Tuesday, March 28, 2017

Chaperone violation and resolution

How to resolve the issue 

by RG

Moderators note:  This post is anonymous at the request of the author.  However his actual identity is known to one of us. 
For more background on this topic refer to the article on chaperones and the article on privacy complaints.


I get my most of my health care from a large group practice in the town where I live; one of my two  primary care providers there was a female nurse-practitioner who I’d been seeing for 5-6 years and had a good professional relationship with. Last summer, I was taking a shower and noticed a large swelling on one of my testicles. Knowing this was not something I could put off, I immediately made an appointment with my NP, who fortunately was able to see me that same morning. I was a little self-conscious about being examined by her, but based on our prior history – and the fact that I’d had intimate exams from other female doctors over the years -- I figured I could get over myself.
Anyway, after talking with me briefly about the swelling I’d noticed, she got up and went to the sink to wash her hands. “When was the last time you had a testicular exam?” she asked. Not exactly an announcement of what she planned to do; on the other hand, I knew it was coming, so I wasn’t surprised. “This will be my first,” I said. She nodded, then instructed me to take my pants and underwear down to my ankles, lie down on the examining table, and cover myself with a large cloth. She left the room for a few minutes while I did so. But then, when she knocked and opened the door again, one of the intake nurses (also female) was right behind her. Without a word, they positioned themselves on either side of me, directly across from each other at my hips. Then the NP pulled the drape completely off me, exposing my genitals to both women. I was so shocked and embarrassed I literally couldn’t speak – the NP hadn’t said anything beforehand about bringing in a witness, and obviously hadn’t asked my permission for someone else to be in the room. Before this experience, I had never even heard of “chaperones,” and had never been undressed in a doctor’s office for anyone but that doctor. The other thing that bothered me was that the nurse literally did nothing the entire time but stand there staring at my exposed equipment. She did not say a word to me or make eye contact at any point, and wasn’t assisting the NP in any way. As soon as the exam was finished, she turned and left the room.
The swelling turned out to be a cyst, and I was referred to a (male) urologist who recommended surgery to remove it. That took up most of my attention for the next several weeks, during which time I noticed some glaring differences from my initial exam in terms of modesty acknowledgement. I’ll just give you two examples. First, a female ultrasound technician who not only didn’t demand a witness, but made sure to drape me in such a way that only my testicles were exposed and nothing else (not even my bare thighs), and only while she was actually examining me. When she had to stop for a few minutes to check her records, she readjusted the drape so that I was completely covered until she returned to resume the ultrasound.  Secondly, in the recovery room after my surgery, the nurse attending me asked if I would like her to change places with my wife when getting dressed to leave – an offer I gratefully accepted.  Gradually, as I pieced together my memories of the initial exam, I began to realize how seriously and unnecessarily my privacy had been violated. At that point, I sent a letter to the NP, asking why the nurse had been present and why I hadn’t been consulted about it. She replied in a 4-line email stating that it was her “policy” to have a witness present whenever patients were undressed, that it was “for your protection as well as mine,” and recommending that I see a different provider in future for intimate exams. I took her advice a bit further, and sent her another note terminating our relationship. I obtained a copy of her clinical note for the exam, which to my surprise did not list the name or credentials of the witness, just the phrase “Chaperone during exam: female present.”  I went back to the facility in person to get that information; the clerk I spoke with seemed surprised that I was asking, but obliged me.
Since the NP’s response was so unsatisfactory, I decided to follow Dr. Joel Sherman’s recommendations (see http://patientprivacyreview.blogspot.com/2010/10/privacy-complaints-what-to-do-about.html), and gradually worked my way up through their chain of command (threatening to file a complaint with the state medical board probably helped). Ultimately, I was invited to meet with their two top directors. I told them I preferred not to seek disciplinary action, but did require an acknowledgement that both their NP and their nurse had acted improperly, along with some meaningful protections that would keep me from being placed in that situation again. I pointed out the implicit double standard in allowing two female staff members to attend an undressed male patient; they agreed that the reverse situation would never be allowed to happen at their facility, but said that the small number of male nurses on their staff made that double standard difficult to avoid. I offered to sign an a priori waiver of legal liability in exchange for a universal exemption from “chaperones” in their practice, but they did not agree to it. Their position was that individual providers had a right to third-party witnesses if they desired. Instead, they told me they would post a note in my electronic chart so that any provider in their practice would know my wishes in advance; they also agreed to attach a letter from my therapist, stating that the presence of such third-party observers was emotionally harmful for me. Their thinking was that any provider seeing that information would be likely to respect my preference and not be worried that I was just looking for a way to trap them into a lawsuit.
At my request, they also gave me some advice for negotiating with any new providers: if circumstances permitted, I should arrange for an “establish care visit” in which the provider and I addressed my refusal of witnesses and came to some agreement in advance about how to proceed. In the event of an urgent situation, such as I’d had with my cyst, and the new provider was not willing to work without a “chaperone,” I could ask that provider to switch places with a colleague who would honor my wishes, so that I wouldn’t have to delay treatment by rescheduling.
In our meeting, the directors also announced that they were planning to train their entire staff in proper chaperoning protocols – something they admitted they had not done previously. I asked for, and subsequently received, a copy of the informational materials they developed for this training. To their credit, every one of my complaints is being addressed: providers know they have to announce their intention to have an observer beforehand and specifically ask for consent; “chaperones” themselves are explicitly instructed to be attentive to patients’ signs of vulnerability and embarrassment, and to provide reassurance -- verbally and by maintaining eye contact. The training materials also clearly state that opposite-sex witnessesc are equally inappropriate for male and female patients, thus apparently ending that double-standard at their institution. I sent a written reply, thanking them and commending them specifically for their progressive stance on male modesty.
In closing, I’d like to offer my thanks to Mr. Capra for hosting this site, and to everyone else who has posted here. Your thoughts and shared wisdom helped me learn how to advocate for myself, and to believe that change is possible if one is willing to help make it possible.

