Monday, December 5, 2011

Nursing Violations of Patient Privacy
by Doug Capra & Joel Sherman

Nursing history emerged from a tradition of nurses as angels of mercy, selflessly devoting their working hours to care of patients.  Although modern nurses don’t like to view themselves that way, there is much truth to that image, even today.  We would trust our care to the large majority of nurses we have known.  But like all stories, there is another side to it.
Physicians have been criticized for releasing too much patient information on their blogs.  Nurses do the same. claims to be the largest online nursing community with over half a million members, the vast majority of whom are undoubtedly active nurses though membership is not restricted.    A recent thread on  reveals many disturbing anecdotes.   The thread is called “Nine things nurses don’t want you to know.”  The first item is: “Yeah, we look......and no, we're not above whispering to our co-workers, "Psst! Did you get a peek at the guy with the foot-long whatsis in 216?"   Now the poster said after being challenged that this was a tongue in cheek comment, but other posters in this thread make it clear that similar incidents do happen.  Although a few do condemn this as being a serious infraction (probably many more than posted that point of view), still too many seem to consider this behavior just part of the culture.  
Comments include a poster who said that she might not comment upon a man’s body parts but knows nurses who do.  Another said nurses have always engaged in shop talk and always will, but added that it’s reasonable as long as it is not done in public.  After a protest, the original poster commented that it may not be nice to discuss the anatomy of a patient over coffee, such as the guy who needs an extra long Foley, but it happens and it doesn’t help to get upset over it.  Another poster recounted having a pre-op woman up in stirrups, and people coming in to view her shark tattoo between her legs.  She doesn’t say whether the patient was under anesthesia at the time though that is likely.
In this long thread there were initially no complaints registered but slowly a negative reaction occurred, mostly from posters who are probably not nurses. Two posters challenged the female nurses to consider how they would have reacted had a male nurse written a similar statement about female patient body parts. Others warned that is not a private blog, but goes all over the web and is read by some who look for just such evidence to condemn nurses.
To be fair, a few nurses commented that anything like the first item (the foot long whatsis) had never occurred in their career.   We believe both of them.  Incidents like this are very individual; they may occur on one floor of a hospital and never in another.   It only needs one person to offend.  We have never been made aware of an incident like this, but it’s unlikely any nurse would confide this to a physician.  What perhaps is most disturbing about this thread is that very few people would be willing to criticize their fellow nurses for actions like this, not to mention report them. This demonstrates a very unhealthy culture of silence at some hospitals where nurses and nurse assistances fear retaliation for reporting incidents like this. It is further reinforced by a recent thread on allnurses titled “And it’s all going to be your fault."  Look below this post to see how many nurses agree with this view. In some hospitals, nurses feel they are at the bottom of the pecking order and are scapegoats for whatever goes wrong. They fear any challenge to the powers above.
These gross violations of privacy described in the original post titled “Nine Things” are against the law, but they are not covered specifically by HIPAA.  We don’t think the feds have ever brought an action against providers for physical encounters or oral breaches of privacy, though oral transfers of protected health information are covered.  HIPAA is almost all centered on digital and printed information protection, not on personal encounters.  Yet likely all states have laws regarding personal privacy in healthcare that would cover it.  Certainly taking an unnecessary peek at a patient’s genitals is considered sexual misconduct which could result in the loss of license in every state. 
There is reluctance in every profession to report one’s comrades.  This happens with physicians as well as nurses.  A New Mexico otolaryngologist, Dr. Twana Sparks, was disciplined by the state board following years of operating room misconduct wherein she would fondle the genitals of male patients under anesthesia in the presence of the OR staff, making derogatory comments about the patients.  The hospital was aware of this and did nothing until one nurse filed a formal complaint.   For years the hospital laughed off the incidents.   There have of course been many incidents over the years against male physicians though there is perhaps less reluctance to lodge complaints against men for sexual misconduct.
In the initial ‘Nine things’ thread, some patients commented that they avoid medical care because they’d get demeaned because of their obesity.   It’s not uncommon on allnurses to read what are called “rants” about obese or otherwise stigmatized patients. This is not to say there are not “difficult” patients who can be rude and overbearing. But some of these rants offer no benefit to the vast majority of nurses who treat patients with respect not only in the hospital room, but also in the break room. It’s hard to reassure anyone that their fears are unwarranted, especially if they have an unusual anatomy or disability. 
It’s astounding to us that so few nurses looked upon divulging prurient tidbits about identified patients as a serious infraction.  They seem to think that as long as it stayed on the floor or in the coffee room it was business as usual.   It is widely accepted now that no information should be divulged unless there is a need to know.  Regulations mandate that all hospital staff must be instructed on patient privacy concerns.  It seems like they do a very poor job of it.  JCAHO should mandate reforms.

Tuesday, October 25, 2011

Modesty, A Woman's Perspective
by Nicole Lee

From their website.  Click on to read.
Nicole Lee is the creative director of Stirrups and Stories.   She has worked in the area of sexual and reproductive health for over five years: taking sexual histories, training others to do the same, working in HIV prevention, and providing quality control for clinic and agency management.

The word “modesty” is loaded with too much emotional and cultural connotative meaning to be a neutral concept.  Who is saying the word, and how, and to whom, and for what purpose?  Is “immodesty,” with all of its attendant frightful connotations, the shadow defining the edges of modesty?

In the context of health care provision, modesty is a double-edged ideal:  on one hand, respecting patient-initiated modesty enhances our ability to serve patients.  Some of the ways we do this include:  acknowledging and responding to the cues our patient gives us about her level of comfort; by asking for permission and consent before touching her; by echoing the language she uses; by avoiding unnecessary, invasive procedures; by acknowledging the legitimacy of her family structure.  We do this by listening – and hearing – what she is saying to us.  By explaining in language she understands why we are asking intrusive questions, and working with her to procure the necessary information.  By respecting a denial of consent and fully honoring the process of informed consent.  By seeking training on cultural competency specific to the populations we see.    

Such a type of respect requires our acknowledgement of the wholeness of the patient in front of us, including the soul and the heart that embraces that modesty.  No longer is she a composite of parts and organs and symptoms, a medical puzzle waiting for construction (or deconstruction):  her embodied self is not our disembodied medical task.  When we as health care workers are respecting a woman’s own sense of modesty, we are helping to make more visible the value system in which she functions.  Significantly, that value system is fundamental to the context in which our palliatives, prevention, and education must succeed, and is a potentially key part in identifying pathogens or risk.

On the other hand, if a health care worker or policymaker enforces modesty, the relationship between patient and provider is inhibited.  Such a dynamic can silence a patient, leaving health care workers without knowledge that may prove vital to providing care for a given woman. 

The enforcement of modesty is rarely overt, but instead typically a thoughtless perpetuation of a set of cultural norms that liken immodesty to being unladylike.  It provides a prescription of acceptable behaviors and appearances for women to assume, and defines the dimensions of space women are allowed to occupy.

Is it immodest and unladylike for a woman to disclose the number of sexual partners she has had?  To choose not to shave any particular body part?  To use abrupt or rough language to describe her experiences?  To talk openly and unashamedly about her partner(s), who may be of the same sex?  To speak of her abortion with sadness and no shame, or with no sadness at all? 

Is it unladylike for a woman to challenge our authority as medical care providers?

Women are faced with a variety of messages that often boil down to one – the feminine ideal is to be a lady, so avoid an immodest exposure of self.

Are our offices spaces where women can expose the necessary parts of themselves without fear of sanction?

If they are not safe because we (or our staff) judge our female patients for not abiding by the standards that we, possibly unconsciously, have for women, it is nearly impossible to conceal.  Our biases are conveyed in a plethora of ways both subtle and overt, including how we ask questions (and which questions we choose not to ask), our body language, our double standards for men and women.

Conversely, by ignoring a woman’s own unique modesty and sensibilities, we are imposing on her an authoritarian message of subservience and disrespect.  Without thinking, we risk telling her that “her body is ours” and that she has given up certain rights merely by seeking health care.  This encourages a retreat from visibility for many women and a reduced ability to successfully communicate with her health care provider.

What and how we communicate, and how we receive information given, can contribute to a woman’s reluctance to seek prevention or cure for any number of health concerns.
By respecting her values and that which she chooses to conceal or protect, we are inviting her to reveal more of herself to us.  In that exposure is the human for whom we are charged with caring, and in this new relationship is the true potential for health and healing.

By refraining from imposing our own values of modesty on our patients, we open up the possibility to clearly see our patient in her own context.  In that exercise of self-awareness and self-restraint, we lay the groundwork for a respectful and deeply therapeutic relationship with her.

The narrow channel between what we subscribe to and what we prescribe for others is a tricky space to navigate, but that is exactly what we must do. 

Wednesday, October 5, 2011

Feathered Boas and Your Dignity

It is our pleasure to introduce Steven Z. Kussin, M.D. to our blog. He is the author of, Doctor, Your Patient Will See You Now: Gaining the Upper Hand in Your Medical Care, (2011) published by Rowman & Littlefield. Dr. Kussin was a practicing physician in New York for more than thirty years. He has published several journal articles, and has taught at Albert Einstein Medical College and Columbia College of Physicians and Surgeons. He has founded The Shared Decision Center, one of the only free standing independent community based Shared Decision Centers in the country. Dr. Kussin blogs at

Feathered Boas and Your Dignity
by Steven Z. Kussin, M.D.

