Saturday, October 03, 2015 7:41:00 AM, Anonymous Anonymous said...

In a recent, basically negative review, of an ABC comedy entitled “Dr. Ken”, the article is accompanied by a scene from the show of a male patient bent over an exam table obviously about to receive a digital rectal exam. Since this show is a comedy, it’s obvious the audience is supposed to find this at least mildly amusing if not downright hilarious.
Why does the mass media persist in portraying male embarrassment and humiliation as being a subject for humor? As we well know female medical humiliation is never presented thusly.
Examples of misandry such as this appear all too often in the mass media and due untold damage to the case for modesty made by many men. After all, humiliation is really rather humorous isn’t it! So why complain about it?
For what it’s worth, I will register my displeasure by e-mailing the show’s website, I hope others will do the same. For as long as our embarrassment is considered humorous, we will have a much more difficult time having our medical modesty concerns taken seriously.

At Saturday, October 03, 2015 9:48:00 AM, Blogger A. Banterings said...


MG, welcome. (I don’t think I have ever read one of your posts here before. Are you new to the blog?) Can you post a link to the river?

Maurice, Ray, et al,

What I (try to) bring to this issue of patient dignity is a different view of the problem. I also bring a different view of the solutions. For example, as to Ray’s circumcision presentation, I would approach it from a “civil rights” view. I assume that by description of the age of the boys circumcised, they are most likely in the Middle East or Africa; hence they are persons of color.

I am sure that there are organizations (such as the ACLU, Southern Poverty Law Center, etc.) that would take on the issue of this racial issue (gallows humor of people of color). As much as I do not agree with people such as Jesse Jackson and Al Sharpton, they can cause a real nightmare situation for an institution of higher learning.

Would their defense be? We make fun of all patients’ genitals regardless of ethnicity…”

I take my inspiration from how the US government eventually got Al Capone: He was convicted of tax evasion when they could not get him on murder, extortion, bootlegging, racketeering, etc.

I also believe that reinstituting “Peer Physical Exams” would curb such problems as the one of the student witnessing the procedure on her professor. I know that many oppose these things, but they were once a standard part of the medical education (up to the 2000s), and when the profession had more respect.


At Monday, October 05, 2015 11:03:00 AM, Anonymous Anonymous said...


Thanks for the WOW! I suspect that there was not a consistent understanding of what I wrote across members of the student group. I’m curious to know what different students’ understanding was. I’ve an e-mail ( and you’ve a blog. Invite them to communicate and participate.
To know where I was coming from requires some understanding of the history of medicine (as described in particular by Paul Starr in “The Social Transformation of American Medicine”) and how scholars have conceptualized “profession,” a concept which is used loosely by members of the general public.

You asked Kevin what he would suggest you teach your first year students “on how to behave when they see or hear their superiors do or say something ‘dark.’” In the best of all possible worlds, such things would not occur. But we don’t live in a perfect world. Nevertheless, students as an aggregate have the power to move in that direction. Here’s how.*
Let’s assume that students want to protect themselves, protect patients, and protect the integrity of medicine as a profession. Regarding the latter, let’s assume that they wish to protect their future profession as much as they can from the scrutiny of outside institutions and from insiders who threaten to sully its reputation. Let’s also assume that they know, either before or soon after matriculating to medical school, that the likelihood of “dark” things occurring during their tenure as students is high. What’s to keep them, as an aggregate, from creating a written manifesto that 1) identifies the problem, 2) gives evidence of its prevalence and incidence, 4) explains in what ways it is a problem, 5) identifies what actions students will take if they observe the occurrence of ethically questionable behaviors committed by healthcare providers, and 6) provides reasonable justifications for these actions? They can submit this manifesto to the powers that be and insist that its content be included in some form in the medical school’s manual that specifies the rights and obligations of those who work there. Students at Harvard Medical School did something like this when they compelled their professors to get consent from patients before practicing pelvic exams on them while they were anesthetized.
I suspect the students at Harvard had support from some medical school faculty. Whether that is so or not, what’s to keep you and your colleagues, who you have oft suggested are committed to the ethical delivery of healthcare, from supporting these students by, for example, 1) encouraging them to create a manifesto, 2) providing them with relevant data so that they can create a manifesto, 3) supporting them in their efforts to create change, and 4) coming to their defense when they take action to deter those who deviate from ethically appropriate behavior. To do this would test your and your colleagues’ mettle and your commitment to the ethical delivery of health care.**

Tell them this – I dare you. :) 


* Some time ago, I introduced to this blog a piece which identified the factors that contribute to successful social movements. The following recommendations emerge from this piece.
** Research cited earlier in this blog provided evidence that medical students’ movement away from the ethical delivery of health care began to occur during the third year of medical school. If I recall, at the time you claimed to have little control over what your colleagues who instruct 3rd year students do. I was skeptical then and I am skeptical now because I know first hand that members of professions can exert pressure on defenders of the status quo to initiate ameliorative change. Success, of course, requires collective action. During my tenure as a college professor, there wasn’t a year that went by that I and my colleagues were not collectively involved in bringing about constructive change that was resisted by some administers and other faculty.

At Monday, October 05, 2015 9:48:00 PM, Anonymous Anonymous said...


I would like to address your observation that “dark humour is a natural human response.” I have oft heard this explanation used for all kinds of behaviors, both deviant and conforming. To suggest that any behavior is a “natural human response” is to attribute the behavior to biogenic and psychogenic factors (nature v. nurture). This may be part of the story, but, of course, the other part is that human behavior, including the transmission of dark humor, can be explained using social psychological and sociological variables. To date, I don’t believe scientists have discovered biological or genetic etiologies of humor, whether dark or otherwise. On the other hand, explanations of humor have long been the subject of theory and research in the social sciences. One runs the risk of being accused of reductionism if s/he tries to explain any human behavior using only one level of explanation (biological, psychological, social psychological, sociological). All these levels interact to explain human behavior (statisticians call this interaction multicollinearity). We know that each level of explanation is important, but because it is somewhere between difficult and impossible to disentangle explanatory factors, it would be tenuous to argue that one is more important than another or even that they are all equally important in determining human behavior.

What gets my goad – a long lived pet peeve of mine – is when people conflate explanation and justification or, more specifically, when people use the “nature” explanation as a justification for deviances, including ethically questionably actions. For example, I have written about having given a presentation to a legal/ethics nursing class where students laughed at what Tomlinson would most assuredly consider unethical gallows humor. Following the class, a covey of students gathered around me and dismissed the unethical behavior described in the class by suggesting “it’s just human nature.” These students, in effect, used the human nature explanation for the unethical behaviors described in the nursing class to normalize those behaviors. The normalization of unethical behavior sanitizes that behavior thereby absolving people of responsibility for their commission. After all, human behavior that has a genetic etiology cannot, short of genetic engineering, be altered. Use of this justification, then, is a recipe for maintaining the status quo.



At Monday, October 05, 2015 9:50:00 PM, Anonymous Anonymous said...

Research I have conducted suggests that the “human nature” explanation tends to be used to absolve in-group members and people in positions held in high regard (e.g., physicians) of responsibility for the commission of social deviances. These people, it is argued, are like us – good people who are driven by internal forces over which they have no control. “Anyone in the same circumstance would do the same thing,” we are told. On the other side of the coin are out-group members and people who occupy positions held in contempt. The same behaviors defined as excusable when committed by the in-group are redefined as despicable when committed by the out-group; their actions tend to be viewed as being a function of their inherently barbarous and violent nature.

The nursing students also defended the unethical behaviors described in class by attributing them to a coping mechanism designed to deal with the stresses and strains they face everyday as they go about saving lives, thereby, again, conflating explanation and justification. What they were alluding to is alternately referred to as scapegoat theory, displacement theory, or frustration-aggression theory – a theory which was first formulated by Theodor Adorno and his colleagues in “The Authoritarian Personality.” The theory was formalized to explain everything from prejudice to human outrages such as the Holocaust. It, or one or more of its propositions, is used even more frequently to justify everything from prejudice to human outrages.

Just as the “human nature” explanation is used to justify questionably ethical and illegal in-group behavior, so too is the “coping mechanism” explanation. For example, the sexual abuses, tortures, killings, rapes, and sodomies committed by U.S. soldiers – supported by U.S. physicians and nurses* – at Abu Ghraib were considered excusable as normal responses to the abnormal stresses and frustrations they faced.** The same behaviors committed by the terrorist enemy, however, are seen as inexcusable products of personal character defects rather than to external forces beyond their control.

My sole purpose for writing this is to alert the reader to some of the subtleties involved in legitimizing behavior that is generally viewed as illegitimate. My hope is that people will not give a pass to those who legitimize the illegitimate by conflating explanation and justification. Were we to carry this line of reasoning to its logical extreme, we could use it to create policies that would cripple efforts of one of the major functions of government; viz., to protect its citizens.

* See, for example, Steven H. Miles. 2006. “Oath Betrayed: Torture, Medical Complicity and the War of Terror.” Random House.
** Indeed, following the revelations of what happened at Abu Ghraib, the major media spent considerable time showing excerpts from the Milgram and Zimbardo experiments to explain how the power of situations can lead people to violate important social mores. Many individuals with whom I spoke conflated the explanations that emerged from the findings of these studies with justifications for the behaviors. A typical response by some to anyone who questioned the propriety of the soldiers’ actions was, “You’d do the same thing when faced with the situations those boys were faced with,” as though, if true, this would make the soldiers’ behaviors less reprehensible.


At Wednesday, October 07, 2015 6:46:00 AM, Anonymous MC said...

There is a whole lot of high level academic writing here; critical thinking, nicely referenced etc.

Whilst there's nothing wrong with academic discussions, I'm going to drag the tone down, for I feel that these types of discussions contribute to part of the problem: that being the division of Us (superior, well educated medical professionals) and Them (inferior, uneducated patients). It is this division that causes so many physicians to see their patients as a diseased body part that has the annoying habit of having a human being attached to it. Perhaps it is part of the reason to revert to juvenile, overtly sexual descriptions of patients? I can only speculate there.

However, ridicule cuts both ways. I am a long-term patient, aka 'frequent flyer'. I have spent untold hours in waiting rooms of various clinics, and multiple wards, listening to other patients. Doctors and nurses are routinely criticised and ridiculed. 'Idiot','useless' and 'hopeless' would be the most common terms I've heard.

There are some reasons for non-compliance that physicians do not seem to realise! Something that has long baffled me. But I digress.

Whilst I think it's great to teach that this ridiculing patients is an unprofessional way for health care providers to behave, I think it discounts human nature. I can't ever see it stopping, on either side of the examination curtain.

Dark humour is also a natural reaction, to SOME people. In my personal experience of chronic illness & talking to hundreds of others, dark humour is employed by those who are the most resilient. To poke fun at something is to lessen its impact. The difference there is that it is the patient who chooses to poke fun at themselves/the disease, as opposed to another person doing it.

I agree that there is a spectrum on which dark humour sits, and that some is acceptable whilst others clearly unpalatable. Academics will want a precise measurement of where the line is crossed, but that is not possible.

Perhaps the solution is for general consensus of an unpalatable event via anonymous debriefing afterwards. Majority rules and therefore cannot be dismissed or argued against. However is yet another element of paperwork just another burden on an overworked system?


