Monday, November 24, 2014

Masculinity and Men's Health



EMBEDDED STEREOTYPES
Masculinity and Men’s Health Care
by
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.

Wednesday, May 1, 2013

Informed Consent for Urinary Catheterization
by Misty Roberts



Informed Patient Consent Is Missing From Urinary Catheters

A urinary catheter is a hollow flexible tube inserted into the bladder to drain urine. This catheter drains urine from your bladder into a bag outside your body. Common reasons for a urinary catheter include staff convenience, urine leakage (incontinence), urinary retention, certain surgeries such as prostatectomy, and surgery lasting more than three hours. Staff Convenience is a very common reason for the use of indwelling catheters, and one which is recommended against by many universities and government organization. There is the perception that it is more convenient for nurses to place a catheter rather than take the patient out of the bed several times a day to change bed sheets and clothing, to help him/her to use a bed pan or walk to the bathroom, and to change diapers. Nurses should never use those reasons to catheterize patients. Foley catheters are not appropriate as a treatment for incontinence.

Many people feel that urinary catheterizations are an invasion of their bodily privacy even if they are done by a nurse or doctor of the same gender especially when they are not really necessary. Patient modesty is not the only concern with urinary catheters. You easily get infections or injuries from urinary catheters. Urinary catheters are the number one cause of hospital-acquired infections. About 80% of hospital-acquired urinary tract infections are related to urinary catheters. About 10% to 30% of male urinary catheterizations result in urethral injury. Check out complications that can occur from urinary catheters.

While it is true that some hospitals and medical facilities have worked to decrease the number of urinary catheterizations on patients due to concerns about infections, many medical facilities in the United States continue to do many unnecessary urinary catheterizations. Outpatient Surgery clinics typically do less urinary catheterizations than hospitals.

Urinary catheter is standard for many surgeries that do not really require them at some medical facilities. One man who had a simple neck surgery in a Georgia hospital was very upset and embarrassed when he woke up and discovered that he had a urinary catheter. He was not even asked for consent to have the urinary catheter inserted. Urinary catheter is not necessary for a simple neck surgery. When his daughter asked the nurse why he had a Foley catheter, the nurse replied by saying he needed one because he could not walk. A patient’s inability to walk is not a reason for a urinary catheter. Unfortunately, what happened to this man is pretty common at some medical facilities.
Some patients have urinary catheters inserted when they go under anesthesia and then removed before they wake up so they are unaware that they had a catheter unless they find out from their records or had difficulty urinating or felt burning sensation as they urinated after they woke up from surgery.  I feel that this is very unethical.

Some medical facilities allow nursing students to practice inserting urinary catheters on patients under anesthesia without their consent. This is very unethical. This unethical practice violates a patient’s wishes for modesty and could cause complications such as blood infection, Urinary Tract Infection, urethral injury, etc. Because nursing students have limited experience, they are more likely to injure patients they catheterize. While it is true that nursing students need practice with urinary catheterizations before they graduate from nursing schools, nursing school students should only do urinary catheterizations that are absolutely necessary under supervision of an experienced nurse and with a patient’s consent. Nursing schools should have their students do urinary catheters on mannequins as much as possible. Every nursing school should have a urinary catheter simulator such as a male catheterization simulator.


When is urinary catheter medically necessary?
Neurogenic bladder, acute urinary retention that cannot be resolved, acute bladder outlet obstruction, oliguria due to hypotensive shock, end of life comfort care of a terminal patient, certain surgeries such as prostatectomy and hysterectomy, prolonged surgical procedure (not a few hours) with general or spinal anesthesia. Most surgeries are less than 3 hours long so most surgery patients should not be catheterized at all.

Different types of anesthesia and effects on bladder functions:

Local Anesthesia – This type of anesthesia has no effect on bladder function at all so there is no need for a urinary catheter if you have local anesthesia. You should strive to have surgeries such as hand, wrist, etc. with local anesthesia if possible. Even knee surgeries can be done with local anesthesia now.
General Anesthesia – In short surgeries that are not longer than 3 hours, there is usually no effect on the bladder. The bladder will become distended in longer cases and the patient could become incontinent over time.