Monday, November 24, 2014

Masculinity and Men's Health

Masculinity and Men’s Health Care
Doug Capra

            What does it mean to be a man? How do we define masculinity? What does a “manly” man look like, sound like? How does a real man behave?
            More importantly, who gets to decide the answers to these questions?
            The Movember Foundation is a respected global organization committed to changing the face of men’s health care.
How? By challenging men.  They challenge men to grow mustaches during November to raise funds and open up dialogue about prostate cancer, testicular cancer, and mental health issues. Since 2004, they have raised over $550 million and have funded over 800 programs in 21 countries. They are an honorable organization.
That’s why I was surprised recently to read a press release promoting this mustache-growing event that contained the following sentence:
“Most men aren’t proactive about their health because they’re ill-informed, lazy or scared. And that’s not manly.”
I’m not questioning the intent of the article. Getting more men to be more proactive about their health is an exemplary goal. But calling men lazy and unmanly?   And how dare a real man be scared. Real men aren’t supposed to be scared, are we? If we are, we’re certainly not supposed to verbalize it or show it in any way. On the other hand, realistically, who wouldn’t be afraid of the possibility of prostate or testicular cancer?
I couldn’t imagine this kind of language being used when the pink ribbons are distributed and women are urged to get checked for breast cancer? Why then do some believe it’s acceptable to use this language to convince men to get health care?
I immediately checked the Movember Foundation website  and read through it. I first went to their visions, values and results section under “about us.”  Everything I read showed tremendous respect for men, so I couldn’t imagine this language coming out of the Movember Foundation. So I sent an email to Movember inform them about this incident and asking if the press release came from them. I immediately got an email back from their representative, Abbie Rumery. She wrote:
“Thank you so much for reaching out. Was this a press release that was put out by a local community group, or was it in a news article that you read? That is not something we would ever say or promote on our website. Movember is all about getting guys to feel more comfortable talking about their health and breaking down stigmas and barriers related to their physical and mental well-being. If any organization is looking to promote their involvement in the Movember campaign, I would normally send them this digital press kit and the attached one pager and press release template. None of which say anything about men not being proactive about their health because they are lazy or scared and that it’s not manly.”
I hadn’t thought those words came from the Movember Foundation. That wasn’t their style. But then – where did that press release come from? I eventually found out, and I was further disappointed
I learned that what appears to be the original article is on a website belonging to the UMC Health System. They claim to be “the leader in comprehensive healthcare delivery in West Texas and Eastern New Mexico.” They say they reach “more than 300,000 patients a year,” patients that have “come to expect our dedication to service and the top-tier care we provide.” I’m not certain that this article originated there; it could have been reproduced from another source. But that’s not an excuse.
I sent an email addressed to four of UMC Health System’s top officials. I’ve not gotten an answer back from them and I note as I write this that the link that contains the sentence about men being lazy and unmanly is still up. You can find it here.   The fact that they haven’t returned my email is also disturbing. By ignoring controversies you just raise more disturbing questions. Did they think my email was from a crank? Do they consider my complaint unjustified or irrelevant? Or do they really believe that many men don’t get health care because they’re lazy and unmanly? By not facing the issue, they leave these questions unanswered.
I’m one of the men who is proactive about his health, and although I’m not a health care professional, I’m actively involved with health care issues. I frequently urge men who aren’t as proactive as I am to get checkups. But let me suggest that there are better ways to persuade them than by calling them “lazy”-- and saying that being afraid – a reasonable response to serious disease – is “unmanly.” Yes, many men are uninformed about health care issues – but not more than the population in general.
The real question – that is rarely asked and rarely researched – is actually why these men (and some women) don’t seek healthcare. And let’s not leave out that high costs may be one reason. Even with insurance, some patients can’t afford the deductibles.