At Wednesday, October 07, 2015 12:01:00 PM, Blogger A. Banterings said...

Here is a change that is being made to the system:

Mom Sues Doctor Over C-Section Fight: ‘I Was Treated Like a Child’

I went into labor on my due date. Everything felt like it was going quickly. We got to hospital around 9 a.m. and I was at six centimeters. There was a midwife on call and she was pretty hands-off. She just let me do what I had to do…

Then [that] doctor came walking in out of nowhere… She came over and said, “I’m going to check you now,” and made me flip over and lie on my back. She put her hands in my vagina without asking…

Then the doctor came over to me and said, “I’m trying to help you, and you’re not letting me, and I don’t like that…

I remember my husband saying, “I don’t want that doctor back in here.” But then she came back in — with pieces of paper that she wanted me to sign. She told me it said, basically, “I don’t care if my baby’s brain damaged or dead.” That’s how she said it: “I don’t care if my baby’s brain damaged or dead.”

...she comes up to me and says, “If you don’t sign off on this C-section, I’m going to call legal people who are going to force you to do it.”

My midwife, who wrote everything down for later, came up to me at one point and said, “Lindsay, you’re being bullied.” But I didn’t know what to do with that information. I was naked and in pain and scared, and believing there was something wrong with my baby and with me.

I thought I was okay for a couple of months — you say, well, I had a healthy baby. But I was having panic attacks. I couldn’t lie on my back in bed because it reminded me of being in the operating room. I was diagnosed with PTSD and an anxiety disorder, and I’d never had any problems before.

[Now, two years later,] I still take medication for panic attacks and anxiety, and I don’t go to the doctor unless I absolutely have to. I’m a defense attorney and I read medical records all the time, and those would trigger a panic attack, because it would say something like “dissected the muscle…”

Had this not happened, I probably would, at the very least, be pregnant with another baby by now. But I don’t think I’ll be ready for a long time, if ever. I hear about other women who are fine, whether they give birth vaginally or by C-section, and I think in large part it’s because they’re treated like human beings during the process. I was just treated as this inconvenient incubator. It’s not the surgery that affected my life. It’s the blatant disregard for my humanity, and my ability to make decisions for myself, and for my kids.

What it came down to with [my suing the doctor] was this: I can’t be the only person out there this is happening to — and I’m a professional, I’m in my 30s, I’m married, I have wonderful family support. What’s happening to the single minority mom? I’m privileged in every way, and I still got treated like a child who couldn’t make her own decision. That’s when I thought maybe I could fight this and do something about it — and the way that works in this country is through a lawsuit.

I think the only leg I have to stand on is that [the doctor] really [doesn’t believe] that a pregnant woman has the same right to informed consent as a non-pregnant person. She testified that under oath, and it’s very scary. It just confirms that women can be misogynist, too.

(Source: Mom Sues Doctor Over C-Section Fight: ‘I Was Treated Like a Child’)


At Wednesday, October 07, 2015 12:04:00 PM, Blogger A. Banterings said...

Part 2:

That has lead to the Exposing the Silence Project, Documenting birth trauma and the strength of women across America. 

Lindsay, of Philadelphia, has spent two years in trauma therapy after giving birth in an environment that left her feeling powerless. She’s one of many women who speak out in the new series “Exposing the Silence.”  

Other common themes: pressure to have a C-section, being lied to (such as the doctor, a woman, who agreed to simply do a quick exam rather than break a laboring mom’s water, but then breaking her water anyway), introducing medical interventions with no warning or explanation, forcing episiotomies. 

Source: Bullied, Powerless, and Defeated: 45 Women Share Their Striking Birth Stories.

Even other physicians ARE being bullied, read:
Pregnant Doctor Shocked by C-Section Pressure:

...why many women fiercely try to avoid the procedure, and then are shocked and even devastated when they realize that avoiding it is often easier said than done. Dr. Carla Keirns was one of those women, as she writes in her Jan. 5 Washington Post essay , “I didn’t realize the pressure to have a C-section until I was about to deliver,” an excerpt from the full version published in the latest issue of the journal Health Affairs.

Even the World Health Organisation (WHO) has warned of the high rate of C-sections and issued guidance suggesting the unnecessary operations could be "putting women and their babies at risk of short and long-term health problems”.

Even when patients choose home birth (excluding physicians), they are bullied. Read Couple Fights for Custody of Children Following Unassisted Home Birth.

The story has been closely followed by Medical Kidnap, a part of Health Impact News that was started, according to its website, because of the growing number of stories like that of the Rengo family. “Due to the increasing frequency of stories being exposed regarding children taken away from their families for simply disagreeing with their doctors,” it notes, “we felt it was time to put up a completely separate website to document these tragic stories.”


At Wednesday, October 07, 2015 12:55:00 PM, Blogger A. Banterings said...


In your comment on "The "Dark Side" of Medical Education," you stated:

I have long been aware of multiple journal articles on the trauma reported by patients that undergo internal examinations as children; the association with rape/abuse, the 'long-term emotional consequences' as you wrote and resultant dissociation as a coping mechanism. Finding these journal articles was one part of a larger personal quest, beginning in my early 20's, to understand my own dissociative issues that developed as a child within the health system.

I would appreciate if you would share with me the references for "these journal articles” that you mention (if at all possible). You can find my email address on my gallows humor (dark humor in situational context).

“The ego refuses to be distressed by the provocations of reality, to let itself be compelled to suffer. It insists that it cannot be affected by the traumas of the external world; it shows, in fact, that such traumas are no more than occasions for it to gain pleasure.” ― Sigmund Freud

I totally agree that it is one of the best coping strategies for stressful, traumatic situations that human beings have to deal with. We have also heard people such as first responders and soldiers in contemporary tragedies say about inappropriate laughter, “If I was not laughing then I would be crying…”

The problem is when it is directed at the patient. In my most vulnerable moment, why would one make fun of me or put me down? That is only adding insult to injury. Your observation of patients doing this to providers is really patients lashing out at the system, who the attending physician happens to be the embodiment and face of that system at the time.

Like sexual boundaries, there is a power imbalance that makes providers directing gallows humor at patients inappropriate.

“First the doctor told me the good news: I was going to have a disease named after me.” ― Steve Martin

In human beings, the physical response of pleasure and pain are the same; the release of dopamine (source:<a href="”>University of Michigan Health System</a>). That is also why many men enjoy a woman “digging her nails into his back” during very intense love making (to the man pain and pleasure at that moment feel the same). That is also where the porn movie cliche of the man slapping the butt of a woman during very intense love making comes from as well.

It has been theorized that the prevalance of tattoos and piercings is due to the pleasure that one receives from the dopamine release. That helps explain why someone would cover so much of their body in tattoos and piercings. There are other reasons that provide "psychological pleasure” (as opposed to dopamine release which is physical pleasure).

So the pleasure derived from gallows humor helps counteract the trauma being experienced at the time, but when directed at the patient, it is injurious to the patient (even though it may be beneficial to the provider).


At Wednesday, October 07, 2015 8:28:00 PM, Anonymous Anonymous said...


I understand what you’re saying. Maurice brought up this issue about a year ago. I expressed my belief that there was room on the blog for approaching subjects associated with modesty from both academic and non-academic perspectives. It seems to me that they more frequently complement and dovetail with one another rather than being at odds. Also, those who prefer to contribute one perspective can learn from the other. The non-academic perspective is important because it reminds us that excesses in medicine continue unabated and that these excesses elicit unwanted emotions and changes in behaviors while the academic perspective helps us understand why that is and what can be done about it. We each have our strengths – some academic and others non-academic. Mine happens to more toward the academic end of the continuum. In spite of that, I don’t think I lacked appreciation for any non-academic contribution I read, contributions which I believe made up the bulk of what was posted on this blog for the first few years.

At the risk of appearing academic, I’d like to comment on something else you wrote. You agreed that “there is a spectrum on which dark humour sits” and added that “academics will want a precise measurement of where the line is crossed, but that is not possible.” Actually, not all academics value precision of measurement, including many academics in the humanities, post-modernists, symbolic interactionists, dramaturgists, social constructionists, and the like. Scientists (both social and natural) must, by necessity, value precision, when defining and conceptualizing their theoretical concepts and when measuring these concepts. Those who train to be attorneys must also understand the importance of precision when defining and conceptualizing legal concepts.

The term reliability (repeated results or measures over time) is usually used by scientists in lieu of precision, and validity (measuring what one intends to measure) is used instead of accuracy. None of these concepts is dichotomous (e.g., precise vs. imprecise); all are matters of degree and their levels are quantifiable. So, while it is true that one cannot create a perfectly precise (or reliable) “measurement of where the line is crossed” and a perfectly accurate (or valid) measurement of that line,* one can create a tool that measures, at acceptable levels of validity and reliability, “where the line is crossed.”

I submit that most Americans not only believe that it is not possible to create an acceptably valid and reliable tool or instrument to measure social concepts; they believe that social concepts – such as romantic love, prejudice, discrimination, conservatism, anomie, social class, status inconsistency, democratization, institutionalization, self esteem, and so on ad infinitum – cannot be measured at all. Were social scientists to agree with either of these beliefs, it would lead to a premature closure of inquiry and the death of positivism (the search for social facts via scientific methods) in the social sciences. Here’s what Earl Babbie writes about the issue: “We begin . . . by confronting the hidden concern people sometimes have about whether it’s truly possible to measure the stuff of life: love, hate, prejudice, religiosity, radicalism, alienation. The answer is yes, but it will take a few pages to see how. Once we establish that researchers can measure anything that exists, we’ll turn to the steps involved in doing just that.”

* Carmines and Zeller (1979: 12) make this point when they write, “Unreliability and invalidity are always present to at least a limited extent.”


Babbie, Earl. 2007. “The Practice of Social Research.” Wadsworth.
Carmines, Edward and Richard Zeller. 1979. “Reliability and Validity Assessment.” Sage.


At Wednesday, October 07, 2015 9:07:00 PM, Blogger Maurice Bernstein, M.D. said...

MC, based on my reading of your word spelling and expressions, I suspect that you might be writing from Great Britain and your personal medical experiences might have originated there. If I am correct, do you find the comments on this thread presumably, mostly American (based on StatCounter service) are familiar to what you have experienced in your own country relative to the behavior and words of your healthcare providers? Are there any special patient modesty-dignity issues that you think are different in your country? I apologize if my assumption about your origin is wrong. ..Maurice.

At Friday, October 16, 2015 9:53:00 AM, Blogger Maurice Bernstein, M.D. said...

If you haven't been recently to the Comments section of the MSU ethics website in response to Dr.Tomlinson's article on "dark humor" in medicine, there are now 27 comments, a few are mine but other's comments are of interest. ..Maurice.

At Friday, October 16, 2015 12:00:00 PM, Anonymous Anonymous said...


In Tomlinson's "Comment" section, you express and interest in adding my contribution re. dark humor in medicine to the comments. You have my consent to do so. I don't think I'd be able to make the transfer myself and am not inclined to recreate what I wrote. As far as I'm concerned, you can use anything I've written for any reason you'd like. I'm always interested in people's feedback. I've found it helpful in communicating what I intend to communicate and in avoiding logical errors.


