Wednesday, October 20, 2010


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.

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


Hexanchus said...


Great article, and I agree that the root of many of these type of problems is miscommunication.

That said, in your hypothetical scenario the failure is clearly on the part of the medical office, and several key opportunities were missed that could have avoided the awkward situation.

1. By making an appointment with a specific provider, Dr. Anderson, Mr. Smith was being proactive. In so doing, he and the clinic entered into a verbal contract for an appointment with Dr. Anderson.
2. Assuming the vacation schedule occurred after the original appointment was made (if they already knew of the vacation & made the appointment anyway, that's just plain incompetence), the office should have called Mr. Smith to tell him of the conflict, and ask if another provider would be OK or if he would like to reschedule with Dr. Anderson.
3. When he checked in for his appointment, the receptionist should have confirmed which provider he was there to see - if he was expecting "Anderson" and she said "Jones", it should have been addressed at that point.
4. When the MA took him to the exam room, she should have told him that "Dr. Jones" would be with him shortly - again, another missed opportunity to address the situation.

In your scenario, Mr. Smith was truly blind sided, and not through any fault of his own. The clinic violated their oral contract with the patient by not timely notifying him when the agreed upon material content of the contract changed.

Poor customer service skills may be an issue as you alluded, but what it really comes down to is a lack of common courtesy and respect.

Had it been me in that situation, my response would have been immediate, simple, calm and straightforward: "I'm sorry, but my appointment is with Dr. Anderson, and I should have been notified ahead of time if he wasn't going to be available. I have an established doctor/patient relationship with Dr. Anderson and am comfortable with him. I don't know you, and would prefer to reschedule when he is available."

Something very similar did actually happen to me once, and that's exactly how I handled it.

As to an assistant/MA/chaperone being present for an exam, I simply will not allow it.

Anonymous said...

Thanks, Hexanchus, for your comments. Yes, opportunities were missed all along the way. Yes, it's as much about common courtesy as it is about customer service. But those who speak up are the exception, unfortunately. The result is that, those caregivers who engage in this kind of behavior, constantly and consistently get away with it. After a while it becomes just a habit, a business practice -- not because they dislike people, but because it's good for the bottom line and they think it doesn't matter to their patients. Those patients who do speak up are considered the exception. But they are remembered. It only takes a small number to speak up for caregivers to begin to see the light switch. Whether they ever turn on the light...well, that's the question.

Anonymous said...

another excellent article. Doug I am so impressed, I am through two articles and they are both exceptional. I have had much the same experience. I have found if I take the intative to ask and be proactive I have found providers to be overwhelmingly receptive and helpful. The problem is we expect them to be proactive for our care and its just not thier culture....outstanding...alan

Anonymous said...

alan --

You're so right. We've got to convince men to be proactive and ask and, as you say, most of the time providers will try to accommodate. At the same time, men need to know how to respond when they are treated unfairly and/or with disrespect. But part of the problem is that many men are taken by surprise -- so, we've got to get more men to ask more questions. If you've not had intimate care before, you just don't think about it as part of hospitalization. Some men probably don't even how they would feel in such situations -- or, more likely, take a macho attitude and, with no experience, say they don't care. Then, the find out they do care.

Anonymous said...

I'm a 52 year old male and had my colon removed from F A P polyps. Then while recovering I was examined be the lead surgeon and completly nude with no gown or,any covering at all,my blanket was left pulled to my feet.I was on several pain meds and really was not concerned about much.but I remember it all. T he University surgeon left me completely exposed and lead 5 med students in to my bedside,3 were female.The pointing,whispering between them and their looking at my genitals,became so disturbing,humiliating and when I learned my surgery was watched by a room full of students. I wonder how many nonconsentual exams were performed on me. I was not even presented with consent,or risks of surgery paperwork to sign untilil after receiving relaxing medications. Now 10 years later I have avioded medical frequently,one reason is to avoid exposure humiliation and the insensitive looks and any inappropriate conversations nurses or other female healthcare givers have,maybe to feel like they are in control or for amusement during break,or after work with friends. I had a non-healing abdominal wound for 8 years with reoccuring infections,also I lived with an incisional hernia for 4 years until getting treatment,then it had become 3 hernias. And then I refused surgery to avokd female nurses looking below my waist. Only to learn there were no male nurses in surgery at that hospital. I knew I wouldn'n go through with arranging surgery at another hospital,going through that all again. The doctor went along with me wearing shorts throuought my stay.and all during surgery. And when I told a nurse my modesty concern and that I did not trust them in not looking at private areas while I would be asleep,she promised it would not.happen. I went through with the surgery. Still if I need medical care that requires me under anesthesia again,it will be from an all male team,and the shorts will stay on. That means a new surgeon and a hospital that hires male nurses. It's offensive as female nurses check an abdominal wound by pulling the covers lower than necessary and smiling at what they look at. I know nurses see it all the time and it doesn't ,they say it doesn't mean anything to them. That is not the's how the patient feels,embarrassed.humiliated and offended. I'm sure that if I need surgery again , If I go through with it ,it will be when it gets to the point where I cannot tollerat the problem any longer,as it has always has been with me. even tollerated urinary tract infection for 6 Weeks before making an appointment.

