After We Die A Book Review

After We Die, The Life and Times of the Human Cadaver is a recently published book by Norman L Cantor who is a law professor at Rutgers University.  The book is an extremely thorough look at a rarely explored subject.   This review is a partial departure for this blog.  Although privacy concerns are not the main topic of the book they are implicit throughout the book and directly addressed in other sections.  If you are interested in respectful post mortem treatment of yourself and your loved ones, this book will explain all there is to know.

The book is part legal treatise and part an entertaining look at customs surrounding death and burial.  It starts at the very beginning with definitions of death, a topic that has become more complicated as modern medicine has learned how to extend life by artificial means such as ventilators and heart lung machines.  The author who has a special interest in bioethics among other topics has an impressive command of medical knowledge.  I could not once fault him for his understanding of medicine which is unusual for a person without any apparent medical training.

The book then delves into the legal status of a cadaver, a topic I have never considered.  But a corpse retains certain legal rights and is never considered inert property.  Thus a cadaver has a presumption that  its premortem wishes will be carried out and respected.   This includes the ability to specify the terms of burial even though it has no ability to enforce its wishes against the desires of next of kin.

Much attention is given to the process of burial starting with how a body is handled in the funeral home.  This includes details which vary from country to country, religion to religion as to how a corpse is processed, the body cleaned and prepared for burial.  Embalming is done in some religions but not all.  I was surprised at how soon decomposition starts no matter the process used.  The differences between below ground and above ground burial are given as well as attention to cremation.

Cadavers are also a commodity, surprisingly enough.  They can be used to supply medical parts thru organ donation programs.  Programs to donate corneas have been in place for decades.  Now many other organs such as hearts, kidneys, lungs and liver can also be donated.  These are usually premortem voluntary donations.  Another major use of cadavers is for teaching.  This includes autopsies which can be either voluntary or mandated by law when the cause of death may involve criminal activity.  Bodies can also be donated for dissection in medical schools.  Nowadays this usually happens by the premortem wishes of the person involved.

The book also contains several sections documenting the abuses that have occurred over the centuries to cadavers.  The most common one was body snatching wherein corpses were illegally dug up to be used for dissection.   In medieval times it was common for the bodies of executed criminals to be publicly displayed and abused, a practice now universally abhorred and forbidden.

Lastly the book also has a section exploring ways bodies have been put on public display in present times for both commercial and educational reasons.  This includes the technique of plastination wherein bodies are preserved in a complex process which turns them into a type of plastic.  There are several traveling shows which display bodies which have been preserved like this for so called educational purposes though much of this serves commercial voyeurism. 

After We Die is thus an exhaustive look at a topic we are all concerned with, but many of us choose to ignore.  The book ends with a plea for readers to plan their own disposition so as not to put the burden on family.  Make your wishes known.  

I found the book to be a surprisingly enjoyable read on a subject most of us have little knowledge of.  Some parts of the book are overly legalistic and difficult to read through, but most of the volume easily retained my interest.  I recommend the book to anyone who is concerned with burial rites in general and personally planning for your own disposition and legacy.

Military Medical Humiliation, German Style by Lars G Petersson

Lars G Petersson is a Swedish born human rights activist and author of many books.  His book, Medical Rape, State Authorized German Perversion, can be obtained here.

                                    

'She has got nothing on but a pair of knickers. The same goes for the other few young women in the waiting room. They are all so lightly dressed - and they all seem uncomfortable with the situation. Constantly men with files are running back and forth, and some of them can’t help having a quick glance at the young ladies while passing.

  After a long waiting at last it is Ursula Müller's turn. A man in a white coat stands in the door and calls her name. For the young woman it’s indeed quite stressful to walk across the room in such an almost naked state. However, she's got no choice: after all, the examination for which she has come is a legal duty, and if she hadn't turned up she could not only have been punished but, worse, police would have 'escorted' her to another 'appointment'. Would the young woman have tried to avoid even that, she could very well have ended up in prison. Not a nice prospect really. No, going to jail Ursula wouldn't fancy. After all, she hasn't done anything bad. In fact she has done nothing at all. She has only grown into an adult or at least almost so - that's all. Seventeen she is, and in another few months she will be eighteen.

  As the young woman then finally enters the examination room she finds herself in the company of two men: one whom she believes is a doctor and another she reckons must be his assistant. However, it's all a guess; none of them has introduced themselves.

  Now something will happen that Ursula never will forget: her body will be thoroughly inspected and assessed - that's why she was 'asked' to come. Nothing will go undetected: head to toe it will be - mouth, teeth, breasts... just everything. In the middle of it all, half naked as she is, she will be asked to do twenty squats - with blood pressure before and after. Bit strange really - as if her blood pressure, due to the forced condition, hasn't gone through the roof already, regardless of being 'asked' to do squats or run a marathon.

  After the young woman had been through all the initial procedure something comes that she has feared all along, actually for years. The last protection of her privacy will be removed. 'Take off your knickers, please!' Ursula's cheeks turn red and hot; she stands there helpless, doesn’t know what to do. No, she doesn't want to do that. 'I don’t want to be stark naked in front of two men,' she thinks to herself. It's too embarrassing a prospect. 'No, don't do it!' a subconscious voice screams at her.

  Ursula is gripped by a terrible anxiety as she notices the young man behind the desk looking in her direction with a slight smile on his face. In the same moment the now impatient doctor repeats his order. With sharpness in his voice he commands: 'KNICKERS OFF!' The young girl at this point obviously see no option but to do as she is told. The little resistance she might have had is gone; she is defenceless. Now she is completely naked; she stands in the middle of the room, totally exposed; she feels the last slight protection of her human dignity has disappeared. She wishes she could sink through the floor; she feels so embarrassed and humiliated.