At Friday, October 16, 2015 4:32:00 PM, Blogger Maurice Bernstein, M.D. said...

Ray, thanks for your offer but actually I assumed that anything published on my blog which is available to all the public as an internet blog could be reproduced elsewhere without specific permission from the author. What I meant in my comment on MSU Ethics was to get permission from the editor of that website to post your writings there. So, instead, I presented a link to your writing here. ..Maurice.

At Friday, October 16, 2015 10:36:00 PM, Anonymous Anonymous said...


I see. I guess I read what you wrote too quickly.


At Monday, October 19, 2015 6:14:00 PM, Blogger A. Banterings said...

I would like to address the issue of "gallows humor" from 2 perspectives; the first being a really good article on the American Society of Clinical Oncology (ASCO) site that I read about "cancer humor." The second deals with looking at some other "social humor taboos."

The article is by James Randolph Hillard, MD, "How Should Clinicians Respond to Cancer Humor?" He frames humor according to Freud’s framework. Although this covers how clinicians should react to jokes told by patients, the analysis of humor shows why humor directed at patients is unacceptable.

Freud, of course, viewed everything in terms of the id, ego, and super ego: The id is all about "what I want or feel right now"—sex, aggression, fear, that sort of thing; 2) the superego is all about "what I should be doing;" and 3) the ego has the often thankless task of mediating between both of these irrational entities and the demands of the outside world.

Freud’s main theory of humor was that when the id feels something that the superego disapproves of, the ego can trick the superego into letting the id get away with it. To do this, jokes often start out seeming to go one socially acceptable direction, and then suddenly change direction to allow the id to share something else entirely. That is when we laugh.

One of the reasons that makes humor directed at patients inappropriate is because (as Dr. Hillard notes), "he two main things that your id wants to express are sex and aggression, and you do not want to express those to your patient…" In the realm of gallows humor, there are characteristics that define when the humor is harmful to both the patient and clinical encounter (and thus, all of healthcare).

The first characteristic is if the patient is included in the conversation or not. The image that comes to mind is from the 1991 movie, "The Doctor" where 2 surgeons are discussing Jack MacKee’s case as he is wheeled into surgery ignoring him. When he chimes in speaking the medical lingo and demonstrating not only his medical knowledge, but the fact that he is a more skilled clinician, the 2 surgeons look at him dumbfounded. He simply responds, "Yes, it talks. Amazing!"

The second characteristic is who the humor is directed at. Generally, the humor is either directed at the patient or not. There is a third, gray area that is sometimes mistaken for being directed at the patient, and that is when the humor is directed at the disease, treatment, or some aspect of it.

That brings me to the next section about an analysis go gallows humor, and that is in terms of race. One best examples of this and the biggest debate has been the use of the "N" word. It is generally understood that this word should never be used. Yet, some black entertainers ( I use the term "black," because all black people are not black people are of African descent) justify using the word by 2 arguments; Taking the power and conniptions away from the word by owning it, OR being able to use it by nature of being who it is directed at.

The following is a monologue by the comedian n Dave Chappele titled: "Why black people hang out with white dudes". Racial humor is very similar to gallows humor in how it can be inappropriate and offensive. Note that in the monologue, Dave Chappele includes both white people and people of color.

A recent example of racial comedy gone wrong was by Michael Richards (who played Cosmo Kramer on ABC’s sitcom "Seinfeld."


At Tuesday, October 20, 2015 7:56:00 AM, Anonymous Anonymous said...


You put forward an excellent analysis of the situation from an academic purview. For me, however, a problem arises. We tend to over-dissect everything and lose sight of the bigger picture. Analysis of any set of population - from small groups to entire civilizations - gives the impression that the 'group' behaviour mimic that of an entire organism. We emphasize conscious thought and decisions on a personal level but ignore innate bio-deterministic behaviour that drive our groups - where the individual comprises a cell within the larger organism and its autonomy exist only within the greater cellular matrix.

The fact that base behaviours are evident when socio-economic systems break down speaks volumes about humans. These very behaviours have ensured our survival and allowed us to thrive as a spp. Without innate response we would have become a food for other spp. in those dark prehistoric times. Due to our large cerebral capacity we have also developed some complex social rituals and erudite philosophical explorations - 'conscious' behaviour vs innate. That our behaviours exists as strata - lower centers and base behaviour are the foundation for higher thought processes. Default is survival(autonomic systems, fight or flight, food/reproduction and on all the way up to art appreciation.

Under stress or breakdown of established social constructs we ratchet down into lower brain centers and our base animal behaviours. It is my belief that behaviour should be viewed in terms of the stress level of the individual. It is natural that nurses would use this as a defense for what would be otherwise unethical behaviours - the problem is that at some point you would expect their experiences to become normative. For a period of my career I was walking in heavy brush in close proximity to grizzly bears. This was became normative for me at the time so I thought nothing of it. Nurses using this as an excuse are merely masking inappropriate behaviour as they should habituate to some extent. As in previous posts I have observed that there is a tendency for females to default to 'victim' to explain/excuse otherwise socially unacceptable behaviour. " It's not my fault because____"

My own response to stressors is entirely predicated upon my own emotional state. In a happy mood I am likely to deal with others in a non-confrontational way. If I am stressed myself I am much more likely to respond with aggression or other behaviours.

So...nature, excused by nurture.


At Tuesday, October 20, 2015 12:57:00 PM, Blogger A. Banterings said...


Let me take that a little further: Just as patients are given the excuse of “professionalism” as justification for having a patient undress and assume a gender neutral stance, that professionalism [should] allow nurses to ignore external stressors and treat patients with dignity all the time.

I find it amusing that nurses (and other providers) use professionalism as their defense to patient modesty but have 100,000 excuses most of which involve the stress of being overworked and lack of time when they err.

Let me give another example; When patients push modesty concerns and want to skip genital exams, they are pushed by physicians as that is part of a thorough exam. The patients’ experiences are discounted as them being outliers, anecdotal, not evidence based, etc. Yet, I can’t tell you how many forums, blogs, etc. that I have been on where physicians respond to the new guidelines that say skip GEs by saying something like, "I once found testicular cancer 25 years ago… and he survived.”

It seems that professionalism (just like patients undressing) is used for the convenience of the provider.

I find that as one delves deeper into guidelines, what you find is pretzel logic. Here is an example; in most guidelines for child sexual abuse, they say one of the signs of possible abuse is refusing to undress for a physical exam. Following these guidelines, the child then must submit to a comprehensive physical exam that would be the same experience as a sexual assault upon that modest child.


At Wednesday, October 21, 2015 5:25:00 PM, Anonymous Anonymous said...


Let's not forget how they ( nurses) behave when they are
the patient.

Only a female nurse will cath them and they must not be a
Cna or an Lpn. They will not be a patient where they work.
They have assured all mammograms are performed by
female technologists. They let everyone know they are a
nurse when they are a patient. In case none of you know
there is something called a face sheet in every patients
chart. It tells where you live, your home phone number,
social security number and where you work and your
occupation. I assure you every nurse looks at this face
sheet and specifically at your occupation.


At Wednesday, October 21, 2015 10:40:00 PM, Anonymous Anonymous said...


You write: “You put forward an excellent analysis of the situation from an academic purview. For me, however, a problem arises. We tend to over-dissect everything and lose sight of the bigger picture. Analysis of any set of population - from small groups to entire civilizations - gives the impression that the 'group' behaviour mimic that of an entire organism. We emphasize conscious thought and decisions on a personal level but ignore innate bio-deterministic behaviour that drive our groups - where the individual comprises a cell within the larger organism and its autonomy exist only within the greater cellular matrix.”

I assume by “we” you mean you and I since “you” and “me” are the antecedents of “we. If so, I’m not sure how you know that I (or maybe academics in general) “tend to over-dissect everything and lose sight of the bigger picture.” Indeed, I’ve no idea where sufficient dissection (or whatever one wants to name that which precedes over-dissection”) ends and over-dissection begins. I think of “bigger picture” theorists (or, I prefer, macro-level theorists) – including classical theorists such as Auguste Comte, Karl Marx, Emile Durkheim, and Herbert Spencer – as those who explain variations in human behavior, variations in group behavior, variations in social institutions, and variations in social conditions as being the result of macro-level social structural and cultural factors rather than “bio-deterministic” factors. Indeed, using “bio-deterministic” factors to explain these phenomena certainly seems more micro than the former.

Your reference to “innate bio-deterministic behavior that drive our groups,” is founded in biosociology or sociobiology which borrows from and expands on Charles Darwin’s ideas and posits that biogenetic factors interact with environmental (social, ecological, etc.) factors to determine patterns in the social and cultural worlds. This idea is not inconsistent with the part of my analysis where I suggest that a combination of biogenic, psychogenic, and sociogenic forces determine the human condition (understood broadly). However, theoretically, sociobiologists are heavy on the biogenic level of explanation and light on the sociogenic level of explanation, a position which is empirically untenable. Indeed, sociobiology has gotten a lot of flack because it really doesn’t do a very good job explaining patterns of group behavior and cultural variations. Nor does it do a very good job in explaining cultural universals (e.g., incest) as its proponents purport it does. I was tickled by one critics view. He wrote of Israeli kibbutzims’ cultural idiosyncrasy of raising all of their children together as if they were brothers and sisters. Boys and girls play together, study together, eat together, work together, bathe together, micturate together, etc. – you get the picture – but when they grow up, they don’t have sex together nor do they marry (they are exogamous – marry out of the group) because it would be like marrying one’s own sibling. “On the kibbutz,” the critic points out, “the genes must have been fooled.”

A second criticism of sociobiology is political – if swallowed hook, line, and sinker, it is part of a formula that props up the status quo and thereby discourages change. If biogenetic adaptations are primary in determining patterns of deviance in health care organizations, then how can we hope to change these patterns?


At Thursday, October 22, 2015 1:42:00 PM, Blogger A. Banterings said...

I do this in 3 parts:


You make a very good point about nurses. I also believe that nurses are an emerging problem in US healthcare. As new laws reduce physicians’ power and tie them up with paperwork, and there are fewer GPs, we hear that other providers, specifically nurses will play a bigger role. Nurse practitioners will replace much of what the GP does.

As I have said, the axiom "Power tends to corrupt, and absolute power corrupts absolutely." holds true time and time again. As this group becomes more powerful, they will abuse more (whether knowing or not). On this blog, both Ray and Kevin have provided quite a bit of insight to the problems patients face with nursing.

There is a social phenomon of when disenfranchised groups gaining equality (power) they become militant. (Reference: Have Rappers Gone From Repping The Disenfranchised To Repping The Upper Crust?) I am sure that Ray can help me with additional references about this phenomenon. This has been seen some aspects of the civil rights movement in the US. The Black Panthers and as was the case in Iraq:

In Iraq, a Sunni minority ruled over the Shiite majority for decades. After the U.S. invasion, Saddam Hussein -- a Sunni -- was overthrown, and a Shiite government took over. That government proceeded to marginalize the Sunnis, and now some of those disenfranchised Sunnis have gone on to form the so-called Islamic State, or ISIS. Source: CBS News

That brings me back to nurses. Here is a link to a recent thread on Allnurses, titled The Nurse on the Other Side. The core of the article is that nurses hate to have nurses as patients. The author writes about how she was treated badly as a nurse-patient by nurses.