“In war, truth is the first casualty.” (Aeschylus, celebrated Greek dramatist)
“In medical care, dignity is the first casualty.” (Kussin, unknown American physician)
Whether critically ill in the hospital, or fit as a fiddle in a doctor’s office, an individual’s dignity is an issue dear to me because of a memory. The memory of a mentor. Doctors learn from journals and texts. The best of us also learn from mentors. Rivaling only the military, medicine is a highly hierarchical system. When young doctors find a senior physician who has fulfilled the dreams of how we someday wish to be and be seen, they become our mentors. These role models, properly chosen, can influence not only our knowledge but our attitudes. Most doctors will identify only one or two whose impact is so significant, that their lessons are destined to last a life time. One of my mentors left a circle of young physicians in awe of his knowledge and in shock in the wake of his death. We all knew he had cancer and was to die. But to me, it was his treatment near death that left the lasting message.
During his final hospitalization, I entered his room often finding him fully exposed. His gown thrown aside and with sheets askew he lay there for all to see. Dementia had claimed the mind all were in thrall of. I spoke with the staff and his doctors. Could we close the door? Could we pull the drapes? Could we secure his gown beyond his ability to remove it? Apparently not. So, a cadre of his acolytes, including me, guarded him during his final days.
And so it is today. So let’s talk a bit about your dignity, privacy and how it is so casually and gratuitously subtracted from your care. You may need your own night’s Knights Templar when you are stricken. Neither your family nor your doctors should restrain you physically or chemically when you already have enough to deal with. To maintain the dignity you will surely lose, you need what, in my book, I have called ‘Designated Sitters’. Family who are constant and consistently present. To protect your body from soulless comments delivered in your ‘absence’ demands their help.
But how about when you are well? Gowns that are side tied (available at your hospital supply store or on line) prevent the world from regaling in either of your nethers. Better yet, bring your own PJs and robe.
You should demand a private room because they are, well, private. Privacy is where dignity starts. Privacy increases the quality of your consultations. The bonus is the possibility of entering your doctors’ circle of empathy. Your doctors would prefer death to a semi-private room. When you are bivouacked in a private room, your domain becomes bespoke. Fill it with photos of you when you were your doctors’ age and litter the room with upscale magazines. Architectural Digest or even the Robb Report comes to mind. Let them see themselves in you. Being stared at, jaw agape, by your providers, let alone the ten year old guest of your roommate just adds to your woes.
And the physical examination? Enter the pictured feathered boas. How can it be when physical examinations are almost a relic of the past you nonetheless find yourself with your sundry body parts needlessly defying gravity, dangling in front of your providers? Breasts, gonads and penises swinging free for all to see. Well it’s precisely because physical exams are a lost art that you get to show your parts. Back in the day, boa dancers could remain fully demure even when they had nothing but diaphanous throws to throw about their bodies. The art of using examination sheets as skillfully as boas is a rarely used remnant of a lost medical culture. Moving these drapes down the torso artfully and gracefully leaves nothing unseen, while paradoxically, leaving nothing revealed.
“Strip to your underwear. Leave your socks on.”
Why, is there something wrong with my feet? And I refer to both the modern and biblical use of the word feet. Cotton gowns that are clean only by inference and as threadbare as dishrags do you no service. Paper contrivances that, when you sit, bend or recline, ride up and down like a roller coaster prevent any attempt at preserving your status much less hiding your quo.
What to do? What to say?
“Doctor, right at this moment, if I was examining you I’d make sure I’d be seeing a lot less of you than you are seeing of me. Can you spare a drape? Thanks.”
It’s kind of funny, kind of pointed and kind of you too. Let the doctor know that you are being dissed and dismissed by being needlessly and carelessly revealed.
Will you say that? Wait, you’ll find out the next time it happens. When is your next appointment?

Thursday, September 1, 2011

Privacy & Reporters in Locker Rooms
A Physician’s View

Ines Sainz  Sports Reporter
This subject is not medical privacy per se, but it is likely the most egregious violation of personal privacy that our society sanctions and indeed encourages.  As a privacy advocate, I feel that the subject needs to be reviewed with all sides heard.  Certainly the whole topic is never discussed openly on news or sports channels unless there has been a new incident and the athletes’ case for privacy is rarely then explored.   Our present policy of allowing all reporters into locker rooms while the men are showering and changing sets a standard, a very low standard, for the rest of society.   Women reporters sometimes justify their forays into male locker rooms by comparing themselves with female physicians.   This ignores the differences.  All physicians have trained for many years and are sworn to protect and uphold their patients’ privacy.  They have a license to lose if they violate their oaths.  Reporters are under no privacy obligation, may have little training, and are not licensed.  Training is also lacking for the assistants who enter the locker room with the reporters, especially the photographers.  Thus there is no comparison between physicians and reporters as it concerns protecting privacy.  In fact much of reporters’ jobs consist of violating privacy; an extreme example is the UK’s scandal with Murdoch’s News of the World.   Medicine routinely protects their patients’ privacy even in locker rooms.  It is my understanding that the training/medical areas of professional locker rooms are usually off limits to reporters.   Medical standards of privacy far surpass anything in sports.

But there is a larger legal question as well.  In locker rooms, prisons, and healthcare equal employment rights have generally been held to trump privacy rights.  This is especially true when it’s women’s employment rights versus male privacy.  The laws work both ways in theory, but they often aren’t applied equally.  In medicine, some courts have held that male nurses can be excluded from labor and delivery.  In urology clinics no one has even suggested that male nurses and assistants should be given preference, let alone that female nurses could be excluded.  This is despite the fact that lots of men are embarrassed by the presence of women assisting on intimate procedures.  The situation is confounded by the reluctance of men to complain; it is not macho to be modest or embarrassed.  That of course is especially true in professional sports locker rooms where testosterone rules.

Let me say at the outset, I support women’s right to equal access to athletes and it is the accepted law in this country.  I’m against it being accomplished at the expense of athletes.  Women did not devise this system, but the leagues and their owners remain far more concerned with maximum publicity and profits than with privacy.  I’m disappointed that women reporters use their considerable influence to support the present system instead of reforming it as women have often done when their own privacy is at stake.  Many women reporters have stated that they would prefer interviewing athletes at a neutral time when they are not showering or dressing.  But the AWSM (Association of Women in Sports Media), their trade lobby in effect, has never pushed for it.  They should; it would greatly increase their credibility.

The precedent setting decision that opened the way for women in locker rooms is now over 30  years old  (Melissa Ludtke & Time Inc vs. Bowie Kuhn, 1978).  The decision applies strictly only in New York, but has never been challenged.  Women have entered locker rooms in increasing numbers since that time.   The decision is sometimes misinterpreted.  It does not mandate access to locker rooms by women reporters or anyone else for that matter.  Locker rooms remain private and the leagues control all access.  But they can no longer discriminate by gender when they grant access.  In other words, they can ban all access or limit it under any non discriminatory rules.  Some reporters have claimed that professional locker rooms are public areas.  That couldn’t be further from the truth.  If it was, fans would try to enter after each game.  Access passes are tightly controlled.

Reporters often defend the status quo on the basis that no athlete is exposed against their will.  That is basically correct.  The athletes are encouraged to wear towels or robes, but surely that is still an imposition which few women would tolerate themselves when dressing.  If that was generally accepted behavior, we’d see people changing on beaches all the time.  Even with robes and towels however, it was not always possible to avoid exposure and may still not be possible in some locker rooms, especially in baseball’s minor leagues.  Sports reporter Susan Fornoff in her book Lady in the Locker Room, Uncovering the Oakland Athletics (1993) describes one MLB locker room, Cleveland Municipal Stadium, where reporters had to walk past an open shower area and urinals to get to the locker room, regularly going past nude athletes.  Ms. Fornoff says she complained about it to management.  It took years for them to even hang a curtain to block visual access.  She states Candlestick Park in San Francisco was similar.  Even today most athletes are briefly exposed while they change, and there are always a few who will prance around nude, sometimes to purposely harass the ladies that are present.  But the answer is not to register these guys as sex offenders as would happen if this occurred outside the locker room, but to change an unreasonable system.

There is no doubt that if the genders were reversed, the situation would be considered a hostile work environment under Federal law subject to lawsuit and redress.  Instead the situation has been turned upside down.  If the men should post pinups on their lockers, it would be declared a hostile work environment for women!  This issue arose again in 2008 when the Chicago White Sox put a blow up doll in the locker room and a woman reporter complained of a hostile environment.  It’s a lose-lose situation for the men.  They are denigrated if they complain about the presence of women while they are changing and showering but are not permitted any locker room antics themselves without the risk of a complaint being made by the media.