Doug Capra said...

Yes, this is mostly a communication problem. But you've also been proactive in communicating your concerns with providers. I urge you to continue to do that, perhaps even telling them the story you wrote here to impress upon them how that traumatized you. I urge you not to avoid treatment, but to be assertive by expressing your needs and values, even in writing if necessary. I believe you'll be accommodated most of the time. If you feel ignored or disrespected, make that know in writing to those in charge and find another provider.
Patients need to be assertive, like you have been, and communicate with the medical system.

Anonymous said...

Anonymous,following the hernia and nonhealing wound surgeries I had two Weeks of coughing and sneezing. Now I am sure I may have torn the stitching to the mesh loose,I have more discomfort in the surgery area than I had before my surgery.It makes me feel that everything I went through was a waste of time and effort. The way I feel about going through all that again to take care of the same problem...not a chance.I'm so against another surgery with caregivers,especially female nurses,techs and scrubs. Someone close to me has admitted to me that she is worried that I act like I am tired of living. I have had 82 medical appointments and too many medical errors.I have little trust in doctors and nurses. After discussing the poor medical care I've received in the past 10 years ,my case manager said it would be very unlikely for that many medical errors to be accidental...that means at least some were intentional ? Then after my case manager dealt with another of my medical quality of care complaints,she told me''You can expect problems like that with all your appointments.'' Making another doctor appointment , something to avoid.

Anonymous said...

Recently my husband had abdominal hernia surgery,he's han many surgeries relateto F A P complications and avoidable medical mistakes,mrsa aquired 3 times in hospitals. He's very much opposed to female nurses and any other females seeing his private areas,never has been in public with his shirt off. Keeps to himself a lot and social skills are a weak point for him. He has been wrongly completely exposed to female nurses and students in hospitals. He is bothered by it a lot and as time goes on ,he feels increasingly humiliated. Anyway he asked for only males in the room during his hernia surgery, The nurze told him there were no male nurses in surgery there.she promised him his request to keep his shorts on would be ok.Maybe they left them on,maybe they didn't . My husband shaved the area good before the appointment but the nurze wanted him shaved on part of his chest too.I know he would have much prefered shaving himself, Hshaved prior going to the hospital to avoid a female doing it. He never thought of asking her to let him do the shaving on his chest. She done it and I think it pushed him even further away. He is finding it impossible to find more medical care he needs .Since he says,only male nurses,scrubs and doctors. Hospitals can't grant that for him. He won't make further appointments,and he needs to. I see how women in hospitals have for the most part unintentionally embarrassed him so many times. He drinks to forget the memories. Avoids people and things he use to enjoy. Even a major hospital in Indianapolis has no male nurses,now he won't make an appointment there either. He can be very stubborn, he's only preventing more humiliation. It effects him worse over time. But he seems closer to being content when he is alone having nothing to do with anyone. Hospitals still ignore patient's if there is definite need for same gender care. My husband is not gay either,as some may think wben they try to think of,reasons he doesn't want any more care from ladies working in hospitals and doctor offices.Even our marriage is suffering a lot as he now sleeps in a seperate room from me. The only way I could get him to go through with the last surgery was to say I would leave him if he didn't get it taken care .Now he says ,next time I say that, he is leaving me. Hope he finds a hospital with what he wants.Maybe his medical problems wont get to the point that he needs to go to a doctor.

Joel Sherman MD said...