Catherine E. Dube, EdD, has been doing research into men’s health attitudes for years. She and her colleagues published “Talking with male patients about cancer screening” in the Dec. 17, 2004 issue of the Journal of the American Academy of Physician Assistants. They wrote:
“Clinicians may hold certain assumptions about male patients that are not well founded. Clinicians may believe, for example, that men are immodest and unlikely to feel embarrassment during genital exams, don’t care about their health, are emotionally insensitive, and will seek medical care only if pressed to do so by a woman in their life. In our focus group research, however, we discovered that men were surprisingly modest about physical exposure in clinical settings, concerned about embarrassing exams, and interested in their health. We also learned that they desired closer personal relationships with their health care providers.”
This can be a sensitive issue that is worthy of much more discussion than I have time or space to offer here. Dube and her colleagues also wrote:
            “Understanding male communication and behaviors has become even more important with women entering the health professions at ever increasing numbers. Stereotypes held by practicing clinicians and handed down to trainees need to be challenged and adjusted to provide more effective care to men. Since men are less likely to be connected with the health care system than women, special efforts should be made to encourage appropriate preventive care, including age-appropriate cancer screening and early detection strategies.”
This article was published ten years ago, and perhaps we have made some progress – but not nearly enough. Indeed, the health care system is under even more stress today than it was then. Rising costs place a tremendous stress on efficiency. Safety, quality, standardization and patient experience issues dominate many a discussion in medical boardrooms.
And patient experience is an especially hot topic today. Some experts in customer service will tell you that the medical community, generally speaking, is twenty-years behind the times. In the early 1990’s a team from the Harvard Business School, Pine and Gilmore, published a book called The Experience Economy. Consumers were not merely after food or coffee or beer, they contended. They wanted an experience. That’s what they would pay for. They pointed out how Starbucks turned a commodity into a successful experience. Disney may have started the movement, or at least perfected it – but other businesses followed.
The patient experience begins with the patient’s first encounter with the system.
At the end of their book, Pine and Gilmore said that the experience economy has already peaked and we’re moving into what they called the Transformation Economy. Consumers don’t just want experiences, they want peak experiences that will transform their lives. We see that today especially in the tourism industry.
As we’ve consistently pointed out on this website, medical modesty and privacy are extremely important values for some patients and very important for many others. We’re not claiming that most or all men who avoid health care do it for modesty reasons – but certainly some do – as do some women. One of the key elements of American capitalism is choice. Patients in general, both men and women, should be offered the caregiver gender they feel most comfortable with, especially for the most sensitive exams and procedures. This may be one reason why some men and women don’t seek the care they need.
Certainly, we can push people into all kinds of behaviors by using name-calling and guilt. But that’s not persuasion. At its best it’s intimidation. At it’s worst it’s bullying. Of course, if one believes that the end justifies the means, than I suppose anything goes.
But the idea is to create lasting change, a “transformation,” -- not just one visit to the clinic where the experience may or may not be positive. The idea is to get rid of sexist stereotypes in both language and practice and start dealing with reality. Most men at heart want to stay healthy, not just for themselves but for their families as well. They may be afraid, but that’s natural. They may be strongly influenced by masculine stereotypes themselves and feel they can’t be afraid or embarrassed, or express their true feelings to health care providers. Certainly, telling them that this fear makes them “unmanly” is counterproductive and plain wrong.
But we’re not only dealing with the stereotyped attitudes some men may have been raised with.  We’re also dealing with attitudes from the medical community as Catherine Dube points out in her research.
As the month of November ends, let’s not drop the issue of men’s health. Let’s keep it open. And let’s all of us start taking openly about the issues that prevent men and women from seeking the health care they need to better their lives and those they love.