A year ago, another in a series of periodic incidents arose when Ines Sainz, a Mexican feature reporter, accused the New York Jets of harassing her.  This charge was really made public by the AWSM.   In response to the resulting media storm, WTTW, Chicago public TV, organized a forum consisting of 4 women sports reporters to discuss the issue.  The opening question was ‘why are we still discussing this decades later.’   The answer is simple, because it still remains an unprecedented violation of privacy.  The issue will never go away until it is redressed.  Their discussion does make some good points and is well worth listening through.   Still a basic question remains, why invite only women reporters to discuss the issue?   That’s like having a forum on the causes of poverty and inviting only billionaires to be on the panel.  Is it any wonder these women don’t see a problem?  Why not constitute a panel with an equal representation of athletes?  If current athletes feel inhibited from commenting, I’m sure they could find former athletes willing to talk on the record.  The only athletes that the mass media quoted at the time of the incident were those that made sexist remarks, such as Clinton Portis whose comment about women reporters finding some of the ‘packages’ they see attractive was widely publicized.  That comment was made off the cuff by an athlete who wasn’t familiar with the incident.  I’m sure they’d have no trouble finding some more thoughtful comments.  Lance Briggs is another example of a player who was criticized for saying women don’t belong in the locker room.  In prior years they also did a number on Reggie White who is still being lambasted for saying that he saw no reason to be naked in front of any woman who wasn’t his wife, hardly an outrageous opinion.  Does the mass media prefer to paint athletes who’d appreciate some privacy as Neanderthals?  Needless to say there have been a wealth of sexist comments by women reporters as well, the most publicized perhaps being Patti Shea’s giggling adolescent like column of her first impression of nude athletes.  This column was roundly denounced by women reporters as the rare exception to their ‘professionalism.’  The original column from the Santa Clarita Signal is no longer available online, but can be found in its entirety on other sites.   

A brief quote from her foray into the Dodgers locker room:  Just then, Shawn Green emerges from the showers, rubbing a towel on his head and wearing only a towel. Three millimeters thick of terry cloth is separating Green's goodies from my life's most embarrassing moment. I really didn't have that much time to think about it before Green whipped off the towel and began to get dressed. Holy &#$@!!!   I'm going to need to see a chiropractor for the whiplash I gave myself.   

I don’t quote that column to prove that reporters are irresponsible.  Indeed established women reporters are surely overwhelmingly professional and would disapprove of that column.  But we are all human with urges and thoughts we can’t always suppress.  We can only surmise how young women reporters and photographers react early in their careers.  How many private videos are in existence of nude athletes in the locker room or unseen interviews that had to be discarded because a nude athlete walked by during the filming?  A few have indeed been inadvertently shown on TV; an example is Minnesota Viking’s tight end VisantheShiancoe on local Fox TV.  This caused no Federal reaction unlike the brouhaha over a microsecond exposure of Janet Jackson’s nipple during the Super Bowl.  

Even according to this WTTW discussion, most athletes would rather be left alone in the locker room.  The panelists said the men preferred to be free of any reporters, regardless of gender.   I’m sure that is true, yet this was not an issue 30 years ago before women entered locker rooms.  Women in the locker room are a game changer.  The athletes’ opinions were looked at in a poll by Sports Illustrated, October 15, 1990.  Of 143 NFL players 38.5 percent were in favor of women reporters entering the locker room, while 47.6 percent were opposed, and 13.9 percent were undecided.   A poll is almost beside the point though as any individual’s right to bodily privacy is not subject to and cannot be taken away by majority vote.  Still, an updated survey is needed which not only asks athletes if they support the status quo but if they would prefer alternative solutions.  Athletes remain role models and celebrities in our society.  If they would admit that they too like a little privacy, it would make it much easier for all men.  The average guy would be less embarrassed asking for privacy in medical and other situations as well.  The behavior of athletes helps set a standard for society.

The WNBA had no trouble finding an acceptable solution giving equal access to all reporters: “The room (locker room) will re-open 5 to 10 minutes after the final buzzer and will remain open for a minimum of 30 minutes. Following the 30-minute media access period, locker rooms will be closed for a 20-30 minute period to allow players to shower and dress. The locker rooms may then again be opened to the media.”   

The male sports leagues could adopt a similar policy tomorrow.  Indeed similar solution have been advocated for years for the men; here’s one from Sports Illustrated in 1990.  The WNBA solution satisfies all reporter demands for immediate access to catch the emotions of the players following a game.  It doesn’t require any modifications to the locker room layouts.  What prevents it,  maybe only tradition.  Occasionally the need to make immediate travel connections shortens the time allowed after a game.  If time was in short supply, the leagues can already eliminate or shorten access time.

In summary, I am in favor of equal opportunity employment rights.  I am also in favor of full privacy rights given to male athletes just as they are presently granted to women athletes.  These objectives are not incompatible.  The time is long past due when professional sports leagues revise their rules so that all reporters, photographers et al are prohibited from locker room access while athletes are showering and dressing.  I believe that we are the only country in the world where this situation is routine (excluding American leagues in Canada).  Better yet locker rooms should all be remodeled to provide areas which are not sensitive for media access to athletes.  Recognition and correction of this issue would reverberate throughout all of society improving privacy rights for all including patients under treatment.

