Wednesday, October 20, 2010
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.”
“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
Posted by Doug Capra at 7:17 PM