Bioethics Discussion Blog: Preserving Patient Dignity (Formerly Patient Modesty) Volume 112

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Wednesday, July 15, 2020

Preserving Patient Dignity (Formerly Patient Modesty) Volume 112





The ongoing anguish being presented by the participants on this web blog topic is whether being a patient who doesn't conform ("be yourself") with the behavior and requests or even demands of the medical system itself  will provide harm to the patient. This patient concern may be the basis for many patients to hesitate to "speak up!".

It is my opinion that patients entering into the medical system should indeed "be themselves" and the challenge for the medical profession should always be beyond making a clinical diagnosis and performing a treatment to understand their patient as a individual, a unique individual to which the diagnosis and treatment and overall attention should be crafted for that patients personality and goals as well as the clinical diagnosis.

Unfortunately, in many relationships between the patient and members of the medical system it is the clinical diagnosis and treatment which overrides consideration of the patient as a unique individual who presents as "himself" or "herself". This defect in the system as expressed to the patient leads to  forcing the patient into personal non-conformity toward themselves in order to get diagnosed and treated and does limit the option or, if attempted, the volume of "speaking up" to the system.  

Remember, patient dignity involves the patient as a unique human and not just a named disease or when hospitalized a room number. So.. "BE YOURSELF".  ..Maurice.

Graphic: Provided by a reader of this blog thread.

Starting September 12 2020, Volume 112 will be CLOSED FOR  COMMENTS.
HOWEVER COMMENTS WILL CONTINUE ON Volume 113.

180 Comments:

At Wednesday, July 15, 2020 5:04:00 PM, Blogger Biker said...

Great graphic!

Banterings, in regards to your last post, you are right, but given 58flyer was "fired' from his prior urologist, he is likely best at this critical juncture in his pursuing treatment to not pursue every infraction. Yes the practice mishandled the situation initially but they did shift gears and try to make it right. I see it as focusing on winning the war rather than focusing on winning every battle.

 
At Thursday, July 16, 2020 10:36:00 AM, Anonymous Anonymous said...

Hello Dr. Bernstein,

Your descriptive leader for this volume seems to fit the position in which many of us are placed when seeking medical care. I'm sure that all posters wish that the descriptive could be disseminated to every physician in the country.

Reginald

 
At Thursday, July 16, 2020 1:01:00 PM, Blogger A. Banterings said...

Maurice,

Going back to when I started posting here and discussions that we had with opposing view points, mainly that certain procedures that are performed in a strictly scientific manner may be perceived as sexual assault by the patient. In this NIH referenced article, Development of the Healthcare Triggering Questionnaire in Adult Sexual Abuse Survivors, the authors develop a brief Healthcare Triggering Questionnaire (HTQ) with the goal to describe the prevalence of healthcare triggering memories, thoughts, feelings or sensations related to the patient's past sexual abuse.

What catches my attention is that to date (April 2017), no healthcare triggering assessment tool exists.

If the profession of medicine is so learned, compassionate, thorough, patient centered, and conscientious, why has this questionnaire never existed before?

This also validates that these exams, procedures, and situations are experienced with the same emotions, feelings, and perceptions of the patients' past sexual abuse. So why would a patient who has not experienced sexual abuse NOT experience these things as sexual abuse?

Your argument way back when was that this was not sexual to the practitioner, but this 2019 article A Pot Ignored Boils On: Sustained Calls for Explicit Consent of Intimate Medical Exams. refutes that argument that you once made.

Please note, I am not sure of your position on this issue now since your view on the existence and frequency of the things claimed by those who post here has changed.)

The article supports the patient's perception of such exams as sexual assault:

...Patients and members of the general public are often shocked to learn that physicians and medical students may perform intimate exams on them without explicit consent and believe such exams meet the criteria for battery, malpractice, or sexual assault. Whether these exams meet any such criteria is contested, but this tension underscores the dichotomy between societal and medical views of the intimate regions of the body. While the medical professional may aspire to a professional, scientific detachment, patients simply do not think of their intimate regions in a detached or neutral way and tend to have an inherent conviction that consent practices should mark this distinction.

...Ubel stated, “We don’t see a pelvic exam as having any sexual content at all, but that’s not how other people perceive it” (Goldstein 2003). “There’s no way a physician would ever equate a pelvic exam with rape—there is no rape content to it. But the fact that someone else perceives it that way makes it important” (Goldstein 2003). An unconsented intimate exam may feel like a sexual violation to patients.


What is even worse is that this 2019 paper refutes the reasons that providers, medical students, and teachers hold on to as justification to continue to perform unconsented intimate exams.

How can society look at physicians as anything but sexual predators?