Saturday, August 13, 2011

American Medical Students in 19th Century Paris

‘It’s no trifle to be a medical student in Paris’
American Medical Students in 19th Century Paris
by Doug Capra © 2011
This spring I read a fascinating book, The Greater Journey: Americans in Paris, by David McCullough. It chronicles American intellectuals in Paris from about 1830 to 1900. McCullough focuses on painters and artists, but he does cover other professions. It’s interesting to see how this experience changed them and how it influenced the development of this country in many ways.
At this point you may be wondering what all this has to do with the history of medicine, and with modesty and privacy in particular. Chapter 4 is titled “The Medicals.” It tells the story of American medical students who traveled to Paris to study because that was the place to be. Why Paris became the center of medical education is a long story best told in another post. It’s disappointing that McCullough doesn’t even touch on this story. In brief, after the French Revolution, the hospitals were secularized. Before that, many had been run by religious orders. The ethic and medical worldview changed and, in essence, medical students and doctors finally had almost unlimited access to bodies, both living and dead.
“It’s no trifle to be a medical student in Paris,” wrote Oliver Wendell Holmes. McCullough points out that Paris offered at least two advantages over medical studies in the U.S. First of all, in Paris, medical students had “ample opportunity to examine female patients as well as men.” In America, “most women would have preferred to die than have a physician – a man – examine their bodies.” In reality, many women did die because of this, and American medical students’ knowledge of female anatomy came mostly from books. McCullough’s source for this is a book published in 1848 by surgeon Augustus Gordon, Old Wine in New Bottles: Spare Hours of a Student in Paris. Wanting to delve deeper into McCullough’s sources, I read Gordon’s book.
The flight of so many talented American medical students to Paris –frankly, only those who could afford it – did concern leaders in American medicine. A Philadelphia surgeon, Gardner, visited Paris to observe the medical education system. “The French woman…knows nothing at all of this queasy sensibility,” he wrote. “She has no hesitation, not only to describe, but to permit her physician to see every complaint.” Interestingly, this modesty issue seems to be one of the major reasons for wealthy American medical students to go to Paris. “In this respect,” wrote Gardner, “the Paris educated physician enjoys superior advantage to the homebred man.”
The second advantage of a Paris medical education involved the “supply of cadavers for dissection.” In the U.S. dead bodies were expensive and difficult to obtain. In fact, trade in dead bodies had been illegal in Massachusetts until after 1831. Medical involvement in grave robbing wasn’t uncommon. Doctors and medical students could get bodies of those who died in prison or who were executed, or, in the South, the bodies of slaves. But it was still difficult.
In Paris, it was claimed that even those about to die in hospitals were “aware of their fate,” knowing and accepting they were headed to dissecting room. Due to disease and poverty, cadavers were cheap – about $2.50 or an adult and less for a child. An American medical student living in the Latin Quarter, described watching carts full of naked bodies, men and women – dumped, “as you do a cord of wood upon the pavement,” to be distributed to the dissecting rooms. Six hundred students could work at the same time at the Amphitheatre d’Anatomie at the Hospital de la Pitie. Gardner observed that the blood and pieces of flesh on the floor are regarded “as the sculptor does the fragments of marble lying round the unfinished statue.” Caged dogs were kept outside and fed the discards. In summer, the heat and stench was so bad that dissecting was suspended.
Students and observers like Gardner, took instruction from such noted female obstetricians, called sage femmes, as Madame Marie-Louise La Chapelle. For the first time, these male medical students and doctors were allowed to examine with their hands the wombs of pregnant women. Student Henry Bowditch said he “learned more about midwifery from Madame La Chapelle in her private course than he had in three years at the Harvard Medical School. Oliver Wendell Holmes saw La Chapelle – as did other American medical students -- as a good argument for allowing women to study medicine. Americans also saw students of color studying medicine successfully, and that convinced many of them that American blacks were capable of being doctors.
Gardner wrote of his experience studying midwifery:
“Whenever a female is in labor, a signal is placed at the door indicating this fact. All, who see the notice, enter. The first comer is the accoucheur under the direction of the resident sage-femme. Around the bed, railings keep off the multitude, who often number fifty or more. I have seen the room crowded during the performance of such operations… The patient is uncovered as the labor advances, for the benefit of those around. How many of the very lowest classes in the United States would be thus willingly exposed? Yet hither quite decent women are frequently brought…” (203)
I want to point out that the medical perspective is that these female patients don’t really care about all this exposure. But that’s the medical perspective. We never get the patient perspective. I grant that mores and cultures differ as to modesty. Perhaps these women didn’t care one way or the other. But Gardner makes another statement that I believe is enlightening – a quote that McCullough leaves out – a perspective we must understand if we want to really compare modesty in France and the U.S. at this time period. He writes:
“Every patient who enters a hospital is, in a certain degree, Government property, and, not only through life, but even after death, is subject, in some cases, to the control of the physician. Thus science is benefited by the post-mortem examination, which is made of every disease that is marked with anything peculiar, whether objected to by friends or not. (161).”
I want to make it clear – these medical students in Paris brought back many positive medical techniques. They saved many lives and dramatically improved the quality of medical training in the U.S. The were heros during serious epidemics and helped the wounded during the Franco-Prussian War. They studied under celebrated teachers like Pierre-Charles Alexandre Louis who was known, even ridiculed “for his extended questioning of patients, his slow, careful examinations and endless note-taking.” He insisted on precise observations, that is, really listening to what the patient had to say. He encouraged careful use of the stethoscope, an instrument invented in 1819 by French physician Rene Laennec. I’m not implying at all that this Paris medical education was not positive. Most of it enriched the medical culture of this country and contributed to better lives for Americans.
According to McCullough, between 1830 and 1860, nearly 700 American students came to Paris to study medicine. And most of these would have come from wealthy, influential families -- thus, many of not most would have been leaders in the American medical field.
It was said of Mason Warren -- "Apart from all other considerations, the mere fact that of his long absence in Europe caused a degree of importance to be attached to him, as in those days few of our countrymen traveled abroad..."
McCullough writes: "Decades later, in the 1890's, William Osler, one of the founders of the John Hopkins Medical School and as respected a figure as any in American medicine, would write that 'modern scientific medicine' had had 'its rise in France in the early days of this century.' More than any others, it was the pupils of Pierre Louis who gave 'impetus' to the scientific study of medicine in the United States."
Seventy of those who had trained in Paris, one out of three, taught in American medical schools.
-- William Gibson became chief of surgery at University of Pennsylvania.
-- Henry Williams became the first professor of ophthalmology at Harvard. He later wrote three important books on diseases of the eyes.
-- George Shattuck became dean of Harvard Medical School.
-- Henry Bowditch became professor of clinical medicine at Harvard. He was an expert in diseases of the chest, especially T.B. He published a book, The Young Stethoscopist, in 1846, used by medical students until the early 20th century.
I could go on and on. These men created modern scientific American medicine and ended up saving and improving thousands and thousands of lives.
But these American doctors, I’m suggesting, may also have brought back other, less positive attitudes and perhaps behaviors. Modesty shouldn’t matter at all. Once you’re in the hospital, you are really there, not just to get well, but for the benefit of science, and you need to accept the fact that you’re a teaching tool and may be observed, in any state of undress, by whomever few we see fit to permit access. Modesty is an old fashion, not worthy of modern human beings, especially when it comes to medical treatment. We know this attitude isn’t part of the codes of conduct or core values of the profession or the hospitals in which they work. We know it’s not the ideal. But the system isn’t perfect
We see this attitude in some literature of the later 19th and early 20th century. In Chapter 1 of Part 2 of Anna Karenina (1873-77) by Leo Tolstoy. Eighteen-year-old Kitty has been ill throughout the winter and she gets worse as spring arrives. The first two older, family doctors do nothing but give her cod liver oil, iron, and nitrate of silver. They perform no examination. The family doctor recommends a “celebrated physician” be called. Tolstoy writes:
“The celebrated physician, a very handsome man, still youngish, asked to examine the patient. He maintained, with peculiar satisfaction, it seemed, that maiden modesty is a mere relic of barbarism, and that nothing could be more natural than for a man still youngish to handle a young girl naked. He thought it natural because he did it every day, and felt and thought, as it seemed to him, no harm as he did it and consequently he considered modesty in the girl not merely as a relic of barbarism, but also as an insult to himself.”
Here we begin to see this new gender-neutral worldview emerging. It’s never stated outright, but the fact that he is a young doctor, newly trained, and “celebrated” indicates that he was foreign trained, most likely in Paris. That Tolstoy says he maintains his position with ”particular satisfaction” underscores his condescending attitude. Modesty is for barbarians, the uneducated, uncivilized masses – for the “herd,” as Nietzsche might say. It’s the “I do this every day. There’ s nothing you have that I haven’t seen” attitude we sometimes see even today. A patent exhibiting modesty represents an insult to this doctor’s status, to his moral and intellectual superiority. No respect is shown to the patient, nor is the patient’s dignity preserved. Everybody in Kitty’s family is uncomfortable with what the “celebrated physician” wants to do, even the family doctor, but they reluctantly agree. Tolstoy continues:
“There was nothing for it but to submit, since, although all the doctors had studied in the same school, had read the same books, and learned the same science, and though some people said this celebrated doctor was a bad doctor, in the princess's household and circle it was for some reason accepted that this celebrated doctor alone had some special knowledge, and that he alone could save Kitty. After a careful examination and sounding of the bewildered patient, dazed with shame, the celebrated doctor, having scrupulously washed his hands, was standing in the drawing room talking to the prince.”
The doctors confer alone. The family doctor starts to give his opinion. “The celebrated doctor listened to him, and in the middle of his sentence looked at his big gold watch. "Yes," said he. "But..." The whole issue of the value of this “celebrated” doctor’s time is brought up with the symbol of his “big gold watch.” The family is called in for the results and Tolstoy writes: “The celebrated doctor announced to the princess (a feeling of what was due from him dictated his doing so) that he ought to see the patient once more. "What! another examination!" cried the mother, with horror. "Oh, no, only a few details, princess." "Come this way." And the mother, accompanied by the doctor, went into the drawing room to Kitty. Wasted and flushed, with a peculiar glitter in her eyes, left there by the agony of shame she had been put through, Kitty stood in the middle of the room. When the doctor came in she flushed crimson, and her eyes filled with tears.”
Here we see clearly the gender neutral, patient as object worldview that a significant number of these Paris trained doctors brought back to their countries. That view hasn’t disappeared today. Indeed, I might suggest that with the introduction of all the technology today, sometimes the patient is viewed more as an xray or an ultrasound, than as a person. Sometimes doctors spend more time with “images” of the patient than with the patient him or herself.
For another example of a more idealistic young Paris-trained doctor, Tertius Lydgate, read George Eliot’s (Mary Anne Evans) Middlemarch (1872). Interestingly, British sensibilities would never allow a Victorian female novelist to write as bluntly as Tolstoy does about the physical examination of a young girl. With Lydgate, we see more of the positive gifts such Paris-trained doctors brought back to their countries.
There has always been a dark side to science and medicine. The data gathered by some Nazi, Japanese, and, yes, even American doctors using unethical, immoral procedures on unsuspecting or coerced patients – that data could be very useful to save lives. Do we use it? Or do we discard it because of how it was obtained? As long as a patient is cured, a life is saved, a baby born alive and healthy – is that all that matters? Or is preserving the patient’s dignity, privacy, and modesty equally important as the end result? Do the ends justify the means?
This worldview I’ve highlighted has not disappeared from American medicine. It’s still out there. But medicine is dramatically changing as write with a new generation of doctors and nurses entering the field. How they’re trained, the cultural assumptions behind the training, is as important as the technical medical information they learn. How they are taught to complete exams and procedures, the human aspects of human contact, is as important as the scientific information they need to save lives. And this training isn’t just embedded in their formal schooling. It’s also intimately embedded in the culture within the institution where they work, and within the general culture of our society.
The hidden curriculum, what they learn day to day from their supervisors and colleagues, what they learn from our media, is as important as what they learned in their formal training.

Wednesday, July 20, 2011

Medical Education & Modesty Concerns
A former medical student's troubled path

Moderator's note:  This blog does not usually publish anonymous posts but because of the highly personal nature of this contribution, we have agreed to anonymity.  The article is an important contribution to a rarely acknowledged subject.

by  'Stressed Student'

I was a University of Illinois at Chicago (UIC) medical student. Like many teenagers and young adults, I had never visited a gynecologist or proctologist. I did not come from a medical family either. And because pelvic and prostate exams are not mentioned in the premedical curriculum nor explained to medical school applicants and incoming UIC students, I did not know about these exams when I first moved to Chicago to begin my medical education.

My faculty did not bother to explain what bimanual exams were my entire first year of medical school. I only learned about them from classmates cracking jokes, and from receiving e-mails from students selling T-shirts that compared the exams to sexual activities, making light of the way we must complete the exam once on an actor as part of our Essentials in Clinical Medicine (ECM) physical exam course in our second year.