Notice how some “fellow” nurses attack her saying she is mentally ill (delusional) where have I heard this before..., she is too demanding, the tone of the article is arrogant, etc. The point I make here is that someone who works within the industry and knows first hand what happens is being told that she imagined the events when she experienced them. I think that there is a pathology that permeates providers that cause denial of abuses within the healthcare system.


At Thursday, October 22, 2015 1:42:00 PM, Blogger A. Banterings said...

Part 2:

It is not uncommon for (dysfunctional) professions, systems, families, etc., to deny the internal abuses (reference; The Third Wave), this is very common in the dynamics of dysfunctional families. This is very often seen in families where sexual abuse and/or alcoholism is/are problems.

Experience “reality shifting” in which what is said contradicts what is actually happening (e.g., a parent may deny something happened that the child actually observed, for example, when a parent describes a disastrous holiday dinner as a “good time”). Source: Brown University

This may be due to (psychological) projection as a defense mechanism. In order to hide one’s own sociopathic characteristics (the lack of empathy that prevents some providers to validate patients’ modesty issues), they project mental illness upon patients. Why should anyone have a problem letting all the doctors, nurses, and students examine their genitals, you are getting hundreds of second opinions...

Another cause is burnout. Burnout in healthcare has long been considered "a state of chronic stress” that can lead to illnesses both physical and psychological, most notably depression, substance abuse, and suicide. (source: Psychology Today, The Tell Tale Signs of Burnout ... Do You Have Them?) There is a question does burnout describe a set of symptoms describing an illness OR is it one of the symptoms describing an illness:

Experts have not yet agreed on how to define burnout. And strictly speaking, there is no such diagnosis as “burnout”, unlike depression, which is a widely accepted and well-studied illness. That is not the case with burnout. Some experts think that there might be other symptoms behind being "burned out" – depression or an anxiety disorder, for instance. Physical illnesses may also cause burnout-like symptoms. Diagnosing "burnout" too quickly could then mean that the actual problems are not identified and treated properly.(source: Depression: What is burnout syndrome?) There is growing support that burnout is an illness with comorbidities. (reference: Oxford Journal, Burnout as a clinical entity--its importance in health care workers.

Burnout has also been causes of patient neglect frequently relate to organisational factors (e.g. high workloads that constrain the behaviours of healthcare staff, burnout) (source: Patient neglect in healthcare institutions: a systematic review and conceptual model). It has lead to "an unfeeling and impersonal response toward recipients of one’s service, care treatment or instruction,” "treat patients as objects" (source: Society of Critical Care Medicine: Physician Burnout - A Threat to Quality and Integrity).

This is significant because providers who did not learn disregard for patient dignity and modesty as part of the formal or hidden curriculum of their training are at risk to become offenders due to burnout.


At Thursday, October 22, 2015 1:42:00 PM, Blogger A. Banterings said...

Part 3:

In previous volumes we discussed how the disregard for patient modesty was a combination of what was learned and the use/abuse of power. We have entered a new view here where it is also from burnout (and other factors associated with the profession) AND/OR the rise in power of previously disempowered groups (nurses).

We must also recognize that (as I mentioned in previous volumes) that power issues in nursing are due to the profession being female dominated. In addition to being lower on the hierarchy of power (attending physician in charge, nurses follow physician orders), the population (women) has been traditionally disenfranchised. There is speculation that the equal rights movement and feminism has not only helped to bring women up to the status quo, but it has pushed men behind, and even had a negative impact on men such as stereotyping men as sexual predators.

(Reference: Time Magazine, Ironic Misandry: Why Feminists Pretending to Hate Men Isn’t Funny, The Economist, The Weaker Sex, and NY Times, The Boys Have Fallen Behind).

Andrea Rita Dworkin the radical feminist and writer best known for her criticism of pornography (which she argued was linked to rape and other forms of violence against women) furthered the idea that all (hetero.) sex is rape. In her 1987 published work, Intercourse, she extended her analysis from pornography to sexual intercourse itself, and argued that the sort of sexual subordination depicted in pornography was central to men's and women's experiences of heterosexual intercourse in a male supremacist society. In the book, she argues that all heterosexual sex in our patriarchal society is coercive and degrading to women, and sexual penetration may by its very nature doom women to inferiority and submission, and "may be immune to reform”. (Reference: Wikipedia)

Many people have noted the stark difference in the sentences male and female sex offenders receive. Female offenders tend to walk away with probation, time served, or very low jail sentences compared to male offenders. Many have denied this bias. Yet researchers find female sex offenders get slaps on the wrist. (Source: Sage Journals, Sex-Based Sentencing Sentencing Discrepancies Between Male and Female Sex Offenders) Let me demonstrate how this is practiced in healthcare; it is well established that the majority of chaperone use occurs when a male physician examines a female patient.


At Friday, October 23, 2015 10:38:00 PM, Anonymous Anonymous said...


You suggest “that base behaviours are evident when socio-economic systems break down.” In fact, base behaviors are evident whether socioeconomic systems break down or not – during times of economic crises as well as in periods of economic boons. Also, the relationship between economic conditions over time in certain geographical areas and the rate of “base behaviours” has not been found to be consistent. Let’s assume that the 7 index crimes in the FBI yearly report are among the “base behaviours” about which you refer. Contrary to popular opinion, the Great Depression in the U.S. saw a decrease in the rate of index crimes which leveled off until the late ‘60s and then began to climb as we entered a period of economic boon. By contrast, the collapse of the Soviet Union was followed by a 400%, more or less, increase in comparable crimes over a short period of time.

“Without innate response,” you write, “we would have become a food for other spp. in those dark prehistoric times. Due to our large cerebral capacity we have developed some complex social rituals. . .” Is there evidence that “innate response” was more important than socialization in determining the survival of H. sapiens “in those dark prehistoric times”? And, regarding “our large cerebral capacity,” size apparently isn’t everything. After all, Neanderthals had a cranial size two cubic centimeters larger than humans and look where that got them. I also cannot visualize how behaviors, whether in the “lower centers” or “base,” can be foundations for “higher thought processes.” How, for example, are fighting, fleeing, and food reproduction foundations for critical thought?

In the next paragraph you posit a causal relationship between stress and the ratcheting “down into lower brain centers and our base animal behaviours.” Of course, this is not the behavioral reaction of all people to stress. The best guess from research conducted by social psychologists such as Milgram, Burger, Zimbardo, among others is that about one-third of those who experience stress do not, in fact, engage in “base animal behaviours.” Not all soldiers at My Lai participated in the slaughter of innocent civilians there, in spite of the stress they had experienced, and several – in particular Hugh Thompson – actually threatened to open fire on Charlie Company troops – including William Calley – if they interfered with efforts to move civilians out of harm’s way. In short, several of Charlie Company’s troops, in spite of the stress they had experienced and in spite of being threatened by superior officers with court martial and possible execution, refused to participate in the massacre while others rose above the typical response to stress and saved a number of civilians.

How people respond to stress also varies from one culture to another. For example, stress among simple hunter/gatherers (e.g., Pygmies of Central Africa, Kaska Indians of northwestern Canada, the Aborigines of Australia, the Semai of Malaysia, the Khoisan of southwestern Africa, and the Hazda of Tanzania) tended in the past and tend today not to result in “base animal behaviours” but in increased cooperation among members of a village designed to decrease that stress. Similarly, the Hopi people have historically eschewed violence, even under stress.



At Friday, October 23, 2015 10:42:00 PM, Anonymous Anonymous said...


To your statement, “It is natural that nurses would use this [stress] as a defense for” unethical behavior, I repeat a question I have raised several times to those who insist that nature rather than nurture is a predictor of any particular type of human behavior (in this case, the use of justifications for unethical or illegal behaviors) – Where is the evidence? I’ve been exposed to none and would be thrilled if someone would inform my ignorance if the evidence is out there. By contrast, there is a wealth of evidence from scholars – including, but not limited to, Ronald Akers, David Matza, Erving Goffman, and Edwin Sutherland – that use of justifications for unethical and illegal behaviors are functions of the socialization or resocialization of individuals in groups or organizations; i.e., nurture. People learn justification techniques for unethical/illegal behaviors in the process of interacting with others in groups and organizations in which these behaviors are commonly practiced. And, you are correct, the evidence does indeed suggest that unethical behaviors (and the justifications used to defend them) are highly likely to become “normative” for any particular person – indeed, for the majority of persons – who becomes a member of a group or organization in which unethical behaviors (and the overt or subtle “teaching” of justification techniques) constitute standard operational procedures (see, e.g., research conducted by Solomon Asch, Stanley Milgram, Phillip Zimbardo, John Dovidio, Jerry Burger, Joshua Duntley, Craig Anderson, and so may others).

I have oft asked my students, “When the typical person moves from one culture to another that is different, is s/he more likely to replace her values, beliefs, and behaviors learned in the old culture with those of the new culture or retain the values, beliefs, and behaviors of the old culture?” The answer, of course, is the former. The writings of physicians about their medical school experiences, the interviews I’ve conducted with health care providers, the musings of health care providers on blogs, and the research conducted by medical ethicists all suggest that resocialization tends to occur to people who enter health care fields. The frightening thing to me is that the health care culture, especially that which exists in hospitals, constitutes a counter culture – a culture which is, more or less, at odds with the greater culture. George Annas in “Judging Medicine” (1988) recognized this when he dubbed the modern hospital a “human rights wasteland.” He wrote: “Civil libertarians have little difficulty appreciating the plight of prisoners or mental patients. But tell the average civil libertarian that there are significant and unnecessary restrictions on the individual rights and liberties of patients in general hospitals, and you are likely to encounter a blank stare” (4). I’ve often exclaimed when it comes to health care in the U.S., “I wish I didn’t know now what I didn’t know then. If Annas knew then what we know now, he’d most likely consider his reference to a “wasteland” a misnomer. Modern hospitals – at least some of them – are human rights abattoirs.



At Friday, October 23, 2015 10:43:00 PM, Anonymous Anonymous said...


I’m bewildered by your suggestion that “there is a tendency for females to default to ‘victim’ to explain/excuse otherwise socially unacceptable behavior. ‘It’s not my fault because _____.’” I don’t know why you limit your statement to “females.” Researchers, such as David Matza, have recognized that this justification technique is used by males as well as females. He refers to this technique as “denial of responsibility.” In law, this technique is used in a limited sense; when a person (male or female) is convicted of a crime, his/her sentence may be lighter than it otherwise would be if there are mitigating circumstances such as intoxication, bad home environment, bad crowd, stressful job, etc.

I like your quip, “nature, excused by nurture” and may reference you when apropos. If one assumes that the stress leading to unethical behaviors by providers has a biogenetic foundation (nature) and that excuses for unethical behaviors are learned (nurture), then it follows that the consequences of nurture can be used to excuse the consequences of nature. However, I am also confused because in an earlier paragraph you asserted that excuses used by nurses are the result of nature not nurture – “It is natural that nurses would use this [stress] as a defense for” unethical behavior. Which is it?


At Saturday, October 24, 2015 8:15:00 PM, Blogger A. Banterings said...