FAP (familial adenomatous polyposis) is a serious disease with many ramifications that requires long term follow up. If he has had a total colectomy with all that it entails, he likely needs lots of support, any way he can get it. Hope you can mutually arrange for it.

I'm surprised that any large city hospital can say that they have no male OR nurses. They are common. Have you looked into other hospitals in the area?

Anonymous said...

It's very clear that looking for all male procedure and surgical teams is a waste of effort to avoid medical humiliation,embarrassment,inapprppriate genital viewing. I've tried and it's not possible to find a hospital to have am all male surgery team.It seems trivial to the caregivers I've made the request to. What about their impressive websites promising,''The patient is our #1 priority.'' Is that true ,or does it exclude doing everything possible to improve patient care ? Keep in mind that some patients refuse and avoid lifesaving medical care to avoid the humiliation of a stranger of the opposite sex freely able to see ,touch and talk about their private areas. Even if we are under anesthesia,we know it happens.

Anonymous said...

W H Y This is my last posting, I'm annonamyous and have posted as a patient with f a p disease...I have reported so many complaints to my insurance provider, so many that it was obvious that I have been blacklisted. Earlier on a posting I spoke of working with a medical case manager assigned to me , to help me with improving my healthcare . After a lengthy discussion about having far too many medical errors and careless , potentially lethal mistakes made in my care at hospitals. And after she helpped me with Billing and authorization code mix-ups from my most recent surgery...she admitted to me that I have had a lot of trouble with my care. Then she said,''Well,you can expect mistakes with all your appointments.'' Everything turned hopeless and then I realized I would not be calling her again. She even said that I couldn't have that many problems accidently. Soon I began suspecting doctors,nurses and technicians of deliberately making errors with my care. I looked extensively on the internet and soon realized blacklisted patients are at times , given very poor care , delayed in receiving critically needed care while doctors stand by and obsurve the unnecessary,preventable suffering and pain. Then I entered'' Nurses that deliberately poison patients'' in my computer search ...and found dozens of convictions of nurses reusing disposable needles on patients. A nurse substituted muscle relaxing drugs in place of saline solution,killing infants and children in the hospital she worked in. A nurse was convicted of innecting elderly patients with bleach. Another nurse confessed to poisoning patients to free up beds for more patients....The horrors are listed in such numbers ,involving hundreds and thousands of pelpless patients dying ''murdered'' by nurses in hospitals. How many times have nurses deliberately killed patients... and never been caught ? THIS IS NOT HEALTHCARE. And how can any patient know if their nurse is giving them a needed medication or givind them a needlefull of bleach. I even read of patients being injected with needles contaminated with HIV and hepatitis b and c. From all this , healthcare is just far too risky. The trust is gone. How can any hospital administration say that their nurses are never giong to do anything to deliberately harm or kill a patient ?

watchman said...

This is an interesting topic because it involves feelings that can run from one extreme to the other---depending on the person. Some males certainly are very sensitive, modest and even threatened by medical procedures involving their nudity/privacy and a female staff member---I get it. I am older (65) and have noticed something of a change in male attitudes over the years. When I was a teen, locker room nudity was just part of the program---- whereas now I see many boys and men that shower with their swimsuits on or don't shower at all or dress in a protected area---that's ok. To me, though, sports and medical nudity is part of life and I'm not sure why we should be threatened by it. Surely there are a plethora of more uncomfortable things we must deal with. Then again, personal insecurity, rigid upbringing, religious dogma, etc. can and do come into play---I understand completely. So, I would just have to say that I feel fortunate not to be hung up on this issue--- generally I react to my own experiences with a sense of humor. For example, every so often I require a steroid injection in my lower back. This means I will have to lie on a table on my stomach with my lower back and upper glutes exposed. The first time I had it done, the young female radiologist exposed just a minimal area of my lower back and hips. Recently, the second time, a different female radiologist casually whipped my shorts down to upper thigh level---leaving my bum totally exposed while she got ready to prep the area. Other female nurses came and went from the room while I was lying there. One said "Oh, sorry" the others said nothing. Quite honestly, I saw nothing wrong with the situation. Inside, I was dying laughing about it. These young gals were doing their job---- what your body looks like is not the issue----they see it all. What they think of my body does not concern me. Anyway, for some, I suppose the best thing to do is make your concerns known ahead of time. Either that or try to change your mindset. This having been said, I stand in judgment of no one. It is simply something we men have to come to grips with as best we can.