I immediately had problems with pelvic and rectal exams. I found them violating in concept. I believed it had to be wrong for my school not to explain to applicants beforehand that there was more to examining men than testicular exams and more to examining women than breast exams and catching babies. I thought that training students to lubricate and insert their fingers into male and female sexual organs was much more taboo than what many young students would creatively imagine on their own before matriculating. I thought it was not right to assume that every student must agree with digitally penetrative exams just because they are widely accepted as valid medical procedures, at least in this country. After describing these exams to my younger sister and a few friends from college, I was confident I was not the only human being who viewed these exams as more than just a little uncomfortable, but also violating.

There was ample support at my school for students with academic problems regarding written exams. But there was nobody to speak with for students who had personal, cultural, or ethical conflicts regarding clinical procedures. I did speak with a school psychologist who specialized in stress management because she gave students her contact information during orientation week, but all she did was invalidate my perspective by repeating "There is nothing sexual or violating about these exams." Realizing that a broken-record psychologist could not alleviate my stress, I decided to complete the first year curriculum and resolve my issues over the summertime.

I entered the program at UIC to prepare for a career in translational services between medicine and investigational science. I wanted to focus on pathologies of the brain and nervous system. So I was looking to develop into the capacity of a pathologist or maybe a neurologist who conducted translational research on that organ system. I was not aspiring for a career in a field like family medicine, emergency medicine, internal medicine, and obviously gynecology. And so when I learned about these invasive genital exams, I found them violating enough to refuse. Realizing they were not part of my future responsibilities, I thought the most professional and honest approach would be to discuss all of this with faculty

Over the summer, I confided in faculty that even though I understood many people saw these exams as being just another part of the physical exam, I saw pelvic and rectal exams as being violating procedures, and that unless I went through some psychological change where I could perform them without feeling violated, I would decline to perform them, especially in non-emergency scenarios such as practicing on an actor in an artificial environment, and especially since it was not listed as a graduation competency to students beforehand (or even at all anywhere). What happened when I said this is they withdrew my scholarship, and shunned me for asking for "special privileges". I withstood so much abuse when I brought the topic up with faculty, ridiculing me with "What? We have to tell students that doctors touch people?", guilt-tripping me with "If you cared about patients, you would do the exam", and victim-blaming me with "You knew all about these exams before you got here, you just repressed it."


Over the summer, the first person I contacted was an instructor of ECM (the physical exam class where we must complete these exams). I vaguely told him I had "concerns" about the ECM course for second-year students. He offered to meet with me, but said most students speak with other ECM instructors first, and then with him if things are not resolved. So I spoke with all the other course instructors, and by then he knew what my issues were, and was no longer interested in meeting with me. I did learn a lot of unacceptable facts about the ECM class from the other course instructors though.

I was appalled and frustrated to realize my school has watched students suffer personal conflicts like me for decades:

1) Every single year, the instructors watch a "few" students resist these exams. One instructor told me these students say "I just can't do this" and "I don't want to do this". Some students abruptly walk out of the exam room, and some postpone their dates, all the way until summertime when they must complete it once to advance to third year.

2) Students have fainted during the exams.

3) Students have cried during the exams. The worst was a recent student who said she was a rape-survivor and had problems with the male rectal exam. My instructors still forced her to do it, and she left the room sobbing in front of the actor and instructors.

4) The instructors have a rule that one female must be in the room for the male rectal exam. The rule was established to mitigate any "homophobia" among male students, and apparently my school thinks the presence of a female neutralizes any viewpoints students might possess that the exam is a "gay thing". I thought this "rule" reeked with discrimination and hypocrisy. It seemed to me this "rule" was conjured up decades ago by the primarily male heterosexual faculty who empathized with problems male heterosexual students as a selective group would face, and made it easier for them to at least graduate, when many male students never even asked for it. The most disturbing part about this "rule" though is that the faculty EXPECT a few young students to be unable to desexualize the prostate exam when it is introduced to them. To then force students to complete the exam, knowing that some cannot desexualize it, must be sexual abuse. But not wanting to "scare students away", these instructors deliberately keep students in the dark until they have invested too much time and money into school. Because at that point, students who find these exams unacceptable must choose between getting sexually abused or crawling away with a mountain of debt as a medical school dropout. The instructor who told me about this "rule" said it was handed down to her when she took the position in 1982. In other words, this "rule" is over three decades old!

What do you think of these four points? I think they unfold like rape scenes. A self-proclaimed rape-survivor leaving the exam room sobbing? Students crying and fainting while doing "intimate exams" that were not explicitly explained beforehand? Students "resisting" and "postponing" the exams for months? One instructor assured me that I was not out of place, and said he always sees students "make horrified faces". Unfortunately, his comments did not make me feel better, they made me feel angry that my school failed to question why this is the case. It disgusted me that nobody advocated for the rape-survivor. I believe they raped a rape-survivor. And it outraged me that this student cried in front of her peers, and then felt she needed to reveal personal information about herself too. There is no justification for the fact that they did absolutely nothing after that for future students.

I was sickened by the degree instructors deny they are hurting a few students each year. They assured me "I always ask those kids who keep postponing the exam how it turned out, and they say it was not as bad as they thought." What else can these students say when their own abusers fish for an agreeable response like that? The instructors even told me matter-of-factly "Students faint during the pelvic exam because they did not eat a big breakfast." They cannot possibly be keeping tabs on 200 students breakfast schedules. It irritated me they never considered why nobody fainted during the ear exam. As of now, their "solution" to the fainting episodes is to remind students earlier in the week when they explain the pelvic exam workshop to eat a big breakfast on the morning of the workshop.


I read a book "Public Privates" by Terri Kapsalis. When I learned halfway through the book the author was a pelvic exam actor at UIC, I was shocked to discover she wrote an entire chapter about UIC students having problems with pelvic exams. This book was published 20 years ago, and nothing at my school has changed. Here are some quotes from her book about my school:

1) [The author discusses a paper by a physician named Buchwald] "Students seem to find it very difficult to consider female genital display and manipulation in the medical context as entirely separate from sexual acts and their accompanying fears. Buchwald's lists of fears makes explicit the perceived connection between a pelvic examination and a sexual act. "A fear of the inability to recognize pathology" also reflects a fear of contracting a sexually transmitted disease, an actual worry expressed by some of Buchwald's student doctors. Likewise, "a fear of sexual arousal" makes explicit the connection between the pelvic exam and various sexual acts. Buchwald notes that both men and women are subject to this fear of sexual arousal. "A fear of being judged inept" signals a kind of "performance anxiety," a feeling common in both inexperienced and experienced clinical and sexual performers. "A fear of disturbance of the doctor-patient relationship" recognized the existence of a type of "incest taboo" within the pelvic exam scenario."

... "Buchwald's work deviates from most publications dealing with the topic of medical students and pelvic exams. Largely, any acknowledgment of the precarious relationship between pelvic exams and sex acts is relatively private and informal, taking place in conversations between students, residents, and doctors, sometimes leaking into private patient interactions. For example, as a student in the 1960s, a male physician was told by the male OB/GYN resident in charge, 'During your first 70 pelvic exams, the only anatomy you'll feel is your own." Cultural attitudes about women and their bodies are not checked at the hospital door."

... "In his article about medical students' six fears of pelvic exams, Buchwald accepted student fear without either questioning why young physicians-to-be would have such fears or searching for the cultural attitudes underlying them."

2) [The author discusses that schools hired prostitutes to teach the exam] "In a sense, the patriarchal medical establishment took the position of a rich uncle, paying for his nephew, the medical student, to have his first sexual experience with a prostitute. This gendered suggestion assumes that female medical students are structurally positioned as masculinized "nephew" subjects as well."

3) [The author quotes a fellow pelvic exam actor] "I think the students are afraid it's sexual. They're afraid about how they're going to react, whether they're going to be aroused, but it's so clinical."

4) "Only with the use of GTAs [pelvic exam actors] have medical schools attempted to incorporate women patients' thoughts, feelings, and ideas into pelvic exam teaching. And yet, as these feminist teachers pointed out decades ago and as my experiences have occasionally confirmed, it may be impossible to educate students properly within the medical institution given unacknowledged cultural attitudes about female bodies and female sexuality."

The author of this book is correct: There is no validation from faculty at UIC that some students suffer problems regarding these exams, and there is no effort to investigate why this is the case. I also agree there is no search for "cultural attitudes" that could underlie students perceiving these exams differently. In fact, although I have American citizenship, I was raised overseas from age four and returned to America for college at age nineteen. I retrospectively learned that in many developed nations, the thought of asymptomatic women paying strangers in white-coats to routinely penetrate their vaginas is the exception rather than the norm. In Korea, for instance, some women use vaginal swabs in the privacy of their homes. In Japan, screening for cervical cancer at all is not commonplace. In other developed countries, there are self-pap tests that some women use because they find the traditional gynecological exam to be inappropriate in the absence of symptoms. In addition, the developers of the CSA blood test cite "cultural taboos" as being a primary motivation for them inventing a non-invasive alternative to check for cervical cancer. So I think my school is very ethnocentric to believe all incoming students automatically agree not only with these exams, but also with practicing them on asymptomatic actors. It is undeniable some students discover personal clashes that might derive from cultural upbringings while learning about the most taboo aspects of physical exam for both sexes, and I find it unethical that schools would not inform students about these potential problems before they move to new cities and matriculate.