  Ursula's most intimate parts of the body are now to be zealously scrutinised und inspected. The doctor starts to check her genitals, and he is doing it with great thoroughness. After all, it must be tested as to its functionality, or so it seems. He repeats his movements not just once but twice. In this moment Ursula's most private parts sort of belong to another person, something she would never have allowed had she had had a choice. Then another order is heard: 'turn around, bend forward and spread the buttocks!' Automatically, now without resistance, the girl does as she is told. Her bum is now being thoroughly inspected with a little torch. She is, however, lucky: a finger in her anus she is spared (other 'patients' have to experience that to).

  Ursula has had more luck this day as she has only been inspected by one doctor not two, which often can be the case. Sometimes also two assistants can be present, as new staff from time to time have to be trained for the job. Indeed, it can be quite crowded around the 'object'.

  Finally Ursula is allowed to put back on her knickers and leave the room. As she returns to the waiting area the other girls out there note that her face is like a tomato. Rest assured, they will soon, one after another, have the same experience.'

-----    

                 

Of course, this story never happened as it was here told. After all, that's not a way to treat young women. Completely out of order it would have been - impossible, simply perverse. Most people would share that view. Some might even ask: what fucking pervert has written such nonsense?

Lars Petersson

 Yes, what do I actually want to tell with such a story? In fact this: that a story like the one about Ursula not exclusively is to be found in the sick fantasy world of a sadomasochistic old bugger - actually it has all a very real background. To make the story true we only need to swap the genders of all people involved. Having done so, it all turns into reality. Then we can also give it a name: a 'military medical induction' or, in German, 'musterung'. We now talk about a legally enforced medical where young men, mainly by women, as cattle on a market place, are examined, inspected and assessed for forced military or civilian service. 

  At least one thousand times this scenario has been repeated all across Germany every day for the last one hundred and fifty years. The number of similar examinations and controls has, however, been much higher, as not only have young men been selected this way or discarded as possible candidates for forced service, a process which can mean repeated requests to make one self available for scrutiny, but in all barracks and by all civilian authorities responsible for 'employing' conscientious objectors all of it in every detail have been repeated not only when starting but also when leaving service - and sometimes even in between. On top of that comes and will continue to come thousands of identical checks of young men who, for one reason or another, totally voluntarily or due to civilian unemployment, have chosen the military as a temporary or permanent employer. Also these individuals (contrary to their female colleagues...) are constantly exposed to the same kind of intrusive 'examinations'.

Of course, testicles and backsides of young people can hardly have anything to do with defence of a country. Even for the defence authorities themselves that seems to make sense, as, certainly, nothing in this area would serve as a reason for anybody to be excluded from forced service or for that sake not to be accepted as a volunteer. Despite that, however, eager officials continue to order these parts of the body to be checked as to their optimal function - as said not only repeatedly before but also after ending the service. After all, the foreskin might have got stuck since the last examination.... Better make sure it hasn't.

  No matter what, how odd it all might seem, all what we talk about here is in Germany fully legitimate and established. All right, economic woes due to the recession (not calls for human rights) will soon end conscription. But, on a smaller scale the abuse will continue as usual – now with ‘volunteers’ as sole victims. Again and again the call will sound: strip! Again and again the state and its willing helpers will reach out after young men's testicles and foreskins, and again and again they will be commanded to turn around, bend forward and spread their buttocks. And (isn't it remarkable?), all of a sudden nobody seems to see a problem in it any longer. Nobody will see it as an assault - as they certainly would, had 'Ursula' really been the victim. No, 'so are the rules, and that has to be tolerated.’ 

  All right, this particular story was about Germany, but, unfortunately, that country has no monopoly on degrading military medicals: for hundreds of years, all around the world, willing doctors have ‘forgotten’ the oaths they once swore, joined the armed forces and allowed themselves to be used to humiliate and abuse their ‘patients’ – all of it with only one purpose: to create obedient, subservient soldiers. 

  Mental anguish due to such humiliation is widespread. After having researched the subject in Germany, I would state it's pandemic (though very well hidden away). And, why should it not be the same elsewhere? After all, many Americans will remember the days of the Vietnam War draft offices, and most Russian men will be painfully aware of their own armed forces’ outstanding abilities in the field of degrading strip examinations. For them it can hardly be a surprise that (according to official statistic) 231 recruits committed suicide in 2008 alone. There will be other reasons behind that shocking number - mainly bullying and extremely harsh conditions - but I am certain that perverted medical 'examinations' played a big part in why many of those young men tragically chose to end their own lives.

  Due to all this, in the name of millions of defenceless victims and victims to be, no matter if conscripts or volunteers, the civilised world must demand that at least health professionals refuse to further participate in ruining young people’s lives. We must demand they stop performing abusive and degrading medical ‘examinations’ which pure objective is to remove the last remnant of dignity from vulnerable recruits. Also, we must openly recognise and acknowledge the harm this kind of universal abusive treatment through the years has done to millions of men’s mental well-being and sexual development. We must place the shame where it belongs  – on the perpetrators, not on the victims. More than anything else, state authorised sadomasochistic abuse must stop no matter where it takes place. We can all help make that happen. A few words from you to responsible authorities could be a good start in that process. After all, that was how Amnesty International once started - a call in favour of the forgotten political prisoners and a call against torture and degrading treatment of people in captivity. 

