Wednesday, August 25, 2010

Male Modesty

Male modesty is a subject that’s generally ignored in our society.  Very little documentation is available to even discuss it intelligently.  I know physicians who believe that their male patients are more modest than the ladies, yet almost nothing is written about this.  To be clear, let me clarify that I am talking about modesty concerning ones own body.  A  recent study has touted that male modesty is looked down upon by society, but they were referring to the trait of humility or a perceived absence of aggressiveness, especially in the business world.  But medical modesty isn’t respected either.  What percentage of men are modest in a medical situation?  It would perhaps be clearer to ask a similar question, what percentage of men are embarrassed by being exposed in a medical situation?  I would guess that over half are, but it is rarely a subject for discussion.

Is this any different from the situation that women face?  There is no doubt that exposure in medical settings is common for both male and female patients.  On the whole though, the medical establishment is far more sensitive to female modesty than to male modesty.  Examples can be found on the other blog.  One poster related that he had a testicular ultrasound done by a female technician.  As he was leaving, the tech told a waiting woman that her ultrasound was to be done by a male technician, but she could wait until the women tech was again free.  No such courtesy was offered to the male patient.  Obviously men are at a disadvantage in that medical personnel outside of physicians are overwhelmingly female.  But little attempt is made to offer gender choice to men when available.  Even in most Urology offices, men are given no choice of personnel for intimate procedures.  I once questioned my urologist about this.  He freely admitted that many men are clearly embarrassed when a woman assists on a urologic procedure.  He even observed that the embarrassment was more pronounced when the assistant was a young woman.  When I asked why they didn’t hire men, he explained only that they couldn’t find any to hire.  Clearly though the practice had made no concerted effort to hire men.

The concept of medical modesty also needs to be amplified to include respect as they go hand in hand.  As an example, I would be angry about being given a gown open in the back and paraded in the hall.  I personally would not be that embarrassed, but I would be angry about being treated with so little respect that no one thought to close the gown in back.  When exposure is necessary, respectful care with thorough explanations can frequently make a patient comfortable with embarrassing situations.  It is vital that the patients’ feelings be taken into account whenever possible.  For many patients, both men and women, the loss of independence is the most embarrassing part of the situation.  That is a much bigger factor for men though.

We need to be clear that not all men prefer male assistants for medical procedures.  At least 10-20% prefer women and many more will accept either gender.  The reasons why some men prefer female nurses or techs vary.    Some believe that a woman’s touch is gentler, others are homophobic, and still others have a sexual fetish about being treated by women.  Some are childhood victims of sexual assault, usually committed by a man.  This is a very significant segment which is poorly acknowledged.   Best estimates are that boys are assaulted at 25-50% of the rate that girls are  (Finkelhor, Current Information on the Scope and Nature of Child Sexual Abuse, The Future of Children, Summer Fall 1994).  No matter the reason for a preference, patients should be given a choice whenever possible.

Another very important variable is age.  Adolescents are far more subject to embarrassment than mature adults.  I’ve seen it estimated that 90% of adolescent girls prefer a female gynecologist.  The analogous figure is less for boys as many are used to female pediatricians.  Still it is a major factor.  It should be assumed that an adolescent is embarrassed by exposure.  Any necessary exposure should be done as discreetly as possible.  Chaperones should be only used when necessary and desired by the patient, and priority should be given to same sex chaperones, which almost never happens for boys.

Why do we hear so little about male modesty?  It’s hard to say.  First of all, men are much less likely to protest than women are.  It’s just not macho to be complaining about the presence of women, whereas the reverse situation is much more acceptable.  Nurses are taught in training to respect a patient’s modesty.  In this regard, they are better trained than doctors.  I think any female nurse would tell you that many of her male patients are embarrassed when they have to give intimate care.   Yet it is rare indeed that they would offer to find a male nurse.  The reverse situation is not rare by the way.  Many male nurses will offer to find a female nurse to provide intimate care for their female patients.  Numbers are against men here, but there may be other factors.  Some nurses just get jaded and want to do their job and get on with it.  Others will tell you that the men prefer female nurses.  But most men either don’t care or would prefer a male for intimate care.  The nurses don’t ask, so they can’t know how any individual would feel about this.   Some nurses may be reluctant to admit that there is a need for more male nurses.

These issues are important.  Men seek far less medical care than women and die younger.  The reasons for this are poorly studied, but clearly a very significant part of this is that men are too embarrassed to seek care.  It’s common to see occasional advertisements offering screening exams for prostate cancer which are totally run by female nurses.  One can’t even imagine the analogous situation, a breast screening program totally run by men.  Is it any wonder that many men are turned off by this?  The majority of hospitals and cities have clinics and practices that specialize in women’s health.  They are nearly always run solely by women.  It is rare to find a men’s clinic anywhere.  Even Urology clinics don’t make men feel comfortable.  You might have to explain your potency difficulties to the young woman at the front desk.

More information is urgently needed to know how to deal with these problems.  Please add your comments.  Further discussion on this topic can be found at the discussion blog.