At the same time, the author conveys similar beliefs as the instructors I met at UIC, hastily diagnosing students as having "anxieties" and "fears" that they can "cure" us of via "education". I think the quote the author provided from a fellow pelvic exam instructor ("Students are afraid it's sexual") is nauseatingly narrow-minded. How does this woman believe she can tell all adults that an exam, mechanically the same as digital sex, is not sexual? Why does she think she can speak her mind for all adults about human sexuality in medicine by resorting to empty buzzwords like "professional" and "clinical" to do so? In fact, she cannot define what is and is not sexual (or sexually violating) for any other adult.

This reminds me of one instructor who concluded I had an "irrational phobia". Do you think it was fair for this instructor to tell me I had a "phobia" of being forced to have digital sex with an actor without my consent? Because you could easily make the reverse argument: Students who do not want to do these exams when introduced to them (as this apparently happens each year), but still complete them have "phobias" about disobeying orders from faculty, or have "phobias" about standing up for themselves, or have "phobias" about what instructors will think of them if they admit they see a medical exam as being sexual. The same with patients too: I have seen peer-reviewed papers written by gynecologists investigating why some women have "fears" about getting exams. But the counterargument here is that women who dread the thought of being humiliated and penetrated by strangers, but force themselves to suck it up, have hypochondriac "fears" about developing a rare cancer and benefiting from a notoriously inaccurate exam. Depending on their lifestyles, some women are more likely to be harmed than benefited from the outdated pap smear, and the World Health Organization does not recommend ovarian cancer screening via bimanual exams. For these reasons, I believe smart and responsible women can decide to never submit to these exams while asymptomatic, without being diagnosed by pushy and one-sided doctors as having "curable fears".

It is too easy for instructors to label and ostracize students as having "fears". These instructors told a rape-survivor she was being irrational to "fear" the prostate exam. What is particularly evil is they knew this teenage girl or young woman likely did not know about taboo old men healthcare to decide for herself before starting school whether or not she found completing a prostate exam to be acceptable. In any case, her "fear" turned out to be a rational one because the experience did cause pain, as she expected, seeing that she left the room crying. These instructors pride themselves on walking over students and their problems, and believe that with their supremely rational minds, they can triumph over anything, when in fact they have not proven any strength unless they have all been raped themselves. So who are they to judge a rape-survivor student with long-term effects of depression? And then to boast that they gave this student such a valuable educational experience, just because they cannot relate to her suffering from traumatic life events? I thought that was just plain childish.

I do not think my instructors are very intelligent. There is more to intelligence than exercising the rational mind. The author refers to these exams as being a "first sexual experience" for many students. If it is indeed true (that medical exams can be sexual experiences), then forcing teenagers and young adults to perform them without consent using shame and blackmail, when it causes problems for a few of them each year, is institutionally-sanctioned serial sexual abuse and rape. At least that is how my intellect - both rational and emotional - sees it.


After I spoke with all physical exam instructors, they sent me to an OBGYN faculty involved with curriculum planning. I met with him twice, and our second conversation bothered me.

He told me he was "ignorant" medical students had problems. But really, he was anything but "ignorant" since he works with the same instructors who watch students cry and faint.

I asked him if I could bring in "evidence" that students have problems. So the second time we met, I brought detailed information about UIC students having problems, as well as news articles about students across the nation being "known to faint, cry, vomit, become hysterical and sweat" over these exams

I also brought one article about teenagers and women getting unwanted pregnancies because they could not obtain birth control from gynecologists when they refused pelvic exams. I brought this last article because I empathized and related to the female patients, as I would also refuse the exam if I were in their positions. The article was pointing out that because the medical community does not respect and accommodate these women and their opposition to pelvic exams, it leads to bigger problems like unwanted pregnancies. And I felt that was a similar message to what I was trying to voice to my school: I think a small number of medical students can find out they disagree with exams, and they should no longer be marginalized and ignored for it because that only leads to bigger problems.

When I handed him the paper, his demeanor changed from the previous meeting, and he suddenly raised his voice at me (even though I never raised my voice at him). He actually balled up his fist like he was holding pills and growled at me "If I have something a patient needs, I withhold it until they get the exam!" He was steaming with anger, even though I never thought to question his practice at all. I had read about why it was unethical to require pelvic exams for birth control
, but I assumed the doctors who abused their power in this manner were working in private clinics out in the boonies. It never even crossed my mind that an OBYGN faculty of a medical school would fit that profile.

Shocked and creeped out, because I saw his true color, I asked "Shouldn't doctors at least tell patients they could go elsewhere and get birth control without a pelvic exam?" I thought it would be lacking informed consent not to do so. He just sneered at my comment. It was very clear to me this person went into gynecology for all the wrong reasons one might expect. It infuriated me he could not even pretend to empathize with the girls and women in the article who found pelvic exams to be intolerable, just as he could not empathize with his own students who have felt the same way for years. Any gynecologist, especially one who is training the next generation of gynecologists, should understand and respect how various patients feel about their reproductive rights and healthcare. Hurdles should never be imposed for women seeking contraception. In my opinion, this has nothing to do with health care, and everything to do with power, control, and making money.

His thinking and practice is outrageously sexist: When he was a teenager who needed a condom, he did not need to confront an old woman in a white coat who withheld what he needed until he had digital sex with her first. He presents himself as someone who cares so much for women, but then dupes them into accepting pelvic exams for birth control, even though the World Health Organization and numerous medical associations have consistently stated that the only recommendation is a blood pressure check, since hormonal contraceptives are as hazardous as Aspirin. Medically speaking, there is no greater logic to requiring pelvic exams for women who want birth control than there would be for requiring prostate exams for men who want Viagra.

You can only imagine some terrible scenarios he has exploited: An adolescent patient from a poor family shows up for birth control but does not want a pelvic exam, and does not know beforehand that she will be pressured to accept one. Once in the office, she might view doctors as authoritative figures whom she cannot question. She might be time-pressured for immediate access to birth control. She might be too scared to challenge a doctor. She might find it more embarrassing to try to resist the exam. She might be fooled that the pill will harm her body if she does not accept the exam. She might be intimidated by the medical setting, and maybe cannot speak fluent English. At that point, she can either run away from the exam room (and get undesirably pregnant), or reluctantly submit to the exam (and suffer rape-like symptoms). And I am not just speculating here, I have read about female patients who realize they were mistreated after being coerced into something they adamantly did not want but ultimately accepted because of false guidelines presented to them. I have also read about women feeling "raped" from this practice, and driving for miles to find a doctor who actually follows the law.

I wonder why no students speak up when they see him mistreat patients? Maybe their voices have no impact. Maybe they worry they are out of line to defend patients. It agitates me because I know his misogynistic attitudes have an exponentially poisonous impact, seeing that his peers actually respect his philosophies enough to bestow him the responsibility of training future gynecologists at the largest public medical school in the country.

When I was about to leave the room, I recalled a discussion I had with a kind-hearted classmate who recently drove me home. I told him I had problems with these exams, and he urged me to speak with faculty and resolve the issue. Then he told me although he did not have problems performing the exams, he did have problems the way some instructors handled them: He said he shadowed an ECM instructor, and watched him reprimand each female patient who asked for a female to do her pelvic exam. Evidently, the instructor believes such requests are backwards and bigoted.

So when the OBGYN faculty asked me if I had anything else to add, I said I was concerned about an ECM instructor teaching students to reprimand patients when they prefer one sex over another for intimate care. The OBGYn faculty scolded me, and said he applauded that ECM instructor. He believed it was sexist for me to assist these patients and their wishes. He asked me "Would you ask a black person to leave the room? Would you ask a Jewish person to leave the room? Would you ask a short person to leave the room? Probably. Because you would ask a man to leave the room!"

I thought his analogy here was meager and self-serving. Funny how he was offended by modesty in medicine to vilify it as condoning sexism, when he is the one who abuses his position of power to do such despicably sexist things as withholding birth control from girls and women who refuse pelvic exams.

Patients requesting same-or-opposite-sex care for intimate exams was legalized under the Bona Fide Occupational Qualification (BFOQ) by humanitarians who advocated for patient rights to preserve cultural and personal beliefs about sexuality and bodily modesty. There are scenarios where patients know they will experience the exam as being less sexual because of their sexual history and preferences. For instance, a heterosexual man who has only had sex with women might prefer a male to do his exams because he might experience that as being less sexual. But another heterosexual man who has only had sex with women might prefer a female to do his exams because he might experience that as being more natural. And yet another might have no preference. So really, all individuals have unique sexualities both in and out of medicine. For these reasons, I believe my instructors are the ones who pass judgments on their patients and their sexual values and identities.

Some patients might find it more logical to speak with a provider who has experienced physical problems, like a female patient talking about cramps. And some patients might prefer same or opposite intimate care to protect the intimacy between their partners and spouses. How can a health provider admonish a patient and his or her relationship values?