-- Banterings





 
At Thursday, July 16, 2020 2:27:00 PM, Blogger Maurice Bernstein, M.D. said...

Banterins, I understand your documentation and the concern you and others have been expressing over the years. And, it has merit. But while medical students are instructed that taking a sexual history from the patient as part of a initial complete history and physical exam should they be instructed to review with the patient, male or female, their sexual concerns, in light of any past traumatic experiences, before genitalia or female breasts are exposed with the professional's intent of "laying on hands"? Really, what you reminded us all is that the medical profession should look at these exams as potentially psycho-traumatic even in patients without a traumatic past-history.

I would say that as physicians and nurses ask about allergies before beginning therapy with medications, past traumatic experiences with regard to genitalia et al should precede "laying on of hands". It would take just a moments delay but would create better understanding by the professional regarding the psychological impact of the upcoming "laying on". ..Maurice.

 
At Thursday, July 16, 2020 4:09:00 PM, Anonymous Anonymous said...

Hello Dr. Bernstein,

You have given a very creative solution to the dignity/ modesty/ trauma problem, which doesn't require the patient to "speak up" first. Again, is it possible to convince the entire medical community to ask trauma-informed questions BEFORE laying on hands?

Reginald

 
At Thursday, July 16, 2020 7:58:00 PM, Blogger Maurice Bernstein, M.D. said...

Banterings, first, I apologize for misspelling your name.

Speaking about apologies, I think a valid observation regarding the medical system is likely a tendency for professionals to avoid apologizing to patients or patient's family.
There is much written in the medical and law literature about apologies by medical professionals about errors in diagnosis or errors in treatment and there is an excellent review of this matter by the American Association of Family Practitioners.

However, there is often more to warrant an apology from a healthcare provider than a specific error in the technical diagnosis and treatment of a patient's illness. Let's see if we can have our readers here create a list, though over years of this blog thread many examples have been written here. But let's see a list of actions or inactions which deserve a professional apology. ..Maurice.

 
At Thursday, July 16, 2020 8:24:00 PM, Anonymous JR Issues4Thought.com said...

Here's a very interesting article I found after sexual assault of hospitalized patients:

https://www.plaintiffmagazine.com/recent-issues/item/sexual-assault-of-hospital-patients

It says what I have been saying is that sedated patients are some of their favorite victims especially post-op.

 
At Friday, July 17, 2020 8:03:00 AM, Anonymous Anonymous said...

Hello Banterings,

Thank you for your article by Lori Bruce, "A Pot Ignored Boils On ...." Supposedly, general acceptance of a new drug by physicians takes approx. 6 mos. It will be interesting to see if the medical profession will address this issue within 6 mos. Additionally, do you have the URL for the actual Triggering Questionnaire you referenced in your 16 Jul post?

Thanks.

Reginald

 
At Friday, July 17, 2020 8:54:00 AM, Blogger Maurice Bernstein, M.D. said...

Forbes has published "An Open Letter to Medical Students On the Road Ahead to Becoming a Professional Physician"

Read the letter and the advice to the medical students and write back here what is worthy advice but also what you find as misleading or simply missing. ..Maurice.

 
At Friday, July 17, 2020 2:36:00 PM, Blogger A. Banterings said...

Maurice,

Should'a, would'a, could'a...

It doesn't happen.

Empirically, what are we to conclude other than the profession does NOT care about the patient and does what ever they want to with impunity. My proof to this is in the second article that AGAIN, someone has to refute the justifications by physicians, teachers, and medical students for obtaining EXPLICIT consent for intimate exams.

What this article supports is the fact that one has a MAGIC STETHOSCOPE, the patient may perceive the exam as a sexual assault AND their point of view is valid.

If these exams are so necessary, why do the students NOT practice on each other, their teachers, or other healthcare providers? Instead they have to drug and rape a patient. That is what it is. My litmus test is to take the situation out of the hospital or facility and put it in a motel room. When you do that, the actions are drugging and raping for the gratification (benefit) of the student.






-- Banterings





 
At Friday, July 17, 2020 3:56:00 PM, Blogger Biker said...

Dr. Bernstein, that Open Letter essay seems to ignore patients and what patients think and feel and want from their doctors.

 
At Friday, July 17, 2020 6:45:00 PM, Blogger Maurice Bernstein, M.D. said...

I agree, the letter was oriented to the dynamics of the medical student (and beyond) learning process not with regard to the very subjects of their learning--the patients. I want to stress "subjects" (their current and future patients) and not "objects" which I think is, as I have repeated the distinction (subjects vs objects) here on this thread as well as many other threads on this blog. It is this transition in time that some doctors and nurses, often associated with heavy patient loads) look at patients as objects and therefore behave with the patient as such. No..none of you become "objects" or "some disease or disorder" when you interact with the medical system. Your personal uniqueness is what is part of your dignity which needs to be preserved. ..Maurice.