You state: "I also cannot visualize how behaviors, whether in the "lower centers" or "base," can be foundations for "higher thought processes." How, for example, are fighting, fleeing, and food reproduction foundations for critical thought?"

There is a common joke among males going to college. They are trying to get a good job to make the money to afford the "hot wife." This is referred to as thee "beauty-status exchange." (Reference: The Although this correlation is questioned, there is evidence of it.

Further, the use of tools were to help meet the base needs: spears to get food, fire to protect us from predators, the "night," and the elements (cold). Our social structures promoted survival, men hunting, women gathering, cooking, raising children, making clothes, etc.

Your comment "It is natural that nurses would use this [stress] as a defense for" unethical behavior, I repeat a question I have raised several times to those who insist that nature rather than nurture is a predictor of any particular type of human behavior (in this case, the use of justifications for unethical or illegal behaviors)..."

I had developed some theories on psychopathy/sociopathy. Those are described (generally) as a person lacking a conscience, (lacking the ability to empathize or feel remorse). I pondered how such a person approaches decision making? This can only be explained by making decisions on "pleasure drives" (i.e. those base instincts).

I had also read about child development where 2 year olds learn that they cannot lie to their parents ("…mommy, the monster broke that…"). Amazing how mommy knew the monster didn’t do it. (Reference: Psychology Today) So is learning to lie nature or nurture?

Both you and Kevin are correct about "denial of responsibility." You are correct when you state that this is used to reduce sentencing in relation to a crime. Kevin is correct that this is used as justification by female nurse, but it is conditionally limited to nurses who HAVE BEEN CAUGHT committing unethical/abusive/illegal behavior. OBVIOUSLY no nurse would justify any behavior that there is no proof that she committed.

IF anonymous surveys are used, then any justification would be in defense of being "found out" (either by evidence or self-admitted). Would a psychopath ever confess that they did it because they were a psychopath? Some comedians use as fodder for their routines a question that psychiatrists have pondered for a very long time; "Do insane people know they are insane?"

The most important thing that I learned from my counseling degree was that one NEVER asks "why?" Take the case of Richard Rosenthal:

He was a highly paid executive in a prominent insurance company. One would not believe him capable of such a crime. Laura Rosenthal was dissected with her heart and lungs removed. There was so much blood in the backyard that the fire department decided to hose down the lawn and wash it away. It was reported that she was referred to as "Jane Doe" on the arrest report because she could not be visually identified.

When asked why, he stated it was a fight over burned pasta.
The burned pasta was the TRIGGER, it was NOT the reason "why."

I believe that nurses are in a unique position; the abuses are learned in the hidden curriculum like ALL healthcare providers, AND they are subject (by nature of being a female dominated profession) to misandry of the feminism that grew out of the equal rights movement. Thus, just as light is explained by waves and particles, nursing is explained by healthcare AND gender.


At Saturday, October 24, 2015 8:32:00 PM, Anonymous Anonymous said...


You suggest that “when disenfranchised groups gaining equality (power), they become militant” after which you requested that I provide references. What I will write is only obliquely related to our concerns on this blog, but I’ll give it my best anyway.

The research with which I am familiar and which is reviewed in Vander Zanden’s “American Minority Relations” and, more recently, Farley’s “Majority-Minority Relations” (Chapter 7) – both of which are probably accessible in most college libraries – suggests that militancy is one, and the least likely, of a number of responses by minority peoples to institutional discrimination. Once a people gain equality – or, more specifically, once they are successfully assimilated into the dominant society (as occurred for most immigrant ethnic groups in the U.S.) – the likelihood of militancy diminishes. Of course, it is also true that when a minority becomes a dominant group as has occurred in Iraq, then the newly franchised are likely to repress the newly disenfranchised, especially if one of the responses of the latter is militancy.

In the 1920s and ‘30s, theorists and researchers from the Chicago School of Sociology such as Ernest Burgess viewed the modern city in the U.S. as being made up of different zones with the poorest living in the “inner city” and the more affluent in the suburbs. Each new European immigrant group tended to settle in the inner city, pushing out former inner city dwellers who moved closer to the suburbs as they became upwardly mobile economically and as they assimilated into the dominant social structure and culture. Militancy as an adaptive response to discrimination was unlikely among these people just as it was among immigrants from Baltic and Bohemian nations who settled in rural areas, and among immigrants from Asian nations who settled primarily on the West Coast. Militancy among American minorities was more likely to occur among what Robert Blauner (“Racial Oppression in America”) referred to as colonized minorities – minorities that become part of a society by forced immigration (African Americans), annexation (Mexican-Americans), and conquest (Native Americans). Colonized minorities in any society tend not to be afforded the same opportunities for upward social mobility (and, thereby, in the case of African Americans, movement through urban zones) as immigrant minorities, even when forced to assimilate culturally (as was the case of Native Americans). Even in recent times, we see ethnic groups that are immigrant minorities in one nation doing quite well but where they are colonized minorities they don’t do so well. For example, Korean Japanese and Burakumin Japanese are colonized minorities in Japan but immigrant minorities in the U.S. As expected, as a group, they don’t do so well in Japan but in the U.S. have excelled.



At Saturday, October 24, 2015 8:34:00 PM, Anonymous Anonymous said...


Militancy is not likely to be the first mode of adaptation to discrimination adopted by minorities. The NAACP, which originated in 1909, was never a militant organization. In 1930, Wallace Fard Muhammad, who was skeptical that the NAACP would ever achieve its goal of structural assimilation for black Americans, founded the Nation of Islam (actually, The Lost-Found Nation of Islam in the Wilderness of North America, referred to as Black Muslims by whites) which, with its paramilitary division called the Fruits of Islam,” was dubbed a militant organization by some and a retreatist or avoidance organization by others. Jim Crow was still cooking, in spite of the 1964 Civil Rights Act and the 1965 Voting Rights Act, when Huey Newton and Bobby Seal founded the militant Black Panther Party in 1966. The most frequently adopted adaptations to minority subordination are acceptance and resignation. Militancy tends to be the least frequently adopted adaptation and tends to occur, not when things are at their worst for minorities as is commonly believed (and was believed by Karl Marx), but when the lives of minorities begin to improve; rising expectations, rather than despair, increases the likelihood of some minorities adopting the militant option. Thus is explained the late start of the militant mode of adaptation in our civil rights history.

So, that’s all I have to say on the matter and it's probably too much. Hope it made sense.


At Saturday, October 24, 2015 8:46:00 PM, Blogger Maurice Bernstein, M.D. said...

As I have previously written, I appreciate all the dissection which in recent Volumes has been going on. It is the dissection which enables pathologists applying their skills on the deceased to come up with a diagnosis which was not established previously. Yet, there must be a time when we can move on to prevention of the pathology.

So.. what is next? How to prevent the "bad" and maintain the "good" of the profession of medicine?

You know, I just finished watching the USC-Utah football game and while the players were the focus of the event, it was those other gentlemen I witnessed standing, looking, commenting amongst themselves and to the public and most importantly pulling out that yellow flag and the first instant of a misbehavior of the players.

Do you think we need in the medical system not just State Medical Boards to respond to patients long after the fact, but we also need monitors whose job is to pick up misbehavior as it happens and act on the spot to penalize the healthcare provider who is found not to be following the rules.

Well, this all may appear as an illogical dream but if the other "players" in medical practice don't or refuse to respond to the "bad medical behavior" they observe in their colleagues, shouldn't we consider some other monitoring and reacting system?
I think that if every physician, nurse and tech knew they were being observed for bad behavior and knew they would be immediately and severely penalized, like on the football field, there might be a whole lot less "bad" going on. In our electronic-video-computer age, surely there would be a way to provide that monitoring and reaction as those "other gentlemen on the football field"> ..Maurice.

At Saturday, October 24, 2015 10:44:00 PM, Anonymous Anonymous said...


You quote me and then introduce red herrings. In your original post, you stated that “base behaviors” are foundations for “higher thought processes.” I could not and still cannot visualize how this might be. In your effort to help me visualize how “base behaviors” are foundations for “higher thought processes,” you direct me to a publication that points out what may be fatal methodological flaws in the research that tests the “beauty-status exchange” theory (e.g., the posited correlation that you consider convincing evidence is actually spurious) and research that debunks the theory.

The second thing you do is give examples of the relationship between use of technology and the meeting of “base needs” (such as the need for food, self-esteem, protection, etc.); you do not give examples of the relationship between “base behaviors” and “higher thought processes,” which you originally posited. I can certainly visualize how activities requiring higher level thought (e.g., the invention and use of some tools) can help satiate “base needs.” However, some qualifiers are in order. First, “higher thought processes” are not needed to use some types of tools. For example, although the invention of a particular spear might require higher level thought, throwing it does not. Learning how and when to throw it does. Second, a cognitive link between invention or use and meeting “base needs” sometimes occurs serendipitously or fortuitously rather than deliberately. These qualifiers, however, do not detract from the proposition that technological invention/use requiring higher thought processes can satiate “base needs.”

The third thing you do is posit a causal relationship between social structure (e.g., women cook, men hunt, etc.) and survival. Again, you are addressing the relationship between higher level reasoning required in the creation of a social structure and satiation of “base needs” (for survival) rather than the relationship between “base behaviors” and “higher thought processes” which you originally posited. But again, a rider is necessary. According to the anthropologists I know who have studied the matter, including a colleague of mine, social structures tend to arise unconsciously rather than with deliberation. If this finding is correct, then using social structure as an example of a phenomenon requiring “higher level thought processes” is a mistake. On the other hand, maintenance, expansion, or the changing of an established social structure is sometimes preceded by deliberate planning in which “higher thought processes” occur.


At Saturday, October 24, 2015 11:29:00 PM, Anonymous Anonymous said...

Woops! I addressed my last comments to Kevin rather than Banterings. I apologize. I’m going to hit the hay and see if I can do better tomorrow.


At Sunday, October 25, 2015 8:34:00 PM, Anonymous Anonymous said...


You attribute to me the following “comment”: “It is natural that nurses would use this [stress] as a defense for” unethical behavior.” That’s not my comment; it’s Kevin’s. You then leave out my most important words, “Where is the evidence?” My comment in full was “To your [Kevin’s] statement, ‘It is natural that nurses would use this [stress] as a defense for’ unethical behavior, I repeat a question I have raised several times to those who insist that nature rather than nurture is a predictor of any particular type of human behavior (in this case, the use of justifications for unethical or illegal behaviors) – Where is the evidence?” You write of theories, but theories are themselves not evidence of anything. They are sets of logically interrelated propositions that are meant to be tested. When research confirms a theory, then we can say that evidence has been provided in support of that theory. I simply have not seen any evidence that confirms some biological/genetic theory of justification.

You ask, “So is learning to lie nature or nurture?” If lying is the result of learning, as your sentence intimates, then lying is necessarily a function of nurture (social milieu) not nature (biogenetic milieu). You also write, “Kevin is correct that this [denial of responsibility] is used as justification by female nurse, but it is conditionally limited to nurses who HAVE BEEN CAUGHT committing unethical/abusive/illegal behavior. OBVIOUSLY no nurse would justify any behavior that there is no proof that she committed.” If I am permitted to infer from research findings generated in other than health care settings in which deviant behavior occurs (e.g., cheating by college students, delinquency by gang members, corporate crime etc.), then it is not difficult to envision people justifying unethical/illegal behavior in advance of their commission. The relevant theory, which I have advanced several times on this blog and which has been confirmed dozens of times, is called neutralization theory. It was originally formalized by David Matza to expand Edwin Sutherland’s differential association theory and to explain delinquent behavior.