Thursday, August 19, 2010

15 Secrets Your Patients Won't Tell You


by Doug Capra © 2010

Earlier this year, Reader's Digest published an article titled "41 Secrets Your Doctor Would Never Share." The article had some interesting insights. All patients should read it. Certainly, it's good to know what's on doctors' and nurses" minds, thoughts they won't say out loud to us. But from my perception, some of these thoughts, or perhaps it's the way they phrase them, seem presumptuous, even paternalistic. How about the chiropractor from Atlanta who writes: "I was told in school to put a patient in a gown when he isn't listening or cooperating. It casts him in a position of subservience." That's a good piece of information for a patient to possess.

Perhaps it’s time for patients to speak up and reveal some “secrets” they don’t often tell their caregivers, and the reasons why. Perhaps it's about time doctors, nurses and patients start really talking with each other -- talking about those "elephant in the room" subjects that tip toe with heavy thuds through hospitals and clinics.

Sometimes, a deep chasm seems to separate patients from their caregivers in our suffering health care system. Both caregivers and patients have a role in bridging this gap. But, as Dr. David H. Newman writes in his book, Hippocrates’ Shadow, “…there is a phenomenon within the culture of modern medicine that guarantees the widening of this patient-doctor chasm."

What is this phenomenon? “Secrecy,” Newman claims. “Doctors have secrets, and we have lots of them.” The culture of hospitals and clinics is quite mysterious to many patients.

Newman hopes, and I agree with him, that acknowledging these elephants in the room is essential for more healthy and open relationships between doctors, nurses and patients. He has great respect of his profession; for, the essence of medicine, he writes, is a “profoundly human, beautifully flawed, and occasionally triumphant endeavor.”

But then there’s the other side: “The truth is,” he writes, “the real secrets of modern medicine are protected by tradition, group-think, and system constructs that punish inquiry and self-examination. They are embedded in the presumptions and thought patterns that we are taught to embrace during our indoctrination and on which we come to rely. They originate at the highest levels and trickle down; physicians are often merely bit players in a systemic – and systematic – dishonesty stemming from these secrets. These are the secrets and lies that shape the practice of modern medicine.”

I embrace his primary solution to this problem. Better communication. Getting these “secrets” out in the open. So…doctors, nurses, various assistants and tech’s – Let’s communicate.

If you’re a doctor or nurse reading this article, it may anger you. You may not agree with some of what’s here. But I can assure you that the thoughts I’ve listed below are on the minds of a significant number of your patients. And most won’t tell you what’s written here, unless you gain their trust, give them your time, and open your hearts to their feelings and what’s really on their minds.

Talk with us.