  This is a call for help for all those forgotten and humiliated soldiers whose lives have been ruined not just by futile wars but also by perverted medical 'examinations' in the name of oppressive military establishments. On my website www.larsgpetersson.com (Military Abuse) you will find all addresses. Write a line or two, copy, paste and press 'send'. Future generations will be grateful for your help.

Lars G Petersson

Informed Consent Is Missing from Cervical Cancer Screening

Really ?

This article of mine was first published in November 2009 on KevinMD.com.  See links.

The American College of Obstetrics and Gynecology (ACOG) has just revised their guidelines for Pap smears under some pressure. This resulted from an Annals of Internal Medicine article which documented that only 16.4% of gynecologists followed the College’s prior guidelines. Most did more screenings than indicated, the worst record of the specialties tested. But the ACOG still recommends that nearly all women obtain regular screening at intervals of 1-3 years.

The facts are that cervical cancer is a rare disease in the US, a point which is never made. The American Cancer Society (ACS) predicts that there will be just over 11,000 cases in 2009. There will be nearly as many cases of testicular cancer, 8,400. In comparison both breast and prostate cancer are just under 200,000. Most women have been led to believe that cervical cancer is rampant and they need yearly screening to prevent it. Testicular cancer however, is rarely mentioned. Most physicians don’t even bother to recommend that young men self-examine.

Cervical cancer was once more common in this country and that accounts for some of the disparity. Pap screening has helped reduce the incidence, but far more is now known about the disease than when the Pap smear was introduced. Cervical cancer is in essence a sexually transmitted disease (STD) caused by the human papillomavirus (HPV). Thus any woman can estimate her personal risk. It’s high if a woman has had multiple sexual partners. With prior negative Paps it’s low if she abstains or if she is in a long term mutually monogamous relationship. The newer HPV DNA test will further increase safety.

For comparison’s sake, HIV (AIDS) is an even more dangerous STD with a five times greater incidence than cervical cancer. Yet no one ever suggests that everyone be tested for HIV, and there are laws in many states restricting testing. Testing is suggested only for those at risk, but this tactic is never used for cervical cancer.
I have seen a spontaneous outpouring of sentiment from women who are angry that the facts on cervical cancer have been hidden from them. They are pushed into getting Paps, but never told the pros and cons of screening. Never mentioned are the high incidence of abnormalities that resolve spontaneously, negative biopsies and colposcopies. It’s an uncommon doctor who even advises that every 2-3 year screening is considered appropriate in low risk women. My wife has had about 45 negative annual Paps and still her doctors haven’t said she can skip any. There are many recent recommendations suggesting that men be carefully told the options concerning prostate screening. We are just beginning to see that for breast cancer screening. But for cervical cancer screening there has been near silence on the issue.

Informed consent on cervical cancer screening is completely lacking in this country. Women are told that they need Pap tests, but rarely told if they might not need them or asked if they want them. The ratio of negative biopsies and colposcopies to cases of cervical cancer is very high given the rarity of cervical cancer. If women are given brochures, they are for the sole purpose of convincing them to get regular testing.

The negative aspects of mass cervical screening are never mentioned. Women should be given the facts and allowed to decide for themselves based on their individual risk benefit ratio whether or not they need regular cervical cancer screenings. The ACS and the ACOG could do a real service by providing pamphlets to providers’ offices that fully explain both the pros and cons of testing. Then let each individual woman decide for herself.

Links and extensive discussion of this topic can be found here.

PATIENT MODESTY, VALUES, & RIGHTS

CORE VALUES AND PATIENT RIGHTS & RESPONSIBILITIES

WHAT THEY “SAY” ABOUT PATIENT MODESTY

by Doug Capra (c) 2010

When you enter a hospital, do you have the right to expect same gender care for intimate needs if that‘s your desire? Note that I’m not wondering whether you have the right to request this, or whether the hospital has the obligation to attempt to grant your request. Of course you do and of course they should.

But first -- I want make it clear that I’m limiting this discussion to non emergency, non life-threatening situations. I’m not suggesting that modesty has no place in these other areas -- but I think their specific contexts need a separate discussion. For now, though, read this article to see how patient modesty can be handled in emergency situations. So often, when I’ve debated the modesty and gender preference issue with medical professionals, they quickly move the discussion to the ER or other extreme situations. I’ve gotten used to this diversion and bring them right back to the main issue. Let’s talk about basic exams that happen thousands of times every day in clinics and hospitals -- procedures and tests of the more intimate variety.

The question I pose is -- do hospitals have an ethical and legal obligation to accommodate you? Since I’m not a lawyer, I won’t go into the legal interpretations here -- but I will attempt to parse and deconstruct an example of a core value statement and another example of a patient bill of rights to see what the hospitals are implying about modesty and gender preference. My contention is that, although the word “modesty” is rarely used, the concept is present.

When you go to a hospital, you should be given these documents. I wonder how many patients actually read them. You should. In fact, although I won’t be delving into the “Your Responsibilities” part of the patients’ rights document, I don’t want to underestimate the importance of that section. It represents the other side of the same coin.

CORE VALUES

If you do a google search online using terms like “hospital or core values,” you’ll get many hits. These can vary considerably, but most seem to contain basic elements. As an example, I’ll be using the core values of the Providence Hospital system because I find them to be especially well-written with clear implications regarding patient modesty.

The Providence Hospital system divides their core values into five categories: Respect, Compassion, Justice, Excellence and Stewardship.

The first two are the most relevant to the modesty issue.

RESPECT -- “We welcome the uniqueness and honor the dignity of every person. We communicate openly and we act with integrity.”