You write that “some comedians use as fodder for their routines a question that psychiatrists have pondered for a very long time; ‘Do insane people know they are insane?’” The answer is, unequivocally, some if not most, in fact, do “know they are insane.” Indeed, I know people who have serious mental illnesses, some with whom I am very close, who are quite aware of their psychiatric conditions and, in some cases, may know more about those conditions than most physicians. Of course, all these people have been diagnosed with mental diseases. Before they were diagnosed by psychiatrists, they were all aware that something was seriously wrong with them and suspected a mental illness, but were not confident until diagnosis occurred. There is a theory, which has some empirical support, that helps us understand the process through which people go in assuming the identity of a mentally ill person. The theory is called labeling and was first formalized by Thomas Scheff (1974. “The Labelling Theory of Mental Illness” American Sociological Review. 39: 444-452.). The theory has been criticized for its inability to explain mental illness. In its defense, the theory was never intended to explain mental illness but to describe the process through which people with mental illnesses go in 1) recognizing that they have a mental illness, 2) taking on an identity of one who is mentally ill, and 3) assuming behaviors typical of those labeled mentally ill.


At Sunday, October 25, 2015 10:16:00 PM, Anonymous Anonymous said...


I see you are pulling us back to relevancy. Good idea.

I recently recommended that you cajole your students into creating a manifesto that would be given to hospital administrators. The manifesto would specify what action they would take as a collective if they observed unethical/illegal behaviors by health care providers. The list of threatened actions would follow a needs assessment which would serve as a foundation from which the threatened actions logically follow. The document needn’t be labeled a manifesto; it could be dubbed “a call to action” or something of the sort. Providers and administrators of conscience such as you and your colleagues would promise students that you would defend them as best you could from retaliation. It would behoove students to secure an attorney whom they could contact at the drop of a dime if they needed protection from retribution.

I wasn’t whistling Dixie when I made this recommendation. But, students are among “the other ‘players’ in medical practice” you write about who are unwilling to commit themselves to deal with the deviancies that occur during health care delivery. If they, physicians, nurses, hospital administrators, hospital social workers, etc. refuse to act in a way that would deter the provider miscreant then, indeed, as you suggest, there is no choice but to turn to other avenues for relief. “Referees” are out there including HHS which administers HIPAA, JCAHO which accredits health care organizations, state nursing boards, and, as you wrote, state medical boards all of which are impotent when it comes to preventing many of the types of human rights violations that occur during the delivery of health care. We can list solutions until we’re blue in the face – that’s easy – but identifying the processes that give us hope for success will be difficult and implementing those processes even more difficult. It took a century before husbands were allowed into OBGYN departments with their wives. Leading the pack to create this change were health care providers, especially nurses. But nowadays, the same specious justifications used to keep husbands away from their wives during delivery are used to keep patients from bringing family advocates into surgery rooms. Those who think that the latter practice would be easy to change should think again.

I’m going on a week’s hike. Might pick up where I left off after I return.


At Sunday, October 25, 2015 11:12:00 PM, Anonymous Anonymous said...

Maurice posted "So.. what is next? How to prevent the "bad" and maintain the "good" of the profession of medicine?

Do you think we need in the medical system but we also need monitors whose job is to pick up misbehavior as it happens and act on the spot to penalize the healthcare provider who is found not to be following the rules.

shouldn't we consider some other monitoring and reacting system?
I think that if every physician, nurse and tech knew they were being observed for bad behavior and knew they would be immediately and severely penalized, like on the football field, there might be a whole lot less "bad" going on. In our electronic-video-computer age, surely there would be a way to provide that monitoring and reaction as those "other gentlemen on the football field" "

It would have to be an outside agency, since medicine has already proven their inability or unwillingness to police their own.

Also, if it's electronic / video monitoring, then that leads to several problems, mainly, who in their right mind would agree to have their private doctor appointments filmed, and what guarantees would you have of the security & confidentiality of the recordings?, and the monitoring of these appointments would have to be live, otherwise it's still a reaction after the fact.

I've said LONG ago that we as patients need to be able to bring our own chaperons, not ones employed by the hospital or some random monitoring company, who remain at our sides the ENTIRE time, and are armed with cameras for audio and video.


At Wednesday, October 28, 2015 5:35:00 AM, Anonymous María said...

There needs to be a balance between keeping us from
violations and even safe, and privacy. The remedies
so far (chaperones, cameras, etc) proved to be worse
than the problems they intended to solve in the first

At Thursday, October 29, 2015 1:30:00 AM, Anonymous Medical Patient Modesty said...


I thought you’d be interested in reading this comments from another web site, ForWomenEyesOnly:

This is an interesting case of misconduct: woman was subjected to an “inappropriate pelvic exam” and later went back to confront the doctor. Fortunately she recorded her second visit, and got the dr’s guilty apologies on recorded audio. She submitted the recording to the College of Physicians and Surgeons. Most likely without the recording she would have been silenced and dismissed. Good for her to go back and confront the dr., and record the whole thing.

It is likely that this doctor may not have been caught if it was not for the lady’s recorded audio. Sometimes, patients have to take steps to prove their doctor’s wrongdoing.


At Thursday, October 29, 2015 7:39:00 AM, Anonymous Anonymous said...

Good for her that she took it upon herself to record the conversation.

I'm a little disappointed that he only got 6 months suspension (or two 3 month vacations...)

He should have outright lost his license, and ... depending on the specifics... face a criminal investigation, thrown into a sex offender list and slapped with a civil suit. IF he's had previously dismissed complaints, they need to go back over them, and treat this guy with a "guilty until proven innocent" attitude since he's proven himself to be a liar.

Had she brought a friend with her to the original appointment... or just set her own camera up on the counter... the whole thing likely never would have happened.


At Saturday, November 21, 2015 10:28:00 PM, Anonymous Anonymous said...

For those of you who missed it, November 19th was
international mens day. A day set aside to raise
awareness about men's health and celebrate positive
role models. But students and some facility at the
University of York signed a letter pointing out that
most high level positions at the University were filled
by men, thus the University scrapped it's own day
of celebration it had scheduled for men.

March 9th is international womens day. A day set aside
to raise awareness about womens health and celebrate
positive role models. Yet, most high level positions at
all hospitals are not only filled by women, but 95% of
all nurses are female. Therefore on March 9th I'll make
my voice heard to hospitals in my city about the disparity
that exists at medical facilities.


At Sunday, November 22, 2015 9:50:00 AM, Anonymous Anonymous said...

PT - you should contact the administration of University of York and ask them if you'll write a letter to the various hospitals as well, since they "obviously" had a very valid and true reason for the cancellation of the celebration / percentage of gender in a field ratio to be applied.


At Tuesday, November 24, 2015 7:16:00 PM, Anonymous Medical Patient Modesty said...

I wanted to let you all know that Urgent Care Magazine did an article on patient modesty, "Medical Modesty and the Patient Experience". I really appreciate them mentioning Medical Patient Modesty. I am sure that all men here will be encouraged that this article addressed male patient modesty.


At Friday, December 04, 2015 8:51:00 AM, Blogger Maurice Bernstein, M.D. said...

I erroneously deleted PT's response to Misty written recently. I apologize. PT's test follows. ..Maurice.


While the comment is a step in the right direction one has to realize this is unrealistic in an Urgent
care setting and here is why. Most Urgent care centers are staffed by a Physician assistant and
usually one office staff. More often than not both are female. Personally, I do not believe that
Urgent care centers can deliver comprehensive care typical of an "Urgent or emergency care
setting. Most Urgent care centers do not have medical imaging nor a medical laboratory. Most
hospitals have what is called a fast track that functions as an Urgent care. Additionally, Urgent
care centers charge more of a co-pay than do hospital based fast tracks. The potential care if
needed provides full hospital care and would save you an ambulance charge should you need to
be sent to a hospital. My advice, avoid Urgent care centers altogether and rather, choose a
hospital that has a fast track built in to their emergency room.


At Friday, December 04, 2015 8:55:00 AM, Blogger Maurice Bernstein, M.D. said...

A visitor wrote the following today but to an inappropriate thread. I am posting it here because it seems more appropriate. The hospital and physician named in the comment I have deleted as is my policy for names not previously made public. The hospital and doctor described is in India.
Is patient modesty concerns in the Western world moving to that of this visitor in India?


- she exposes all her female patients naked to all male staffs and doctors.
- I and my husband are so broken in heart and leading a peace less life from the day of my naked exposure by to other Males.

God should punish her.
Dear Doctors, Please consider your female patients as your mother or your sister and please don’t expose their nakedness to other male doctors and male nurses.
God will punish you.

At Friday, December 04, 2015 9:31:00 AM, Blogger Maurice Bernstein, M.D. said...

Another apology. I erroneously deleted the following comment sent by Ed T this morning. Sorry. I was intending to tap on PUBLISH on my phone but it ended up that I pressed DELETE. ..Maurice.

My heart goes out to the woman you quoted. Thoughtless exposure has become so commonplace that I should have come to expect it. I recently experienced it while visiting a new dermatologist that came highly recommended to me. After a very rude female MA refused to give me an exam gown and flatly stated that she only issued them to females, I expressed concern about meeting the doctor for the first time in a state of undress. She tossed me a drape on the way out the door. After waiting 20 minutes in this state, the doctor finally entered the room without knocking followed by an unidentified female. I skipped the introductions and firmly stated that there was no informed or implied consent for her to be in the room. The doctor had her leave and got on with the exam as if nothing important had happened. Thoughtless and clueless. First and last visit.

Ed T.

At Friday, December 04, 2015 10:54:00 AM, Anonymous Medical Patient Modesty said...

Dr. Bernstein:

The same person from India sent MPM an email on Wednesday. Even though MPM is based out of the US, we have a lot of visitors from other countries concerned about modesty who visit our web site. It has proven to be helpful to people from other countries too. I think it is sad that this woman had a doctor who was not sensitive to patient modesty. I suggested she switch to another female doctor who is more sensitive to patient modesty.

Ed T.:
I am sorry to hear about your experience with the dermatologist. I am glad you stood up and told the dermatologist the female had to leave. I think you should file a complaint about that female medical assistant. It is sad that she seems to think female patient modesty matters more than male patient modesty.


At Saturday, December 05, 2015 9:22:00 AM, Anonymous Anonymous said...

I think follow up is important, so i did send a letter to the doctor directly asking for a response. After a week with no response, I sent an inquiry on the web patient portal simply asking the doctor to contact me regarding my last appointment. I got a standard reply back stating that I would be contacted. After another week had passed, I sent another note with specific questions regarding informed consent,exam gowns, no knock policy etc. This time I did get a call from a "nurse" representing the practice. She hedged on informed consent, seemed shocked that I was refused an exam gown and stated that they did not have a no knock policy. I politely gave her the litany regarding why males avoid healthcare, why consent is important and what effect her office practices have on new male patients. She listened and apologized. I do not know if there will be any impact on how they do business in the future but at least I know that someone in their office heard me.
Ed T.