Friday, April 11, 2014

Medical Scribes, an Evolving Threat to Patient Privacy

by Joel Sherman MD

Medical scribes are a burgeoning field with many institutions and practices exploring their use while the many commercial enterprises who lease out scribes are pushing for their widespread acceptance.  There is no accepted definition of what scribes do or what their background or training should be.  There is no mechanism for licensure of them in any state.  They are poorly defined medical assistants.  The field is in its infancy and its ultimate role in our healthcare system is unclear.

The usual use of a medical scribe is to follow a provider around in their clinical tasks for the purpose of data entry.  This may or may not involve being present for the history and physical exam.  Most commonly they are physically present in the room and witness the entire encounter.  The need they fill is a function of our ever increasing mandates for electronic medical records (EMR).   Before EMRs, the use of data processors in examining rooms was quite rare.  Thus federal mandates have created another whole class of employees who are placed in the middle of health care interactions increasing the potential cost and complexity for all.   Some practices will clearly be tempted to use the scribes for as many uses as possible including assisting with minor procedures which I’ve seen advertised and acting as chaperones, which I know happens. This can help to ameliorate some of the extra cost involved in their employment.

The background of scribes is not standardized.  The minimum requirement appears to be competent data entry ability which translates into typing speed at a terminal.  Some advertisements require applicants to have a high school diploma or a year or two of college.  Many make no mention of education at all.  Some commercial sites train the scribe for a period varying from a few weeks to months.  At the high end, some advertisers require an existing knowledge of medical terminology with the preferred candidate being a medical student or premed student.  This is more often the case when the scribes are being used by academic institutions that have much greater access to people with these qualifications.  The majority of practices will not have access to premed or med students.  The scribes are mostly young and it is likely that few will choose this as a permanent career.  Thus they constantly have to train new ones.  The advertised pay rates vary from a minimum wage of about $8/hr up to about $20-25/hr.  The work may be full time but often is part time.

The touted benefits of scribes are to increase the efficiency of the practice by allowing the physician to see more patients while having a more personal interaction as they are freed from data entry.   It is advertised as a money saving strategy though a practice I discussed this with wasn’t at all sure that it saved money in their practice.  Scribes are a possible solution to the imposition of EMRs whose benefit to the patient and practice are frequently unclear or negative to begin with.  The dangers to patient privacy are clear but not often emphasized.  How much of a concern this is depends on the practice.  My ophthalmologist uses them without difficulty.  Few would object to an assistant hearing your ophthalmological history.  But many patients of general practitioners or internists would be inhibited from giving an intimate history by the presence of an assistant.  A few have the assistant outside the room for this perhaps making the patient more comfortable.  The presence of scribes during intimate physical exams is a further situation where many patients would be uncomfortable.  One article by urologists studied this and found no problems with acceptance, but the study had many caveats which the authors document[1].  This took place in an academic setting with medical students used as scribes.  The majority of the scribes were in fact men.  The one female urologist in the practice with a predominately female following refused to be part of the study.  I think the results would have been different in a urology practice in a private non academic setting where scribes were predominately young women without a medical background.   The routine use of opposite gender scribes would certainly make many patients uncomfortable in a private urology practice.  The most common use of scribes to date is in emergency departments where there are certainly many issues of patient privacy.  But in emergency settings patients are less likely to be concerned about their privacy.

The accuracy of scribes has not been studied to my knowledge.  The results would depend greatly on the background and training of the personnel.  But I do not see how anyone with a high school background and a few months of training could possibly understand all the medical conditions covered in a general practice.  The physician is responsible for signing off all records of course, but if the record is full of errors, it would be of limited use.  If premed or med students are being used, the results should be better, but this is partially mitigated by the fact that there would be immense turn over and new people would always need to be trained.

In summary, the routine use of scribes in a general practice has many potential problems of privacy and accuracy.   I don’t see how scribes without a medical background could ever be competent to understand a general medical history.  It would be far more accurate to have patients fill out detailed questionnaires on the initial visit and then have data entry performed on this later by scribes.  This would also permit a far greater feeling of patient privacy.   Patients have always understood that their medical records may be processed for administrative purposes.  The presence of scribes during intimate histories and exams should be very limited and only done with the express permission of the patient.  They should not be used as chaperones or multipurpose medical assistants without further special training.  In the long run the use of scribes is likely to be a temporary answer to a cumbersome system of mandated EMR which can still cause as many problems as it solves.  There is no intrinsic reason why EMRs need be so intrusive that their use requires a staff of intermediaries.  This makes it increasingly impossible for solo physicians and small groups to stay in practice.

[1] Koshy S et al, J. Urol. Vol 184, 258-262, July 2010.

This article has been re-published on KevinMD.com.