Here’s how I read this relative to the modesty issue: Every human being is unique and that uniqueness must be respected by treating the patient with dignity. Since we’re unique, we may each define our dignity in different ways. Some may find it completely dignified to have intimate care done by the opposite gender. Others may find that undignified. The idea of “dignity” doesn’t rest within the mind and behavior of the medical provider. It rests primarily within the patient and their unique value as a human being.

COMPASSION -- “ We nurture the spiritual, physical and emotional well-being of one another and those we serve. We embrace those who are suffering.“

Here’s how I read this relative to the modesty issue: It’s not just about your body, your physical being. Your spiritual and emotional well-being are at least as important to us. Note that two out of three words in the first sentence represent the non physical -- spiritual and emotional. How patients feel (the emotional) about who sees and works with their bodies under especially private situations is embedded within these words. In some cases, one’s spiritual and/or religious beliefs and values are directly connected with the modesty issue. We will respect this. We realize that “suffering” doesn‘t just mean physical pain; it includes spiritual and emotional anguish as well. For some patients, this may involve modesty issues.

Of course, assumed in all this is that providers “know” your individual and unique concept of dignified treatment and your feelings and spiritual values. How will they know? Well -- you’ll either tell them, or they’ll ask. What benefit is there to such lofty core values unless polices are embedded within the health care system to find out individual patient values? The systems answer might be -- Well, it’s up to the patient to tell us, that’s their “responsibility.” There is some truth to that -- and that’s where patients need to speak up.

On the other hand, health care systems that want to insure that their core values filter down into everyday operations, need to create policies that specify how they will practically accomplish these lofty goals. I have been unable to find any specific policy statements from American hospitals (including Providence) that address how they will handle modesty issues and requests for opposite gender care. I have found several policy statements from the UK, Australia and Canada.

Providence does state in its first core value that “We communicate openly and we act with integrity.” That implies to me that they see their leadership role in opening up communication with patients about this issue. True empathy from providers involves leadership in communicating and helping to empower patients.

PATIENT RIGHTS & RESPONSIBILITIES

When you enter a hospital, you should also be given a copy of their Patient Rights and Responsibilities. Read it carefully. The example I’m using is from the Carolinas Medical Center-NorthEast in North Carolina. I find these to be especially well-written with clear implications regarding patient modesty.

Almost all patient rights documents say something about treating patients with dignity and respect -- using those specific words. Those words alone should be enough to cover basic modesty and even patient gender preference for intimate procedures. Unfortunately, that’s not always the case. Here are a few selected patient rights, given their assigned numbers, from Carolinas Medical Center-NorthEast, followed by my comments:

3. “A patient has the right to every consideration of his privacy concerning his own medical care program. Case discussion, consultation, examination, and treatment are considered confidential and shall be conducted discreetly.”

Note, “every consideration of his privacy.” That should pretty much cover it. Modesty and gender selection considerations are certainly aspects of any medical care program. “Examination” and “Treatment” would cover some of the issues patients bring up, such as gender of the examiner and those who do bed baths or procedures like foley catheterizations, as well as chaperone and/or observer issues.

Don’t let someone tell you that your choice of one gender over the other for intimate care is discrimination, in the legal sense of the word. Don’t let them compare it to racial discrimination. A racist is someone who negatively stereotypes a whole race and/or thinks that race is inferior to his own. If, as a man, you believe that all women are inferior to men and can’t do the kinds of procedures you need, then, indeed, you are practicing discrimination.

But that’s not what most people believe who request same gender care. Most patients welcome basic care from either gender. It’s only for the most sensitive, intimate care that they prefer a same gender provider. Their assumption isn’t that both genders can’t do the job equally as well. For modesty and privacy reasons, these patients just prefer a specific gender. So -- don’t accept this “discrimination” argument if it’s used.

13. “A patient has the right to medical and nursing services without discrimination based upon race, color, religion, sex, sexual preference, national origin or source of payment.”

Well, there are only two sexes (although there are various sexual preferences -- but let’s not go there for now). If one sex is granted gender preferences for whatever reason, the other sex should also be granted the same right. Pretty basic. Most hospital bills of rights provide this basic right in pretty much the same words. Just because they may not practice it regularly, doesn’t mean they haven’t stated it as foundational to their institution and the work they do. You may have to remind them.

18. “The patient has the right to medical treatment that avoids unnecessary physical and mental discomfort. “

Now, we can debate what constitutes “unnecessary.” But patients do have the right to ask:

“What have you done to ‘avoid” this kind of mental discomfort I feel with opposite gender intimate care?

Do you consider gender preference when you schedule? Have you made hiring efforts to balance out caregiver gender?

Why do you consider it ‘necessary’ for me to deal with this mental discomfort?”

In other words, if you need to debate, use the specific language found in the hospital’s core values and bill of rights. Have a copy handy that you’ve highlighted and annotated.

25. “A patient, and when appropriate, the patient’s representative has a right to have any concerns, complaints and grievances addressed. Sharing concerns, complaints and grievances will not compromise a patient’s care, treatment or services.”

Although this doesn’t address the modesty issue specifically, it does cover concerns some patients have about possible repercussions. I’ve included it because on Dr. Maurice Bernstein’s recent modesty blog, (on Wed., Nov. 10, 2010 at 11:52 a.m.) someone challenged me when I defended female nurses (Yes, I have great respect for nurses of both genders). The blogger called me naïve and stated that if a patient dares to “refuse the same female caregiver twice…she’ll throw a tantrum. This happens with female patients as well. And Heaven forbid you have an argument with them, because you will almost certainly face retaliation.”