At Saturday, December 05, 2015 9:44:00 AM, Blogger Maurice Bernstein, M.D. said...

Ed T, I fully agree with your response to your concerns about the office behaviors as an attempt to provide education and change if what you experienced was an ongoing behavior.

I think the doctor-patient, office-patient relationship is a "two way street" and patients should be permitted and encouraged to "speak up" to errors in professional behavior. ..Maurice.

At Saturday, December 05, 2015 7:43:00 PM, Anonymous Anonymous said...


Would you please direct me to the location in which a contributor to this blog who worked for a commercial film company made mention of the protocol they use when filming patients? The only thing I could find was by Joel Sherman; he alluded to it on his Nov. 12, 2007 post as being posted on October 31, 2007 at 11:29 PM, but I can’t find it.

Ed T.

I recently had a similar experience to yours at a dermatologist’s office. I was shown into an examination room by a woman who did not introduce herself. She told me to take off my clothing but did not offer me a hospital gown. I stripped down to my running shorts and t-shirt. The physician – a young fellow – walked in without knocking and introduced himself as Dr. --. I acknowledged his greeting and introduced myself as Dr. Barrow. His eyes widened in surprise. He ordered me to remove my shorts, which I did – down to my underwear. He then turned around and walked out the door, leaving it opened. “Not good,” I said to myself as I walked to the door, closed it, and put my running shorts back on.

I decided to stay to see how far the guy would go. He returned, I removed my shirt and he began the examination whereupon the woman who showed me in entered without knocking, introducing herself, or identifying her role. I asked the physician if two people were needed to conduct the examination. Rather than answer my question, he responded as anyone here would predict, “She’s my nurse.” “She belongs to you? One of your appendages, maybe?” I asked. “She doesn’t belong in here without my consent unless she is directly participating in my healthcare,” I exclaimed as she shot out the door like a bat out of hell. I clearly explained to him proper etiquette but he appeared immunized to reason so I asked, “Did you learn to behave this way at the University of Texas’ Medical
School. He acknowledged sheepishly that he did not when suddenly his face lit up as though he was experiencing an epiphany, “You wear shorts when you go to beaches don’t you?” I was flabbergasted that anyone would make such an inane statement. “So that’s why you behave this way; you liken an examination room in which intimate activities take place to a public beach.”



At Saturday, December 05, 2015 7:43:00 PM, Anonymous Anonymous said...


I permitted him to continue the examination. He said not a word as he went about his business, although I requested that he tell me what he was doing, why he was doing it, and what was his assessment. So, I instructed him regarding my concerns about certain lesions as he went along. He had me stand to inspect my legs – I thought – whereupon he pulled down my pants. I pulled them back up and instructed him to check my legs for lesions. As he did so, I asked him if he was taught in medical school to pull down patients’ pants and underwear without notice, explanation, and consent; again, he indicated that he had not. Before I left the examination room, I suggested he and the elusive nurse get training at a TSA center where he would be instructed in proper etiquette and employ what he learned when treating patients.

Of course, I vowed never to return to the guy, not only because he was resistant to acts of common decency but also because he was as dumb as a skunk. He, nevertheless, saw fit to write me a letter in which, as expected, he defended his approach to patients as being “our routine operating protocol” thereby confirming my assessment of him. I granted him the impression that he had made the final knockout by not responding to his retaliatory act of “firing” me as a patient.

This guy may be a clone of one of your graduates, Maurice. He was taught to treat people decently in medical school (probably the first two years) but by the time he became a practitioner his earlier training was turned on its head. Now, every workday he enters a parallel universe (or counterculture) of contraries whose values, beliefs, norms, behavior patterns, and argot are at odds with those of the greater society – where a closed door behind which intimate things are going on is an invitation to enter without knocking; where a pair of pants that covers a patient’s genitalia is an invitation to pull them down without warning; where a sheet covering a patient’s nakedness is an invitation to whip it off without consent in order to put patients on display for students’ benefit; where adults who question the authority of providers are subjected to retaliation; where those on whom providers are dependent for their economic welfare are subjected to pejoratives that demonstrate contempt for their benefactors, etc. Then after a workday, he and others of his ilk must vacate their insulated universe and reenter the polite world where they are expected to behave themselves or face the consequences. It must be awful for these poor overtaxed health care providers; how difficult it must be for them to accommodate to moving so frequently from the polite world to a perverse parallel universe.

You seem to enjoy writing about how you train students to bring the polite world with them – to prevent countercultural elements from gaining a foothold in their lives – when they are ready to join the army of practitioners. I get the impression that you believe that you are effective in doing this, although you provide not a modicum of evidence. What percent of your students do you think are like this guy about whom I am writing, Maurice? The scientific bases for estimations have been repeatedly presented ad nauseam in this blog by me and others. The percent of those who would do the right thing whether or not you teach them to do so can be induced from evidence. So too can the percent of those who would not do the right thing no matter how you approach them. The percent of those who would have done the right thing had they not been resocialized after their second year in medical school can be estimated. So too can the percent of students on whom your teachings have the intended effect. As an expert who has invested study, sweat, and time in producing students who are able to resist the parallel universe of which I write, how successful do you believe you are?


At Saturday, December 05, 2015 9:03:00 PM, Blogger Maurice Bernstein, M.D. said...

Ray, I think you will find what you are looking for if you go to each of the links below and then use your search function in each to look for the word "filming". There are 4 references in each link to the filming of patients and I think at least one is related to what you are looking for.

link 1

link 2

Let me know if you still can't find it. ..Maurice.

At Saturday, December 05, 2015 9:07:00 PM, Blogger Maurice Bernstein, M.D. said...

In my above posting, I see "link 1" isn't working. I try it again:

link 1


At Saturday, December 05, 2015 9:24:00 PM, Blogger Maurice Bernstein, M.D. said...

Ray, I have no statistical documentation of how my students which I have taught either in year 1 or year 2 of medical school over the past 30 years have functioned later in the profession of medicine. All I can do is keep my fingers crossed and hope for the best.

Society should do the following:
Make medicine so that physicians need to see LESS NUMBERS of patients in order to make a living and so they will be able to SPEND MORE TIME WITH EACH VISIT with the patient. You will see doctors who are less impatient and in a rush since I think a lot of physician, nurse and general office misbehavior is directly related to that "rush" and NOT something more sinister. ..Maurice.

At Sunday, December 06, 2015 9:59:00 AM, Anonymous Anonymous said...

Maurice posted **"they will be able to SPEND MORE TIME WITH EACH VISIT with the patient. You will see doctors who are less impatient and in a rush since I think a lot of physician, nurse and general office misbehavior is directly related to that "rush" and NOT something more sinister. ..Maurice."**

Just wondering if you honestly believe ordering a patient to undress, then leaving the door open behind himself is "because he was in a rush"?

Also, when checking lesions on the leg, wouldn't trying to yank his pants down (pretty sure that's called sexual assault in any other setting) be counter to the "in a rush" reasoning, since it "adds extra skin" for the doctor to check? One would think that a complaint about a lesion on or near the ankle (for example, and yes, I know the general area of the leg wasn't mentioned) would cause a "rushed doctor" to ONLY look at the ankle, and not take the time to so "a more thorough exam" (or whatever his excuse might be).


At Sunday, December 06, 2015 11:28:00 AM, Anonymous Anonymous said...

Hello Dr. Bernstein,

I'm anticipating Total Hip Replacement Anterior. I'm also over 70 and am worried about the urinary catheter causing more problems than good (i.e. trouble urinating and/or incontinence). The surgery is 1-2 hr and I'm wondering if the catheter is truly necessary or, solely for medical convenience. Additionally, I'm concerned about having my genitals exposed to female view. I'd like to ask for an all-male surgery team; however, the ortho doctors seem to have their "people" and I'm not sure they're willing to change these. (I haven't seen the ortho specialist yet.) My primary doc said he'd try to affect this; nevertheless, I'm not sure if he can influence the ortho surgeons. I'd also like to ask that, if a catheter is absolutely necessary for surgery, if the catheter could be removed in the OR so that I won't have Recovery personnel "checking".

I thought I'd give the following note to the ortho docs and a similar one to PACU, if I can find the appropriate individuals in Recovery. I've been told that my concerns are irrational and ridiculous; however, emotions and psyche are also part of the human make-up. My question to you is How or what can I do (short of walking away from the surgery) to achieve my desired privacy/modesty. Who can I see or talk to that might sympathetically respond to my desires. How can I make my requests in a way that medical personnel will find most favorable. Thank you for whatever suggestions you can supply.

Aforementioned note follows:



I’m writing to you because I’m told that you will be on my surgical team for Total Hip Replacement.

Due to a “terribly traumatic experience” as a young boy, I have extreme difficulties having my genital area viewed by females. Presently, just considering that this might occur brings back all the devastation of years ago. I have carried this burden for many years and it has caused me to forego much medical care.

I ask that you not allow my genital area to be viewed by any female staff member; and, that any viewing, scrubbing, draping, catheterization, etc. of this area are be done solely by a male staff member.

Please treat my request as one coming from one of your elderly family members. If you would ask this of me, I would respect your wishes for modesty – in a heartbeat. I beg for your compassion.

This is a cross that I have borne for so many years – too many.
By making the above request, I do not wish to impugn any of the wonderful female staff. I recognize that this problem is mine and, mine alone.
I thank you in advance for your courtesy and respect.

May God bless you and your loved ones.


At Sunday, December 06, 2015 11:53:00 AM, Blogger Maurice Bernstein, M.D. said...

Jason, we teach the students that it is the patient who removes their own clothing for examination of the underlying body and the physician assists if necessary as permitted by the patient. No dramatic "yanking" (abrupt pulling) by the physician except in emergency situations where "immediate" exposure is necessary for medical attention and with the patient's permission if rapid removal is necessary or implied permission if the patient is unconscious.

I am just saying that what the patient defines as physical abuse may, in fact, be the results of the professional being "rushed" and this "abuse" could be prevented if the professional had more time available to attend to each patient. Nothing more sinister. ..Maurice.

At Sunday, December 06, 2015 12:18:00 PM, Anonymous Medical Patient Modesty said...


Welcome to Dr. Bernstein’s blog. I am the founder of Medical Patient Modesty. I encourage you to take time to read this article about urinary catheterizations I wrote. Urinary catheterizations are usually not necessary for surgeries that last a few hours. Urinary catheterizations should be avoided as much as possible due to complications. If they say that they are concerned you cannot walk after surgery, tell them that you would like to have a mini urinal.

You have the right to an all-male team. You also need to talk to the hospital’s nursing department and demand that your surgery be postponed or cancelled if they cannot accommodate your wishes for an all-male team the day of your surgery.


At Sunday, December 06, 2015 10:15:00 PM, Anonymous Anonymous said...