In all honesty, I do not believe that a woman asking for another woman to do her pelvic exam is sexist. Many women perceive the act of getting naked and spreading into the lithotomy position as being sexually vulnerable and submissive. Even if a woman consciously believes that male and female doctors are equivalent caregivers, her natural instincts might strongly prefer a female examiner because she could not get impregnated by a strange female, as opposed to a strange male, between her naked legs strapped in stirrups. The consistent prevalence then of females requesting female intimate caregivers must have instinctive and deeply emotional roots, and must be accommodated by doctors without judgment or ridicule. Because when these women are demonized for making reasonable requests, doctors are punishing them for protecting themselves at a primitive and instinctual level. Hence, these doctors are docking points off patients for being human, known as dehumanization.

I have to say I find it troubling that these male providers harass female patients for requesting same-sex care. The power differential is too unfair. Most (American) female patients are very young when they have their first pelvic exams and are too often pressured by biased propaganda and brainwashed mothers to get them without the opportunity to judge for themselves whether it is really necessary or whether they are candidates for less invasive alternatives routinely offered in other developed countries. The pelvic exam is also longer in duration and so much more visually exposing than the prostate exam. Women also face additional hurdles since our society is still a very patriarchal one, where women are sexually abused by men at much higher rates than any other combination of sexes. Even if a woman has not been directly sexually abused, she has certainly been emotionally abused from a very young age, knowing female friends who have been sexually abused (often by men), reading newspaper articles about women being raped (often by men), reading history books about villages of women being raped (often by men), receiving catcalls and verbal sexual abuses (often by men), and knowing about pornography and prostitution and late night clubs where women are sexually belittled (often by men). She has been surrounded with evidence her whole life that some men might view sexual parts of female bodies differently. Unfortunately, OBGYN is not much different than these phenomena anyway, as it is a field that has abused the sexual organs of women for decades and was created primarily by male minds. And so when a female patient requests same-sex care, it may be because she has read books such as "Women and Doctors" by John M. Smith, MD, which revealed frightening statistics such as how much more likely it is for male gynecologists to recommended unnecessary hysterectomies, and how much more prevalent it is for male gynecologists to be reported as sexually abusive.

So how can this OBGYN faculty, who holds birth control hostage from girls and women until they submit to stirrups, relate to patients who ask for modesty accommodations anyway? Any physician or nurse, male or female, should be open-minded and accommodating with all patients and their valid and legal requests for same or opposite intimate health care, as well as their legal right to refuse degrading exams for contraception. Unfortunately, instead of accepting his patients as human beings with modesty concerns, he exploits their situations to elevate his own status as the heroic physician who is educating students to end what he conveniently believes to be sexual discrimination in medicine.

Even if these instructors are so black-and-white in their thinking to believe they are being discriminated against, they still hold responsibility to follow the law and teach students to do so as well. If they dislike the law, they can always orchestrate their own rallies to advocate for fewer patient rights. But I wonder how honest and humanistic they would feel about their pursuits. All they would be doing is transferring the alleged target of discrimination to the group of people who are in the much more vulnerable position, the patients.


The OBGYN faculty said he did not support my conflicts with the curriculum, and sent me to a Dean who is also involved with curriculum. This Dean gave me an unhelpful psychotherapeutic session the moment I walked into his room. Before I could explain in my own words what I came to speak about, he asked me "Do you remember anything happening to you that would make you see an ear exam differently than a pelvic exam?"

I thought it was unprofessional for him to ask me personal details about my life, but I told him I have never been sexually abused. I told him some students might find the exam itself to be violating if they are not told about it beforehand. He shook his head like I was a child trying to convince him Santa Claus was real, and told me the only explanation for a person to feel angry over medical exams was if he or she had been abused. Even when I reiterated this was not my case, he told me to seek help from a psychiatrist and "connect the dots" to my abusive upbringing. He went so far to ask if I had siblings, and suggested they also seek help.

I did not think this Dean seemed like an intelligent person to preach about sexual abuse inside or outside of medicine, seeing that he gave no exemption to the student who did admit to an abusive past, and maybe even believed the prostate exam granted her the ability to stop overreacting to whatever caused her to cry.

When searching for criticism of modern gynecology, I came across a popular book "(Male)Practice" by Dr. Robert Mendehlson, who was a pediatrician at UIC. The author stated:

"I will never forget a student of mine who wanted to specialize in obstetrics but couldn't swallow all of the ridiculous obstetrical intervention that he was being taught. He began to ask questions of the obstetricians: Why were the mothers' feet up in stirrups? Why were they giving the women analgesia and anesthesia? Why were they inducing labor at such an early stage? Why were they performing Caesarean sections when there was no clear indication of need? Did he get answers? No, but he got action. He was referred by the chairman of the department for a psychiatric examination, because any student who asks a hostile question in medical school is presumed to be 'disturbed.'"

This book was written in 1982, and still thirty years later at the same school, when students disagree with sensitive medical procedures, the Deans immediately send them in for psychological evaluation. I whole-heartedly concur with the author: Instructors at UIC stubbornly maintain there is something wrong with individual students each year, and never with the system itself.

Even worse, this Dean promotes a philosophy to his students that as long as nudity, touching, and penetration occur in the medical setting, then no sane person could possibly feel violated. This is far from the truth, and patients are beginning to speak up about their rights to refuse, request accommodations, and seek alternatives for "intimate" procedures.

For instance, I read the term "birth rape" has been coined. While I understand the term may be legally problematic, I find it conceivable that some women can only describe it this way after what was done to their bodies without permission. And I do not think these women are upset having life-saving C-sections, instead of natural dreamy births. They are upset having unnecessary and aggressive interventions without consent. Can it really be true that so many women must have their labor induced (a known risk factor for pelvic floor damage, perineal tears, epidurals, and C-sections)? Do so many women need episiotomies, when there is no evidence that artificial tears are safer than natural tears, which are rare anyway? Large studies of home births with trained birth attendants show that the majority of women can give birth without interventions, with less injury to mothers and babies, and no increased risk of mortality to either.

There is an unfair rule from doctors that all women automatically accept fingers and instruments in their vaginas if they wish to deliver a baby, even when births are proceeding smoothly. Doctors have an obsession with "checking progress" and recording numbers, with no respect for women who feel the procedures are barbaric. Some insurance providers cash in $250 per bimanual exam, which generates big bucks when doctors perform multiple "cervical checks". There are less demeaning maneuvers that cause less vaginal infections, but these alternatives are never offered. Instead, women who decline pelvic exams and episiotomies receive them against their wills! The baby needs an emotionally healthy mother, and that does not happen when she leaves the experience with so much trauma to call it "birth rape".

As for cancer screening, women are kept in the dark about less intrusive methods to test for cervical cancer (CSA blood tests, urine tests, vaginal swabs, and self-pap tests). Unlike this Dean, I strongly believe patients could feel mistreated by undergoing traditional pap smears should they discover that alternatives, which could have preserved their dignities, were not fairly discussed with them, or should they discover they were not even candidates for cervical testing in the first place.

A report released by Dr. Angela Raffles (cervical cancer screening expert from the UK) demystifies pap smear risks - 1000 women need to be annually tested for 35 years to save one woman from cervical cancer. Meanwhile, 95% of them (950) will require one or more biopsies that can be harmful (emotional stress, sexual problems, cervical stenosis, pregnancy complications, and even infertility). Another article by pathologist Dr. Richard DeMay "Should we abandon pap smear testing?" exposes the fact that cervical cancer mortality was trending downward before the application of pap smear testing, and that when malpractice suits led to higher false-positive rates (and hence more biopsies) cervical cancer mortality actually increased. Hence, the widely proclaimed association between the introduction of the pap smear and decline of cervical cancer might be more casual than causal.

Most doctors do not tell women that "the best kept secret of cervical cancer prevention" is through practicing safe sex and avoiding smoking, not through pap smears. Some women have microscopically slim chances of benefiting from the pap smear, such as virgins, women who only have sex with women, and long-term monogamous women. The same is true with ovarian cancer screening via pelvic exams: The American Cancer Society recommends against it. Why should doctors keep sticking their fingers in places they do not belong when there are no proven benefits?

It is clear to me that dishonesty surrounds much of these "preventative" gynecological exams. Doctors established these tests (money or fear of being sued), and the individual was disregarded. It became: Every Woman must have these exams with No Alternatives.

I can say with confidence that medical students are trained to think this way. In fact, in our first year of medical school, all students practiced interviewing patients with a standardized list of important questions. We asked ALL women: "When was your last pap smear?". But we asked NO men: "When was your last prostate exam?" It would almost make more sense to assume all older men are candidates for prostate exams, than to assume all women are candidates for pap smears since cervical cancer is an STD and so some women are not eligible. Also, the incidence and death rates of prostate cancer are much higher than those of cervical cancer, so it must not be about the numbers. In addition, cervical screening can be a more vulnerable process than prostate screening, because men often have the option of the PSA test (while the CSA test is never offered to women). So really, our first lesson was that female patients do not mind being humiliated in the medical setting, and that we should assume all women accept traditional gynecological exams, even the ones who could only be harmed by them in the first place!