I’m not saying this has never happens. It’s possible but, in my opinion, rare. I am saying that here you have a specific statement that protects you specifically from that kind of bullying behavior. If it does happen, don’t tolerate it.

30. “The patient has the right to personal privacy. Privacy includes a right to respect, dignity, and comfort as well as privacy during personal hygiene activities (e.g. toileting, bathing, dressing), during medical nursing treatments.”

Could this be any clearer in regards to your modesty and your desire for the gender of your caregiver for intimate needs? And remember, within reason, you get to define your own definition of “dignity” and “respect” as a patient. If challenged, ask the hospital for their definitions. I’m convinced you’ll find they have no definitions. That doesn’t mean they don’t care about dignity and respect. It does mean that little thought has gone into policy standards that cover patient modesty and gender preference under the umbrella of those overly used and idealistic words -- dignity and respect.

I will admit that I haven’t found this specific wording on any other patient bill of rights from other hospitals. That’s why I picked Carolinas Medical Center-NorthEast as my example. For a hospital to even use this wording suggests to me some thoughtful analysis of the modesty and gender preference issue.

A few closing thoughts.

1. If you have a choice of hospitals, go online and check various mission statements, core values, and bill of rights. They do vary.

2. Find a hospital whose values reflect yours.

3. Print out copies of those documents. Study them and bring copies with you to the hospital.

4. Don’t go looking for a fight. You’ve read the documents. You know the kind of care to expect. Expect it.

5. Finally, consider your responsibilities as a patient. Carolinas Medical Center-NorthEast lists this as a patient’s first responsibility: “Patients, and their families when appropriate, are responsible for providing correct and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to their health.”

If those “other matters” for you include modesty and gender preference, it’s your responsibility to provide that information to caregivers. Their responsibilities, as I see it, are quite clearly delineated in most core value and bill of rights statements. Unfortunately, you can’t depend upon them offering you these kinds of choices -- even though they should. So make sure you communicate your values to them.

Be proactive. Be an empowered patient. Know your rights and responsibilities and the values of the hospitals you choose.

NOTE -- How about readers providing some other specific core values and patient rights statements from other hospitals? Also, how about some examples of experiences you had with these documents.

Patient Gender Preferences In Healthcare

Modern medicine is assumed to be gender neutral, that is providers, nurses and assistants are equally able to offer their services to all comers no matter the genders involved. It is a tenet of our training. This had little relevance in the past when nearly all physicians were men and nearly all nurses were women. Times have changed. Nowadays medical students are nearly 50% women. Although the percentage of male nurses is also increasing, it is still low, likely over 10%. However the increase in male nurses may be due mostly to the recession and the loss of traditional male jobs rather than to any perceived need for more male nurses.

Changing practices in medicine can be exemplified by male urinary catheterization. Thirty plus years ago this was always done by physicians or male orderlies; nowadays it is usually done by female nurses. The reason for these changes is mostly financial as hospitals got rid of orderlies in favor of less expensive ‘transport aides.’ As all physicians were male, they of course treated all patients. Women providers of today have the same expectations of being able to treat everyone.

Yet no one has ever asked patients how they feel about this. Are patients gender neutral in their preferences? The answer is clearly no. The factors are complex and need analysis. The clearest division is with intimate care. Women have strongly gravitated to female Ob-Gyns. Ninety percent of Ob-Gyns in training are women and men are discouraged from entering the field. The younger the woman, the clearer is the preference for female providers. The results vary somewhat from study to study likely based on how the study was conducted. Older women are used to using male gynecologists and some are reluctant to admit they prefer women because those concerns were made light of in prior years. Yet in nearly all studies, at least 50% of women prefer female OB-Gyn care with no more than 10-15% preferring male care. References include: Obstetrics Gynecology Apr 2005, Vol 105, #4, p 747-750, Obstet Gynecol 99: #6, 2002, 1031-1035, and Plunkett, Beth et al. Amer J Obstet Gynecol, 186: #3, 2002, 926-928. An Australian study put the number at 70%.  I haven’t seen a study which looked just at adolescents, but clearly the percentage is even higher, approaching 90%. Women are not gender neutral in their preferences for intimate care.

Not surprisingly the preferences that men have are not as striking, but still present. A similar study asking men their gender preferences for a urologist has not been done to my knowledge. Yet 90% or urologists are men and many of the few practicing female urologists specialize in women’s problems. The percentage of female urologists is increasing, but nowhere near as dramatically as the number of female Ob-Gyns. Men are not demanding more female urologists to take care of them. In terms of routine male genital exams, men still show a preferences even though the exam is brief and generally done as part of a full physical. In one study 50% of men preferred a male physician whereas the rest had no preference. Other studies have said up to 70% of men have no preferences, but once again it is critical how these studies are performed. An anonymous questionnaire will give different results than a series of questions asked by a nurse. Most men are loathe to admit that they are embarrassed by receiving care from women. They are frequently made to feel humiliated if they do. Women can have this same problem but it is far more acceptable for a woman to be modest than it is for a man. A man is likely to accused of sexism or suspected of homoerotic tendencies if he refuses opposite gender care whereas a woman will just be considered modest. It is much easier for a man just to avoid receiving any medical care which men do in far higher numbers than women who are forced into entering the healthcare system early in their lives for contraception and obstetrical care.