 
At Saturday, July 18, 2020 12:08:00 PM, Anonymous Anonymous said...

Dr B. I'm sick with the Covid. The symptoms are SO OBNOXIOUS! I don't think I'm going to need to go to the hospital though. The hospital is where many of our patients got it. JF

 
At Saturday, July 18, 2020 2:28:00 PM, Blogger Maurice Bernstein, M.D. said...

JF, I and I am sure our contributors here am sorry to read your sad information about yourself. I am sure we all are hopeful that your symptoms will ease and disappear and that hospitalization will not be necessary.

I am also concerned about your notation that "the hospital is where many of our patients got it." I have not seen this discussed in the literature but if so (hospitalized without COVID and then discharged to a followup care institution and then found to be infected) that is very upsetting and I wonder about the etiology of the infection in these patients. Were they already infected on admission to the hospital but not tested or negative on admission but infected by the staff or any visitors permitted.

My concern, however, after reading your posting is that your "obnoxious" symptoms clear, not require your participation in hospital-life as a patient. JF,best wishes. ..Maurice.

 
At Sunday, July 19, 2020 6:54:00 AM, Anonymous JR Issues4Thought.com said...

JF,
My thoughts are with you to have a safe and speedy recovery!

 
At Sunday, July 19, 2020 11:43:00 AM, Anonymous Anonymous said...

Dr B and JR. Thanks JF

 
At Sunday, July 19, 2020 1:10:00 PM, Blogger Maurice Bernstein, M.D. said...

Maybe it's the wrong time in our current COVID-19 pandemic.. but how about our visitors to improve the medical system in its approach to real patients becoming a "Secret Shopper". It might be a constructive approach for clinic or hospital systems to awaken to what is going on by the professionals in their system...and not only would you be doing a civic duty but getting paid for it! "Secret Shoppers" have been going on for a long time in commerce, how about making it a useful tool in medical care? ..Maurice.

 
At Monday, July 20, 2020 3:57:00 AM, Blogger Biker said...

The Secret Shopper thing is very interesting, though it has to be very limited in scope given how far can such a person possibly penetrate into the specialties and functions of a hospital?

I think a better way would be to randomly interview patients upon discharge or shortly thereafter. The Press Ganey surveys may in theory do the same but they are very limited in what questions they ask and depending upon how one answers doesn't generate another question that probes a bit deeper. I just filled out a Press Ganey survey last evening for a recent visit for some tests. Half the questions weren't pertinent to the visit. None of the questions pertained to staff gender or intimate exposure which for that visit didn't matter, but what if it did? If they don't ask they'll never know and so instead they just keep on doing things as if gender doesn't matter.

An example of the kind of follow-up I advocate was a few years ago after an ER visit to the local hospital. A couple days later I got a call inquiring about the visit. It gave me an opportunity to tell them that when the doctor entered the room he had a female scribe in tow and that he never introduced her by name or function or asked if it was OK for her to be there. I noted that had I been intimately exposed (I wasn't) I would have been very unhappy to have her just walk in that way. I also noted that a female clerk just walked into the room to ask an insurance question without knocking or asking for an OK to enter. I could tell my input took the woman on the phone by surprise. She apologized and said she will take my concerns up at their weekly staff meeting.

I will add that such interviews need to be done by a skilled interviewer who knows how to discern when it is time to peel away the layers to find out what the patient really thinks. Most patients wouldn't speak up in the manner I did.

 
At Monday, July 20, 2020 3:07:00 PM, Blogger Maurice Bernstein, M.D. said...

JF, I hope there has been no progression of your illness and, in fact, beginning signs of regression.

Biker, I understand your concern about the limitation of scope available to a Secret Shopper within a medical system, however, you may not fully realize the weight a patient's description of symptoms and the home therapy and the course of the symptoms plays on the differential diagnosis of many disorders by the physician despite the physician unable, at the time, to correlate with any physical findings. What I am getting at is that "laying on of hands" and clinical testing may be carried out simply by the history presented by the patient.
It is possible that the Shopper can potentially "penetrate into the specialties and functions of a hospital" or clinic simply by presenting a intriguing history.
We teach students the critical importance of taking a history, many times diagnostically pertinent physical findings on physical examination may be a bit later in appearing. So.."penetration" of the system depends on how the Secret Shopper presents the history and responds with clinically appropriate answers to the physician's questions.