  1. If we made an appointment with you, we trust you. We may not feel comfortable telling the most intimate details of our private lives or revealing our naked bodies to your unlicensed medical assistants or even your licensed nurses or their assistant. On the other hand, if we’ve developed a relationship with them as well as with you, we may be just fine. Talk with us.
  1. Get rid of your paper and flimsy cloth gowns. Get some that really cover your patients. Better than that – find alternatives to gowns when possible and let patients know about those alternatives. If you do tell us to put on a gown, be specific about whether we can keep any underclothing on. Unless it’s obvious, don’t assume we know exactly what you want. Talk with us.
  1. We’re scared. Actually, hospitals and clinics intimidate some of us. It’s like a different world. Some of us don’t even understand the language. When you ask us questions, we won’t consciously lie to you, but we may not be thinking straight. Look us in the eye and try to read our emotional state. Talk with us.
  1. If you’re a male and we’re a female, we may neither feel comfortable talking with you about intimate matters nor with you examining us in an intimate way. Unless we specifically chose you as a caregiver, ask if we’d prefer a female to do the procedure or exam. The same goes for male patients who prefer same gender care. People have different values. We know. To some of you, there are no male or female doctors or nurses, only doctors and nurses. You’ve been taught that your world is gender neutral, that it doesn’t or shouldn’t matter. Maybe that’s true in a perfect world. But the world we both really live in is not gender neutral when it comes to the most intimate parts of our bodies. You see naked patients every day. To you it may not matter anymore. To some patients it does matters – and it’s not up to you to judge their personal values. Don’t take this personally. It doesn’t mean we never want a male or a female to take care of us. It doesn’t mean we hate men or women. Our choice may depend upon how intimate the exam may be. Respect that choice. Walk in our shoes. Consider what your personal gender preferences might be for intimate procedures. Consider how you would want your mother or father, brother or sister, son our daughter treated. Talk with us.
  1. Let’s talk about men. Some men have problems with their perception of how their modesty is treated by some in the medical community. Many of these men will not speak up and tell you what they prefer – which would be for same gender intimate care. They may appear arrogant, angry, sarcastic, silent or compliant. Speaking up and asking for same gender care is as or more embarrassing or humiliating to them than as is having a female nurse or technician conduct an intimate procedure. You can say, “Oh, they’ll get over it.” But many won’t. They take these unresolved negative feelings home from the hospital with them, and it influences their attitude toward medical care and the system in general. They may feel their dignity hasn’t been respected. “How dare they!” you may be thinking. “I treated them with dignity.” Were they asked about their preferences? Did they get a chance to define their dignity, or did you define it for them? Talk with us.
  1. If you need a chaperone, don’t pretend it’s only for your patient’s comfort. Acknowledge that it’s for your own protection. In our culture, there’s no denying that this may be necessary. But be upfront about it. Many man are unexpectedly faced with a female doctor who then brings in a female nurse or assistant as a chaperone. How often does a male doctor bring in a male nurse or assistant as a chaperone when conducting an intimate exam with a female patient? This is a double standard that needs to be changed. Does your hospital or clinic have a written chaperone policy? Does it insure that patients will be asked if they want a chaperone? Does it insure that same gender chaperones will always be offered? Many studies show that most men don’t want chaperones regardless of the caregiver’s gender. They don’t want an audience. The same is true for some women. Always ask and respect those choices. Talk with us.
  1. We like you and trust you, but some of your staff may be distant, rude and/or unfriendly. We may not feel comfortable telling you this, but you’re responsible for their behavior. If we suddenly stop using you as a provider, or request another caregiver, you may never know why. So why not find a way to make us feel comfortable giving you this valuable feedback. Talk with us.
  1. “Privacy” doesn’t just refer to paperwork and speech. It also refers to patient respect and dignity – and that involves how we feel about our bodies. Drape patients properly, keep doors and curtains closed, don’t “pop in” when another caregiver is working intimately with a patient. Always ask permission (when patients are fully dressed) to bring in a student or observer, especially when intimate exams or procedures are involved. We know – you’ve done this a million times, and “seen it all.” But it’s the first time for some of your patients. Talk with us.
  1. Don’t tell us how many other patients you have or how busy you are. That may certainly be true. And if you’re in a rush, don’t be obvious about it or tell us. When we’re naked, perhaps frightened, vulnerable and sick, we don’t want to hear that. At that moment, the moment we’re in your hands, as far as we’re concerned, we’re your only patient. And we expect you to treat us that way. Talk with us.
  1. Even if we have a valid request or complaint, we may be afraid to state it. Why? Because we may be afraid that you may take it the wrong way, label us as a “bad” patient – and that may negatively affect our care. We realize you may find this absurd or even insulting, and we’re not saying this feeling is necessarily rational. But just because feelings aren’t always rational doesn’t mean we don’t feel that way. So, don’t tell us we don’t feel that way. Respect our feelings and prove to us wrong. Talk with us.
  1. Most of us want to be good patients. We understand about being polite, respectful and not overly demanding. But hospitals operate under all kinds of “under the radar rules” that are unknown to inexperienced patients. There are many “elephants” stomping around in hospital rooms. You live with those unspoken rules day after day, month after month, year after year. You know them by heart. We don’t, and we’re not given a list of them upon admission. Most of the time, you don’t tell us. You expect us to figure them out. Talk with us.
  1. Be careful about using the following expressions in response to patient requests: “Don’t be silly.” -- “I do this all the time. You don’t have anything I haven’t seen before.” -- “We’re all professionals here.” You may have good intentions, but these may seem insulting and disrespectful to some of us. These kinds of expressions are not meant to open up discussion. They’re designed to shut down communication. If you use one of these expressions, and your patient shuts down, don’t assume everything is just fine. We know. You’re busy. But we don’t see ourselves as just another “job” to get done so you can move on to the next one. Talk with us.
  1. We know. You sometimes need to vent. But be very careful. Venting used to be mostly done behind closed doors, whispered in break rooms and over lunch among professionals. Now it’s become more public – blogs, Facebook, at parties, in corridors – sometimes even within patients’ hearing. Don’t underestimate how this public venting can damage the credibility of your profession and destroy patient trust. And remember, patients sometimes need to vent, too. Talk with us.
  1. We know. You know what it’s like to be a patient. Some of you have been hospitalized before. But you’re missing an important point. You don’t know what it’s like to be a patient who doesn’t know what you know about medicine –a patient who doesn’t understand the culture of a hospital, who doesn’t speak the language, a patient without any medical training at all who has rarely or never been hospitalized. You may have known that point of view before you became a doctor or nurse. But you can’t unlearn what you know now. You’ll never see being a patient the same way again. Try to recall how you felt way back then. Talk with us.
  1. Don’t forget -- You have the primary responsibility to open up communication with us. Sometimes we’re tired, frightened, vulnerable, naked, intimidated. Often we won’t say anything, even if we feel uncomfortable, embarrassed or humiliated. Sometimes we’re just too tired and exhausted to fight with you. Don’t assume that everything’s okay just because we don’t speak up. I realize that this may be risky business for you. Asking a question might get you an answer that you don’t like or want. You may know the answer but not want to really hear it. But do ask. Communicate. Talk with us.
Realize that at heart most of us do trust and respect you. We put our lives in your hands everyday. We make incredible leaps of faith. We know we don’t know more than you do about the science of medicine. But we do know our own bodies and our own values – and many of us want to have a critical role in the details of our care. We can bridge this chasm between patients and our health care system.

Talk with us.

NOTE -- I've tried to summarize my ideas within 15 items. What are some other thoughts you as patients would like to tell doctors and nurses (and CNA's and medical techs) that you hesitate to mention? Let's hear from the patient perspective.