You sound to me as if you are begging to have your privacy respected, no disrespect intended. You are paying these peoples
salary. Do you know the cost of an artificial hip? They should respect your wishes or take your business elsewhere and no
that cross you bear is not your fault, it's their fault. The fault of the entire medical industry. A surgical hip replacement will be
comprised of the following staff. Orthopedic surgeon, anesthiologist, x-Ray technologist, scrub technologist, circulating nurse
and some possible operating room staff gawkers. That is whomever decides to come into the surgical suite. Once in pacu, there
will be a nurse assigned to you until you are admitted to a med-surg floor. Once there you will be assigned another nurse and
a nursing assistant. I should add that once in the operating room there may be a surgical representative from one of the
prosthetic companies to help the surgeon with the instrumentation. Quite frankly, the presence of a representative repeatedly
for the orthopedic surgeon is redundant in that the surgeon should have figured the equipment's use and function the first time.


At Monday, December 07, 2015 10:06:00 AM, Anonymous Anonymous said...

Thank you PT and Misty for your concerns. Yes, I am begging, actually groveling. I've seen the waiting room of the ortho docs. They've both done over 400 hip replacements each. They seem to be the best in the area. They don't need me and my requests. All they need to say is that they can't alter their protocol or they can't accommodate my wishes. That means I look elsewhere, possibly settling for an inferior surgery. Ditto the hospital. I will definitely request their accommodation; however, large institutions find change difficult, if not threatening. As I get closer to approaching the doctor and hospital I feel that my only alternative will be to succumb to their protocols (and be "raped" again) or forego medical treatment again, as I've done for 60 years; and, hobble as best I can for the rest of my life. This is the reason I asked Dr. Bernstein if he could indicate approaches to the medical providers which would cause them to be relatively sympathetic. Again, I thank you for your kindness and concern.


At Monday, December 07, 2015 6:44:00 PM, Anonymous Anonymous said...


The surgeons may or may not be employees of the hospital where they have privileges but it doesn't matter. Their two
concerns are that a) the standard of care is met regarding your surgery pre and post operatively and b) the staff assisting
have the appropriate skill set.

If the surgeon is performing your surgery at a hospital then they have no say in who the gender of the team are as long
as a and b are met. You will need to approach administration and voice your concerns. State that if your conditions are
not met you will take your business elsewhere. I doubt seriously that administration will say no, however, if they do then
do your homework first. Does this hospital have a mammography department and does this hospital also have a L&D
suite. If they have either one of these departments and administration says no to your demands state that they are
discriminating against you. That hospital will be owned by a larger regional center and it is that regional center where
you need to voice your concerns and believe me, when you voice your concern to the regional office you will be heard!


At Tuesday, December 08, 2015 12:07:00 AM, Anonymous Medical Patient Modesty said...


Don’t give in. You should work to get them to accommodate your wishes. You will need to talk to the administration, nursing department for orthopedic surgery, and the anesthesiology group that will provide the anesthesiologist. I also encourage you to refuse urinary catheter. There is no need for it unless your surgery lasts longer than few hours. I have helped a male patient take steps to ensure his wishes for an all-male team for a colonoscopy honored. Check out the testimonial of James. Also, I suggest you consider having spinal anesthesia so you can be awake for the surgery. Make sure you read the important article on Versed.

If you are married, perhaps you could look into having your wife as a personal advocate present with you at all times during surgery and in recovery. Don’t give into the argument you cannot have her with you. Many years ago, husbands were not allowed to be with their wives when they had C-Sections. That changed after the 1970s. C-Section is a major surgery like hip replacement surgery.

I encourage you to read discussion I had on Dr. Bernstein’s blog about personal advocates at this link. PT also contributed to this discussion.


At Tuesday, December 08, 2015 9:30:00 AM, Anonymous Anonymous said...

Again, I thank you, PT and Misty, for your comments and concerns. Thanks to you I now have relevant information as I proceed towards surgery. I'll keep you posted. Additionally, if you think of other factors that I should consider, please post them. I'll monitor Dr. Bernstein's blog for any additional help.

Again, a THANK YOU VERY MUCH to both of you.


At Tuesday, December 08, 2015 11:18:00 AM, Anonymous Anonymous said...

RS – I hope your note is well received. Research I completed some years ago suggested that nurses tend to take umbrage at men and women who request same-sex intimate care. “That’s gender discrimination,” they cry.” In fact, it is gender discrimination (you won’t allow a female provider to do intimate procedures on you), but you’ve cogently pointed out that your desire to discriminate is not based on prejudice (e.g., the belief that females are incompetent, insensitive, untrustworthy, etc) but on the devastating psychological/emotional effect it would have on you, an effect that is not voluntarily chosen. In my research, I found this same sentiment among most of the men and women who preferred same-sex providers for intimate care. Even the nurses I know, including my wife, reason in the same way.

Some nurses ranted, “If a hospital or physician gave in to a patient who wanted a same-sex provider, they would be violating the law.” I’ve written about this fiction in other places on this blog. In fact, under some conditions, providers who refuse to accommodate the patient’s request could be violating both criminal and civil law.


At Tuesday, December 08, 2015 12:20:00 PM, Anonymous Anonymous said...


One of the links worked for me. Took awhile but I found what I was looking for. Thank you. I wanted the link because the contents are relevant to some e-mail communication I have had with administrators of HIPAA. My interest in particular was on HIPAA standards re. filming emergency room patients who can’t give consent. The HHS site invites questions. My contact contacted a HIPAA resident “expert”, sent me the latter’s response, and invited me to ask more questions. The expert’s answers made no sense in light of what I understood by studying HIPAA. So I sent another e-mail asking from where in the HIPAA document did the “expert” make his/her inferences and promised my contact that after I received a response, I would send her a copy of my analysis for her purview and critique. After a month’s wait, I had received no response, so I sent my contact another e-mail reminding her of my last e-mail. That was two months ago. My contact did not follow through on her promise, but I plan to follow through on mine. I will note, among other things, that HIPAA “experts” are not above making things up out of whole cloth. Their answers to some questions seem not to emerge from anything in HIPAA and they redefine some HIPAA concepts to fit the interests of commercial film companies rather than patients, as intended by congress.

As I read materials in the link, Maurice, I came up with a research idea. Those of us who have contributed to this blog have oft written about the differential treatment of male v. female patients and providers. I’d like to put that hypothesis to the test. It would require creating an instrument that respondents might find interesting and conducting a simple but elegant experiment using Fisher’s design (or, a randomized post-test only control group design). Are you amenable to carrying out the experiment, Maurice? In a normal class of 30 students, it would take less than one hour to randomly distribute anonymous questionnaires (that contain the instrument) and pick them up. Then you can send the data to me and I’ll analyze it. It would be helpful if all blog participants would help with formulating items for the instrument and on the questionnaire.


At Tuesday, December 08, 2015 12:37:00 PM, Anonymous Anonymous said...


One of the links worked for me. Took awhile but I found what I was looking for. Thank you. I wanted the link because the contents are relevant to some e-mail communication I have had with administrators of HIPAA. My interest in particular was on HIPAA standards re. filming emergency room patients who can’t give consent. The HHS site invites questions. My contact contacted a HIPAA resident “expert”, sent me the latter’s response, and invited me to ask more questions. The expert’s answers made no sense in light of what I understood by studying HIPAA. So I sent another e-mail asking from where in the HIPAA document did the “expert” make his/her inferences and promised my contact that after I received a response, I would send her a copy of my analysis for her purview and critique. After a month’s wait, I had received no response, so I sent my contact another e-mail reminding her of my last e-mail. That was two months ago. My contact did not follow through on her promise, but I plan to follow through on mine. I will note, among other things, that HIPAA “experts” are not above making things up out of whole cloth. Their answers to some questions seem not to emerge from anything in HIPAA and they redefine some HIPAA concepts to fit the interests of commercial film companies rather than patients, as intended by congress.

As I read materials in the link, Maurice, I came up with a research idea. Those of us who have contributed to this blog have oft written about the differential treatment of male v. female patients and providers. I’d like to put that hypothesis to the test. It would require creating an instrument that respondents might find interesting and conducting a simple but elegant experiment using Fisher’s design (or, a randomized post-test only control group design). Are you amenable to carrying out the experiment, Maurice? In a normal class of 30 students, it would take less than one hour to randomly distribute anonymous questionnaires (that contain the instrument) and pick them up. Then you can send the data to me and I’ll analyze it. It would be helpful if all blog participants would help with formulating items for the instrument and on the questionnaire.


At Tuesday, December 08, 2015 7:22:00 PM, Anonymous Anonymous said...


Regarding your answers to my 12/5 blog questions. You are not alone; I’m in the same boat. Few educators have “statistical documentation of how [their] students have functioned later in the profession” for which they have prepared. “All I can do is keep my fingers crossed and hope for the best,” you write. Actually, both you and I can do a little, but maybe not much, better than that. There are at least two forms of scientific reasoning – inductive and deductive. In my 12/5 blog , I challenged you to do the former – to induce from the evidence in sources presented ad nauseam in this blog the percent of your students who would do the “right” thing without your instruction (“inherently good apples”), the percent who would do the “right” thing because of your instruction (“converted good apples”), the percent who would have done the right thing had they not been resocialized to do the “wrong” thing (“good apples gone bad”), and the percent who would do the “wrong” thing because your instruction had no effect on them one way or another (“inherently bad apples”). It’s really not a pretty picture. Educators adapt by acting like the three proverbial monkeys (cover mouth, ears, and eyes), they label the messenger a liar and blithely go their way into Pollyanna Land, they resign themselves to or accept the inevitable (yours truly), they hoodwink themselves to believe it just ain’t so, or they may give it all up and become recluses, drag racers, gang leaders; they jump out of planes, or leap off cliffs.

“Experts” have often been asked to predict x, y, and z. If there is no evidence to predict x, y, and z correctly; if the evidence is there but the “experts” are not familiar with it; or if they are familiar with the evidence but do not know how to reason inductively, they are usually way off on their predictions, as way off as those who are not experts. For example, before Stanley Milgram conducted his famous mock-shock experiments, he surveyed 40 psychiatrists and asked them to predict the percent of “teachers” (subjects) who would follow the orders of an authority to shock a learner. These “experts” predicted, on the average, that the percent of teachers who would go above 300 volts was less than 4%. Senior psychology majors’ mean prediction rate was not far behind. In fact (and I do mean fact), 2/3 of subjects actually followed the orders of the authority all the way to the maximum of 450 volts and back again. These findings were replicated overseas and by a recent study conducted by Jerry Burger.

You say you don’t follow up with students after they complete the last class they take from you. But, do you test students in your course over the materials studied? If “yes,” do you grade their performance over the course period based, at least in part, on their test scores? If you test students, can you describe how you do it (objective test, essay test, practical test)? Do you grade them on how they conduct procedures based, at least in part, on the extent to which they ensure patient modesty and dignity as they carry out the procedure? Do you give them ethical dilemma scenarios and grade them on their answers to questions regarding what course of action is ethically required? For example, do you grade their responses to questions such as, “An exceptionally modest female patient who, in order to protect her dignity, asks for an all female team to carry out surgery requiring intimate treatment and care. It is logistically possible to accommodate the patient, but having a same-sex team violates hospital protocol. Which of the following actions would you take?” Or, “You overhear nurses and doctors using derogatory terms to describe patients. Which of the following actions would you take?”


At Tuesday, December 08, 2015 8:40:00 PM, Blogger Maurice Bernstein, M.D. said...

With over 180 responses to this Volume, I must now move on to Volume 74. No further Comments will be published now on Volume 73. ..Maurice.


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