Oh..and the Secret Shopper can be teamed up with a "family relative" who is also a Secret Shopper and can can "enter" into the narrative being an observer and a commentator to the medical system physician or nurse et al, a role amply described by JR (though not a Secret Shopper) in monitoring and speaking up for her husband. ..Maurice.

 
At Tuesday, July 21, 2020 8:52:00 AM, Anonymous Anonymous said...

Hello,

Dr. Suneel Dhand has written a nice article re treating the patient as an individual. Please see https://suneeldhand.com/2020/07/21/it-is-more-important-to-know-what-sort-of-person-has-a-disease-than-to-know-what-sort-of-disease-a-person-has/

Reginald

 
At Tuesday, July 21, 2020 9:56:00 AM, Blogger Maurice Bernstein, M.D. said...

Patient dignity is not set by the physician's simple input of categorized clinical aspects of the patient's history and physical into a computer system. Dignity is set by the patient's use of words, the patient's own words, including as the physician covers not only the medical history but also, importantly, the patient's social history. One of the first categories we teach the medical students to obtain is the patient's social history (starting with occupation, marital history, education and much much more). Is that patient's narrative able to be incorporated into the common EHR "electronic health record"? Probably not. And yet, it is that history, recorded in some form, which informs others in the patient's medical team important elements which make up a patient's dignity.

In my opinion, careful recording of a patient's social history and how it is presented sets understanding of the patient's own view of his or her dignity.
Can this be detailed and included in EHR? I doubt it. ..Maurice.

 
At Tuesday, July 21, 2020 12:31:00 PM, Blogger A. Banterings said...

Maurice,

Human dignity is endowed on us as being made in the Creator's image (sentient beings for the atheists). That is the whole problem. The profession of medicine doesn't recognize intrinsic human dignity, instead they dole out whatever extra they can afford to part with (but not giving away paternalistic power).

You are correct about the history. If the patient says skip the sexual history, that sets a certain tone. This goes for many aspects of the history. My whole life story is not relevant to whatever issue I am seeing a doc for (usually my ADHD).

Even if the patient doesn't raise red flags (such as gender concurrent care), this should still be offered or questioned if the patient is OK with opposite gender care.

That is the difference between dignity and modesty. We do not have to earn or fight for our dignity, it should be respected, even more so by the fact that we are injured or ill and did not choose to be this way.






-- Banterings






 
At Wednesday, July 22, 2020 11:27:00 AM, Blogger Maurice Bernstein, M.D. said...

Banterings, I have a personal question to ask you regarding the relationship between physician paternalism and adult patient autonomy if the adult patient has a life history persisting with current symptoms associated with ADHD. Does the clinical issues in ADHD require physician paternalistic evaluation and therapy for the best current outcome than strictly follow a concept of the necessity for personal autonomy by the ADHD adult patient? Or is there some balance to be set between the two reactions..to truly attempt to maintain patient dignity? ..Maurice.

 
At Wednesday, July 22, 2020 8:32:00 PM, Blogger 58flyer said...

So, yesterday I had my visit with my Urologist for the MRI follow up. Some changes in the way they do things. No more BP checks, they ask your height and weight, and they didn't do the bladder scan. I suppose this is all to do with Covid.

The doctor was aware of the mix up with the female tech, and he apologized. I am kind of surprised that in such a large and busy practice that the information got to the doctor at all.

Anyway, the cancer is still there and very small. The doctor wants to rebiopsy me to get a baseline to go with the MRI. Once that's done we will decide on Watchful Waiting (WW)/Active Surveillance (AS), or treatment options. If we decide on the former we will attack the BPH issues from there.

The doctor said that during the TRUS/Biopsy, I will definitely have a male assistant. He said that no females are trained in the procedure so that should assure me of the male assistant. We shall see next Wednesday.

Banterings, I saw your post and I appreciate the suggestions. However I think that Biker expressed my situation quite well. I don't want to get labelled a bad patient.


58flyer

 
At Wednesday, July 22, 2020 9:13:00 PM, Blogger Maurice Bernstein, M.D. said...

58flyer, I am pleased to read that you were treated in a way that accomplished what was necessary at this time but given a feeling of future confidence in your clinical management. All doctors should be aware that they are dealing with a human being as a patient and not just a disease. ..Maurice.

 
At Thursday, July 23, 2020 8:10:00 AM, Anonymous Anonymous said...

58flyer, I feel like your story is a success story. Of course that kind of success isn't possible unless the medical staff actually CARES about their patients and obviously by the way your former office dumped you....not all do. JF

 
At Thursday, July 23, 2020 8:58:00 AM, Blogger Maurice Bernstein, M.D. said...