There are other factors besides gender in determining how likely it is that a patient will prefer same gender care. As noted, age is the most important of these. Adolescents are far more likely to be embarrassed by intimate care. A choice should be offered them. This often happens nowadays for girls but rarely for boys. This may become less of a problem for boys in the future as many are used to care by female pediatricians. But as they move into adolescence, this should never be assumed. Conversely elderly patients routinely have less concern. Religion also plays a role especially with Muslims and other orthodox sects. A history of sexual assaults or homophobia may also account for preferences.

Up to now we have only considered gender preferences for providers, but of course this can also be extended to nurses, technicians and assistants. Patients do not look at these healthcare workers like they do physicians. Clearly women are far more likely to accept male physicians than male nurses or technicians. Men who wouldn’t see a female physician routinely accept female nurses. Of course they usually have no choice. But beyond that there is still a common prejudice against male nurses in that they may be considered not as nurturing as women or they may be considered gay. I don’t think that either of these prejudices have much basis in fact, but they keep many men from going into nursing. This is changing, but slowly. Men are clearly at a disadvantage here. Many men who need urinary catheterization would request a male to do it, but they are rarely offered a choice. It is difficult to insist on it as the man may be embarrassed by asking and the need may be urgent. Female nurses almost never offer a man a choice; the only common exception is when the nurse feels the patient will harass her and asks a male nurse to do it instead. In short when men are offered male nurses for procedures, it’s usually done for the nurse’s comfort, not the patient’s. Although there are male nurses who catheterize women, it is far less common and many male nurses will routinely ask a female nurse to do it. Intimate care in hospitals nowadays is usually done by CNAs, who are 98% women. This includes giving baths and showers. The only option a man has is to refuse the care; no male CNA will likely be found.

In summary, American medicine claims to be gender neutral but patients are not. This is essentially a fact we’re not supposed to know. Hospitals routinely publish a patient’s bill of rights, but I’ve never seen one which included gender choice. At best it may be implied by statements that the hospital will respect the patient’s values. Of course gender is a protected class under federal laws so hospitals are in a bind. Federal law does make exceptions (BFOQ) where matters of bodily privacy are involved so it is legal to request a specific gender for care. However hospitals cannot base employment on that in general with rare exceptions. Still and all, hospital employment policies are never based on giving patients a choice of gender; their major consideration is cost and availability.

Will this ever change? It’s not likely to change in the foreseeable future unless a lot more patients speak up about their preferences. Hospitals are only likely to make the change if they see it as in their financial interest. For example, if men routinely asked for a male technician for testicular ultrasound, hospitals would soon provide them just as they provide an all female staff for mammography. Ultimately you as a patient must make your preferences known.

Please add your comments.  Further discussion can be found on my companion blog. This slightly modified article has also been picked for publication on Kevin.MD, a widely read medical blog.

PATIENT MODESTY AND HOW WE COMMUNICATE

PATIENT MODESTY AND HOW WE COMMUNICATE

Assumptions, Stereotypes & Efficiency

The story plots form patterns. They narratives involve patient modesty violations. The main characters are patients, doctors, nurses, medical and nurses assistants, and patient techs . The stories are set in medical clinics and hospitals. The elephant in the room is the entire issue of how the gender of the patient and the caregiver affect patient care. Although the patients in these stories are both male and female, I’ll be using male examples for several reasons.

First, men don’t go to the doctor as often as women. Unless they’ve had chronic health problems from youth, they don’t end up facing the health care system regularly until their 50’s when they begin to have problems with, for example, their prostate. Women have contact with health care at much younger ages for obvious reasons. Second, men often won’t speak up in medical situations, and when doctors and nurses are busy, that’s sometimes regarded as a good thing -- for the caregivers. The job gets done faster -- it's more efficient. Women often fail to communicate, too, but in recent years our culture has empowered women more regarding their health care. Third, with the gender imbalance in bedside care, men often have little choice of gender anyway. Fourth, men are sometimes stereotyped as not caring about the gender of caregivers for intimate exams and procedures. It’s sometimes assumed that it either doesn’t matter, or that, for homophobic reasons, they prefer female caregivers.

As I’ve stated many times, a significant part of what we consider to be modesty violations come down to communication issues. Medical culture today is not known for it’s outstanding communication skills. Like customer service throughout the country, when a patient experiences great communication in medicine, it stands out as exceptional. Poor communication experiences are often the norm, and shrugged off as just the way it is.

Many of us communicate well with our primary care physicians. We should. If we don’t, we should find another. But, as we move away from local care into the hands of a specialist -- the communication sometimes breaks down. When we move from the specialist into a hospital, and face a team of caregivers we don’t know, we often have problems and need to be extremely proactive.

Let's look at a scenario, examine what may be happening and consider how patients might respond.

Mr. Smith, 55 years old, makes an appointment with his long-time male primary care physician, Dr. Anderson, and feels comfortable with him. Anderson has moved and now works with a new team of doctors at a new clinic. At the clinic, Smith goes through the regular routine -- fills out some paperwork, sits and waits, gets escorted into the examining room by the female medical assistant. He’s handed a gown and told to undress. He does so.

After ten minutes, to his shock, a female doctor, a complete stranger, enters the room with the medical assistant and says: “Hello. I’m Dr. Jones. Sorry, Dr. Anderson is on vacation. I’ll be doing the exam today. Kathy will be assisting me.”

Smith doesn’t know what to say. He’s speechless. He’s led a relative healthy life with no hospitalizations since he had his tonsils out at age seven. It’s only been the last few years, since he developed prostate problems, that he’s seen a doctor regularly. He’s greatly embarrassed at this situation, but even more embarrassed to complain. He lets the exam go on as planned, only nodding yes or no to any questions. Jones had planned to ask Dr. Anderson several embarrassing questions about some personal health problems, but on this visit, he asks no questions at all.