Spinal Anesthesia - Spinal anesthetics block activity along the nerve fibers that travel between the nerve centers of the brain and the bladder. Patients lose the sensation to void about 1 minute after being injected with spinal anesthesia, but will continue to feel dull pressure as the bladder reaches full capacity. In addition, the ability to contract the detrusor muscle is lost 2 to 5 minutes following the injection of local anesthetics and still persists even after bladder sensation is fully recovered. Spinal anesthesia with long-acting local anesthetic therefore contributes more to POUR (Post Operative Urinary Retention) than spinal anesthesia with short-acting local anesthetic, since the inhibitory effect of spinal blockade on bladder function lasts longer. Patients receiving spinal anesthesia with short-acting local anesthetic are often able to void shortly after outpatient surgery and are ready to leave the PACU quickly. (Source: What Do You Know About Post-Op Urinary Retention? - Outpatient Surgery) If you have spinal anesthesia, you should request spinal anesthesia with short-acting local anesthesia to reduce your chances of urinary retention.
Any bladder issues after surgery are most likely due to narcotics used for pain control.
Every patient should use the bathroom before surgery takes place. Most surgery patients are asked to not drink anything for at least 6 hours before surgery so their bladders are empty.

Patients who might become incontinent should be given the option of wearing disposable waterproof underwear or boxer shorts. You can buy them before you come to the hospital.


Why is there no informed consent for urinary catheters?
No informed consent is required for urinary catheterization. Despite the common use of urinary catheters and the well-known risks of complications associated with urinary catheters, patients are not asked to sign a written consent that discloses the advantages and disadvantages of urinary catheters. Rarely are patients informed verbally of the risks of urinary catheters. Another concern is that many patients care deeply about their modesty and would not want a urinary catheter to be inserted by an opposite sex medical provider.

John Fisher, a medical malpractice lawyer in New York shares in his article (Why Consent For Urinary Catheters Should Be Mandatory) that in evaluating hospital care throughout New York, he has not seen a single consent form for urinary catheters. Since patients with urinary catheters have a much higher chance of getting a urinary tract infection than those who do not have a catheter, the question must be posed: why is there no informed consent for urinary catheters?
Do patients really give “implied consent” to urinary catheterization?

Physicians and nurses will explain the patients give “implied consent” to urinary catheterization based on the theory that urinary catheterization is a common and routine part of hospital treatment. However, informed consent is important for urinary catheters for the following reasons.
  • Urinary catheter complications pose such a common and significant risk to patients.

  • Urinary catheterization is an invasive procedure and embarrassing for many patients who value their modesty. Every patient should be given the option of having a same gender nurse or doctor for the catheter insertion if it is absolutely necessary. Check out how male urinary catheterization and female urinary catheterization are done.
Once given information about the risks and benefits of urinary catheterization, the patient can make a fully informed decision whether they wish to accept the risk and if they want a same gender nurse or doctor to insert the catheter.

What is the downside of consent for urinary catheterizations? A little more paperwork and time for hospital nurses, but isn’t a fully informed patient worth this minor sacrifice? Patients should be informed that urinary catheter insertion involves the risk of complications, facts about how invasive the procedure is & their option for same gender nurse, and a specific consent relating to the pros and cons of a urinary catheter should be signed by the patient.
If the patient is incapable of making decision about urinary catheter, a family member should be asked for consent.
How to Refuse a Urinary Catheter?

Because there is no informed consent for urinary catheters and urinary catheter is standard for many surgeries and sick patients who cannot move at some hospitals, patients and their families must speak up and take steps to ensure that a urinary catheter is not inserted. Keep in mind that the inability to walk is not a reason to insert a urinary catheter.

Steps To Ensure That No Urinary Catheter Is Inserted:

1.) Request that no urinary catheter be inserted in writing. Write all over your surgical consent form that you do not consent to urinary catheter and that your underwear may not be removed at all for surgeries that do not involve the genitals. Try to get the consent form the day before surgery if possible.
2.) Talk to the surgeon, nurses, and everyone that will be involved in your care about how you do not permit a urinary catheter to be inserted and that your underwear must stay on.
3.) Type up a document saying that you do not consent to a urinary catheter and make several copies to give to everyone involved in your care.
 
Sources:

Misty Roberts is the president / founder of Medical Patient Modesty (http://www.patientmodesty.org), a 501c3 non-profit organization that works to improve patient modesty.