JF, hopefully you are recovering from your symptoms. ..Maurice.

 
At Thursday, July 23, 2020 10:57:00 AM, Anonymous Anonymous said...

Thanks Dr B. I feel good about my progress. I promise you I don't want it again though. JF

 
At Saturday, July 25, 2020 11:29:00 AM, Blogger A. Banterings said...

58flyer,

I (reluctantly) agree. At least moving forward you will be treated with dignity.

Maurice, as to your question, I was diagnosed my a relative who is a physician as will.

After diagnosing my cousin and based on the behavior of other members of the family, ADHD was the diagnosis (history alone, mostly observable behavior), and Ritalin was prescribed. It quelled the symptoms but was not strong enough; medication adjusted. The family member treated me until retirement (about 10 years ago).

He was the senior partner of a very prestigious practice and a med school professor at an Ivy League institution. He is the best physician that I ever knew. He was old school: he would do in office sutures, could determine a cold/flu just by a phone call, was not afraid to "try" a treatment if it seemed logical.

No paternalism, no exam. My issue was solved and to this day I know that he has changed my life. If my ADHD was never diagnosed, I would not have been as successful as I am today.





-- Banterings



 
At Saturday, July 25, 2020 2:26:00 PM, Blogger Maurice Bernstein, M.D. said...

Banterings, I am pleased to read your encouraging self-story. As a member of your family, you obviously knew your doctor well including his practice and his academic work.

Do you think that a deficit of personal knowledge of the patient's physician is a major element in the upsets and worse which have been described over and over on this blog thread?

Of course, there has been longtime discussion in the literature regarding the impairment of beneficial management by family-member physicians.

Here is a link to a 2001 article on the subject of the role and effect of a physician diagnosing and treating a family member. I doubt there has been much change in the past 2 decades. ..Maurice.



 
At Saturday, July 25, 2020 7:22:00 PM, Blogger A. Banterings said...

Maurice,

My point is that there is no "NEED TO" here. Just last year, a close friend was pressured into a pelvic exam to get oral hormonal birth control even though one was NOT required.

It is common for physicians to dangle maintenance meds over patients heads unless they submit to invasive, intimate exams and procedures. My point is that these invasive, intimate exams are NEVER NEEDED, let alone having voyeur(s) in the exam room.

As for family members, if a physician is NOT able to care for a family member, then that person should NOT be allowed to care for ANY patient!

Do physicians NOT need to be impartial with ALL patients?

If a genital exam is indicated, AND physicians are trained to do them professionally, gender neutral, knowing when warranted, in a non-sexual manner, AND how to properly perform one, then if the physician cannot explain and gain the trust of a family member, then how can they do it with ANY patient?

I believe this applies to physicians treating themselves (if they choose) as well.

This is just a means to force a significant number of patients into a system where physicians can push "NEED TO..."

--I need to have a voyeur in the room to protect me...
--I need to fiddle with your junk...
--This med student needs to fiddle with your junk...
--etc.

This was a means to prove that physicians were pushing UNNECESSARY exams. This is why I teach and advocate black market meds, medical tourism, online patient directed tests, online prescribing, opting out of the system, and criminal/civil litigation against providers that do not practice customer service.

As for personal knowledge of the patient's physician, I believe that physicians should share their intimate details with patients to make themselves vulnerable (as patients do) in order to gain the patient's trust.

If they are not willing to do this, that is earn the patient's trust and convince the patient of the best course of treatment, then the patient should have the final say in their treatments.

The longer that the profession lies to itself OR denies the way things really are, the worst it is going to get for them. Just look at your own journey of enlightenment. You now acknowledge as reality what you denied on this blog.

When you believed that these things never happened (or happened as much as was claimed), you were able to support the profession's philosophy, physicians owned their own practices, medical knowledge was locked away in libraries in teaching institutions, and the answer, "because I am a doctor and I say so..." was an acceptable answer.

The internet has shined the light of truth on what really happens. The profession still tries to stick to the same paternalistic story line, and the rest of the world knows that "the king has no clothes."

I like what is happening to the profession.




-- Banterings




 
At Saturday, July 25, 2020 9:06:00 PM, Blogger Maurice Bernstein, M.D. said...

Banterings, you wrote "Just look at your own journey of enlightenment. You now acknowledge as reality what you denied on this blog."

For clarity, I never disputed the professional misbehavior amply described but at first I considered those writing about that here as statistical outliers and it was my assumption that the majority of patients were satisfied with their medical professionals. Now, well..yes..there is an "enlightenment" and concern about the behavior of the medical profession and the need for all patients to "speak up" when they observe misbehavior of the professionals. ..Maurice.