I’ve heard this experience referred to as an “ambush” by some patients. Not only have I read this story pattern on many blogs, but it actually happened to a friend of mine. And, although my friend and I had talked about these kinds of problems and he was aware of male modesty issues -- he responded just as Smith did. Later, he was angry and frustrated as much about his response as he was about the whole incident.

So -- how does one confront or respond to a situation like this?

1. The best response isn’t a response. It’s proactive action. Make it clear from the beginning that your appoint is with a specific doctor. Let the receptionist know that if that doctor’s not available, you want to be notified in order to reschedule. A few days before the appointment, phone and confirm your appointment with your doctor. When you get to the office, confirm the appointment with your doctor. In other words, take control of the situation. Make your personal needs and values clear. Don’t allow yourself to be ambushed.

Savvy medical experts recognize that gender matters in medical encounters. Male and female patients have different ways of communicating, and male and female doctors communicate differently, too, depending upon the gender of their patients.

2. If you haven’t been proactive, and you find yourself in Smith’s position, learn by heart that important four letter word -- STOP. You don’t have to actually say that word -- but your response should make it clear that the direction of the appointment has now changed and you’re leading it. Take charge. For the present, the issue is no longer the exam.

In the scenario described above, there are two issues to deal with, both involving lack of communication and unwarranted assumptions. First, nobody told you about the switch in doctors. It may have been assumed that it didn’t matter to you. The prime responsibility actually should fall upon Dr. Anderson to have seen you were notified. But unless you had made your preferences clear, he may have assumed it didn’t matter to you. Second, it’s just assumed that you have no objection to (or will not object to) a female medical assistant observing your exam.

Let’s go back and look at the initial encounter and imagine a response:

“Hello. I’m Dr. Jones. Sorry, Dr. Anderson is on vacation. I’ll be doing the exam today. Kathy will be assisting me.”

YOUR RESPONSE:

“Oh, I’m sorry to hear that, too. Why wasn’t I informed?”

OR

“I don’t feel comfortable with this situation Let’s talk.”

You may get a sincere apology. You may get indifference. You may get frustration, sarcasm, or even anger. Regardless of the doctor’s response, you should make your disappointment with their communication clear. Right now, the issues is lack of communication, not the exam itself. Indicate that you plan to notify your regular doctor about this incident. At some point, the female doctor may say to you:

“Well, you’re free to cancel and reschedule or we can go ahead with the exam today.” What’s your comfort level? If you received an immediate and sincere apology and you trust this doctor, you may decide to proceed with the exam. Or, you may reschedule

If you allow the exam to continue, there’s a second issue to face -- a female medical assistant chaperone. If you’ve read the two articles about chaperones on this blog, you know that some female doctors feel more comfortable with chaperones, especially with male patients. Make a conscious decision at this point, keeping this in mind. You’re paying for this exam. Your comfort is at the very least as important as the doctors comfort.

“Let’s go ahead with the exam,” you may say. “But I don’t feel comfortable with a chaperone.” See what happens. If a trust relationship has started to develop with you and this doctor, that may be all it will take. She’ll ask he chaperone to leave. If the doctor offers to have the chaperone turn away or stand behind a curtain -- consider how ridiculous that is. A chaperone is a witness, and a witness needs to see as well as hear. Can you imagine a chaperone in court on the witness stand:

“What did you see?”

“I didn’t see anything?

“Why?”

“I couldn’t. I was standing behind a curtain."

If you were on the jury, how much credibility would you give to that witness? I’m not sure why some doctors use this strategy. It doesn’t make sense, unless the chaperone is also supposed to take notes, but that’s another issue. That’s where the concept of efficiency comes in -- how do we balance efficiency issues with your modesty? Even in this situation, you can still state that you don't feel comfortable with anyone else in the room but you and the doctor.

Be prepared for some objections. After all, this is a new doctor. You don’t know each other. There’s no basis for any trust. And you have challenged the status quo. You need to accept the fact that this doctor may now not feel comfortable examining you in private. Of course, that would be as good a reason as any to cancel the exam and reschedule.

With some adaptations, this scenario can be fit may similar situations. Regardless of the specific event, follow a few important principles:

1. Don’t be paranoid. Don’t think everyone’s out to get you. Don’t go looking for a fight. Doctors and nurses are human beings and get busy and have bad days like everyone else. Assume the best about people -- that they have good intentions and want to help you. Having said that…

2. Go into medical situations with your eyes wide open. Have high expectations of your providers -- but be prepared for situations like the one described in this article. Think and plan ahead. How will you react? What are your bottom lines? Don’t expect an “ambush,” but have various plans to deal with them.

3. Learn to read body language, facial expressions and vocal tones. Focus more on those than on the specific behavior. Does your doctor or nurse mean well? Are their intentions in your best interest? Is there real caring behind their actions? You can still state your objections and preferences, but focus on intention.

This becomes especially important when confronted with common expressions caregivers may use in this situation:

“There’s nothing you’ve got that we haven’t seen.”

“We’re all professionals here.”

What’s the tone? The intent? Are the caregivers really trying to put you at ease, trying to make you feel more comfortable? Their strategy may not be working, but that doesn’t mean they don’t care about your modesty. Or, are these statements used to shut down communication and get on with the job? That happens sometimes, too. When you infer that, you need to take control and reframe the entire discussion.

4. Learn to accept an apology, forgive and move on. This doesn’t mean you have to give up your values. Communicate them clearly and civilly. But nobody’s perfect. You’re not, either. If you get an apology, that’s a good sign that you’ve found a good provider. You can count on the fact that, after this encounter, they’ll probably remember your preferences.

5. Even if -- especially if -- the communications gets heated -- maintain control. Be calm and polite. If it turns into a battle, occupy the moral high ground. That’s the most powerful weapon if weapons are needed. If this attitude continues, this is a strong indication that you may need to find new provider. Don’t be bullied.

6. Be reflective and reasonable. Ask yourself if you have contributed to the communication problem. If so, admit it and change your behavior. Be honest. If you have specific modesty preferences and you haven’t communicated them to your provider, they’ll assume whatever may be most convenient them. You and your caregiver may owe each other an apology.

Many of these encounters we refer to as modesty violations are at heart communication issues. As a patient, it's your life, your body. The relationship between you and your providers are partnerships. Take the responsibility for your role in that relationship.

(c) Doug Capra 2010

Privacy ComplaintsWhat to do about them

This article has been chosen for reposting on KevinMD. blog


Few patients enter our health care system prepared for the unexpected and embarrassing circumstances that can routinely happen.  Most can accept it when we’re treated with modesty and respect.  But not many are prepared for those times when you might be unnecessarily exposed or treated rudely.  The possibilities for embarrassment are endless and it is usually unexpected.   When avoidable incidents do happen, most patients are not prepared to speak up.  Many regret their inability to speak at the time of the incident.

In fact it is important to speak up at the time of occurrence if at all possible, or if not, as soon as possible thereafter.  It can often be difficult or impossible to identify the offenders days or weeks after the occurrence.  Situations are most likely to be rectified if they are brought to the immediate attention of the offenders and their superiors.   A common example would be being exposed in an examining room when someone leaves the door open or comes in without warning.  Few patients appreciate that but most don’t say anything.  But if you wait several days to complain, it is likely that the office will not remember who was involved.  Despite your embarrassment, the office personnel may recall nothing unusual; it was just in a day’s work for them and consideration of patient’s privacy doesn’t cross their radar.  In a hospital a common occurrence would be for the patient to be exposed during a bath or procedure with the curtain or door being left open.  The potential is even greater for embarrassment if you’re in a semiprivate room and your roommate has visitors.   Even without exposure, having your history taken in a semiprivate room with or without visitors present may cause you to reveal embarrassing and confidential information.  Once again, if you don’t speak up immediately, it will be difficult to identify the perpetrators later.

It helps to have a clear idea what you want from your protest.  A simple apology is the easiest to obtain and may be all that’s needed.   If you want a clear indication that policies will be changed to prevent re-occurrences of the problem, you will need to go beyond a simple apology and communicate the problem with the physicians or managers in charge.  They may indicate that policy directives will be updated and sent out on their own, but if not you may have to request that they take specific action to correct the problem.

The best course of action to take depends on where the incident occurred.  Usually make the complaint immediately to the person who caused it.  In an office, this could be the physician, nurse or assistant.  If you’re not immediately satisfied with the response, also bring your complaint to the physician in charge.  If the infraction was incidental, a simple apology should be enough.  If the infraction was part of a pattern of behavior, you should notify the physician in charge.  If you don’t complain at once, the next best course is to call or write a letter as soon as possible afterwords.   If the complaint is serious and you remain unsatisfied by the response, the usual next course of action is to lodge a complaint against the physician with the state medical board.  All 50 states have them.  Here is a link to them.  If they don’t handle the complaint themselves, they will tell you where to take it.  All states have a board which investigates complaints against physicians.  In all cases, when a written or electronic complaint is filed, you should keep copies and note that you will send copies to their superiors , or to the state and federal institutions which may have jurisdiction.

In a hospital, again make your displeasure immediately known to the person responsible.   If not satisfied, take your complaint to the head nurse or physician in charge.   Try to get the names of the people involved so that you can pursue the complaint more profitably.  If the complaint is against a specific nurse, you can also complain to the state nursing board.  Again all 50 states have them and will investigate complaints.   State boards are listed here. Most hospitals will deal with complaints against specific personnel internally.  If this doesn’t work, continue up the hospital hierarchy.  Most hospitals have a patient advocate whose job it is to handle complaints.  Start with her, but remember that she still works for the hospital no matter her title.  If still no satisfaction, I would send a letter to the CEO of the hospital.  When formulating complaints against a hospital, it is well to remember that nearly all publish a patient bill of rights which might give you considerable help in outlining your complaint.  If still unsatisfied, you should consider sending a complaint to the state board that regulates and licenses hospitals (I haven’t found one website that lists them for all states.)  Another possibility is sending a complaint to JCAHO, the Joint Commission on Accreditation of Healthcare Organizations, usually now shortened to the Joint Commission.   They are more likely to respond to systemic complaints against a hospital rather than one incident unless there were life threatening implications to the occurrence.

Of other venues to be considered, probably nursing homes are the most common source of complaints.  All states have regulations for nursing homes.  Many also have further laws concerning elder abuse.  Once again, see if the problem can be solved internally in the facility, but if the nursing staff and management won’t help, complaints to the state are appropriate.

Probably the last place to complain is with HIPAA.  They do take patient complaints but they are not oriented towards individual complaints unless it clearly has to do with information transfer.  If say a hospital posted photos of your operation on an instructional site without your permission, it could fall under their purview.  There is no right of private action under federal law though there may be under individual state laws.  Finally you can contact a lawyer at any time but beware that most privacy violations won’t bring large monetary damages.  So do so only if you are really motivated to obtain redress as the attorney bills will be significant.

If you have violations to share or questions to ask, please comment below.