The tunneled vision that this Dean holds (that doctors and nurses are above human modesty) will lead to suboptimal care for many patients outside of gynecology as well. I respect Dr. Joel Sherman and Dr. Maurice Bernstein, and the medical modesty issues for which they are raising awareness for male patients as well. In many ways, it can be a world more difficult for male patients to request and receive modesty accommodations because it is an overlooked topic without enough attention to draw any intelligent conclusions. In addition, people often view modesty as an unmanly characteristic, which might contribute to the ignorance about men having modesty, as well as the silence that fuels this ignorance because when they know to expect ridicule, men do not want to voice their modesty concerns. And I feel very sorry when I read comments from boys and men who have been traumatized by icy nurses and doctors who stereotype males as having no modesty. Unfortunately, I worry this stereotype will die hard, unless male modesty rightfully becomes a component of medical training and education.

I believe most of this ignorance stems from the way doctors are trained. When medical students learn to take sexual histories, we are trained to ask: "Do you have sex with men, women, or both?" (As a side note, I always thought the question should also include "or none" to represent all patients). Before the gay rights movement, this question was systematically swept under the rug to favor the heterosexual population, and hence made gay and bisexual patients less comfortable to openly discuss their sexual histories. Doctors now know not to assume all patients only have straight sex, and this is something that was strongly enforced at my school. I cannot imagine any of my classmates forgetting this simple question, because we are trained and repetitively graded to ask it verbatim from the very beginning. I think many medical students would feel confident to question one of their superiors if they did notice he or she was discriminating against sexual minorities this way, since it is a highly-valued aspect of our training.

On the other hand, when medical students conduct intimate physical exams, we are not trained to ask: "Do you prefer intimate care from a male or female provider, or do you have no preference?" Currently, this question is sidetracked to favor time-pressed doctors and patients who have no preferences, despite it being a legal request unknown to some patients. Obviously this setup makes patients feel ashamed if they do hold strong preferences and values whether a man or woman does their intimate exams. Perhaps then there needs to be a patient modesty movement that might be as successful as the gay patient rights movement by training and grading students to exercise the sexual rights of their patients in this manner as well.

Unfortunately, medical students know they will be shunned if they advocate for patients this way, since sex preference for intimate exams is not an official part of the curriculum. Not only that, but as I mentioned earlier, the instructors at my school reprimand students who bring the topic up for discussion. Therefore, I think dishonesty and silence are fostered in medical school, because I suspect some medical students make their own requests when they are in the vulnerable position as patients. And so they must empathize with patients, but at the same time they must sell their integrity by not questioning their superiors and fitting into what is expected of them, which is to work toward becoming competent physicians who possess minds too perfectly rational to see anything sexual about the exams, and hence too rational to understand why patients might seek modesty accommodations. In other words, doctors pretend not to "see an ear exam differently than a pelvic exam" since they fear admitting so would be a transgression of their medical conduct, and unfortunately this means distancing themselves from patients who do have modesty concerns about exams due to their sexual nature.

I think many medical students sacrifice their integrity subtly at first, and then succumb to the Domino Effect. At first, maybe a student knows he cannot desexualize the pelvic exam, but fearing how his instructors will react, he says nothing, and performs it poorly at the expense of the patient. Next, he might watch an instructor reprimand a female patient when she admits she is not comfortable surrounded by male medical students for her pelvic exam, and he does not stand up for her even though he believes she should not be reprimanded for her request. Now that he has grown more desensitized and dependent on fitting into what instructors expect of him, he might watch an instructor misinform a patient (out of conflict of interest) that pelvic exams are always necessary to obtain birth control, and even though the patient seems weary about the procedure, he does not question the ethics of his instructor. After all, he cannot express his concerns without implying that the instructor is sexually abusing his patient, which would certainly label him as a whistle-blower.

After that, an instructor tells the student that if he admits he is a medical student, then no patients will not allow him to practice sensitive exams on them, and so he follows the advice to flat-out lie to patients about already being a doctor. Ultimately, he agrees to practice pelvic exams on anesthetized patients who have not consented to it, because his instructor tells him these women would have adamantly refused students using their bodies for didactic purposes, and so it is a great opportunity for them to practice their exam skills on unconscious bodies that cannot protect themselves. The student believes the most important skill with a pelvic exam is to obtain informed consent. He sees this "educational" setup as being no different than gang rape. But he has already jeopardized his ethics so many times in the past in relation to sensitive exams. So he does what apparently many medical students do in this country, and gang rapes his own patients.

Gang raping anesthetized patients is apparently a "time-honored tradition" in medical schools, an ethical problem that has garnered media attention for decades, but has never provoked enough frenzy to encourage change. I never witnessed this practice as a first-year student, but I bet my life it is something I would have encountered had I graduated from UIC. I strongly suspect this because when I was sent to the OBGYN faculty, he cautioned that I would face additional dilemmas if I refused to perform pelvic and rectal exams during clinical rotations, and said "You might also have a hard time with... Never mind, we do consent all our patients here." It was patronizing he thought I was gullible enough to believe in his statement when he had to "correct" himself. In any case, I already knew this person was not sincere because he had already lied to me earlier in the conversation. (One of the news articles I brought was about Muslim male medical students refusing certain exams on female patients. When I handed it to him, he casually commented "Oh yes, I have read about this before," when the very reason I brought him articles was because he had told me in our first meeting he was "ignorant" students had problems with aspects of physical exam).

The way he corrected himself mid-sentence told me that in fact UIC has not enforced any policy to end the gang rape of patients, which according to the press, still routinely occurs in most medical schools. This is a topic that was never officially discussed at my school, and I only learned about it through my own research. Hence, students at my school are not prepared to challenge medical gang rape because they will be branded as trouble-makers for suggesting their instructors are gang rapists. This is why I believe most medical students trade in their ethical tenets to complete school, because otherwise repulsively unethical practices like gang raping patients would have died long ago had students followed their hearts, refused to participate, and reported their instructors for legal action.

Two other quotes from Dr. Robert Mendehlson, the pediatrician at UIC:

"The tragedy of this dogmatic approach to medical education is not only that it screens out the most thoughtful, intelligent, and ethical students, or that is perpetrates traditional idiocies, but also that it virtually forestalls the application of creative noninterventionist approaches to medical practice. Dr. Roger J. Williams put it well in his book, Nutrition Against Disease: Medical schools in this country are standardized (if not homogenized). A strong orthodoxy has developed that has without a doubt put a damper on the generation of challenging ideas. Since we all have one kind of medicine now - established medicine - all medical schools teach essentially the same things. The curricula are so full of supposedly necessary things that there is too little time or inclination to explore new approaches. It then becomes easy to drift into the convention that what is accepted is really and unalterably true. When science become orthodoxy, it ceases to be science. It ceases to search for the truth. It also becomes liable to error."

"My colleagues who head the nation's medical schools boast that this process of "survival of the fittest" assures Americans of the finest medical care in the world. My observation is that doctors are taught to provide a lot of medical and surgical intervention, but I don't see evidence of very much 'care.' The fittest do survive, but what are they fit for? They are the survivors of a heartless system that too often weeds out the best and the bravest - the students with compassion, integrity, intelligence, creativity, and the courage to resist the destruction of their own moral and ethical codes."


When they withdrew my scholarship, faculty told me they "firmly believed" future doctors must competently perform these exams. But this obviously is not the case at all, otherwise they would not graduate students who did not complete the exams objectively. All the students who cry and faint and make horrified faces certainly are not demonstrating objective behavior. Moreover, the school does not even give all students the opportunity to prove they have desexualized any type of medical exam, since they enforce their "rule" that one female must be present during the male rectal exam. When problems like this are marginalized, it inevitably translates to a small number of students advancing to clinical rotations ready to hurt patients expecting adequate exams, since these students feel too much pressure to act competent as future doctors, they cannot admit the exam is something they never desexualized (and they cannot admit they might faint or cry on a real patient, like they did on the actors). Students like this avoid pelvic exams as much as possible, and write "pelvic deferred" in patient charts, because they cannot be honest enough about their shortcomings to ask another provider who feels more comfortable to perform the exams instead (Article: "Managing Emotions in Medical School").

So by trivializing something important, like the inevitable cultural and personal attitudes and barriers about human sexuality in medicine, my school is hurting patients by exposing them to students who are too busy hiding their inadequacies. I thought I was more professional than these students to admit I had visceral problems over these exams, than to not admit so and make an already unpleasant exam even more unpleasant for patients. It is blatant that the only thing faculty "firmly believed" was that students never stand up for themselves if they cannot find peace with a small component of the curriculum.

Before I left, I recommended to several faculty members to start screening students. It is unprofessional and unethical to not explain these taboo exams to students before matriculation. When I suggested this to the OBGYN faculty, he nonchalantly replied that they "might consider it." He said this in a very condescending and indifferent tone of voice, even though as a physician, he should respect and practice full informed consent. The only person who ever got back to me was one of the ECM instructors who sent me an e-mail saying she would voice my concerns for future students but she "can't promise that there will be a change."


I am not angry I did not graduate from medical school: I do not want to work in such a hostile and uninspiring environment. But I am angry I moved to a new city to start school without knowing that the same problems that mistreated students in the past would mistreat me because my school will not clean up their system. I am angry I had to arrange so many embarrassing conversations with faculty, only to be told I was "too immature", "too sheltered", "too squeamish", and sexually abused as a child. I am angry my school ostracizes a minority of students each year over something personal like their sexualities, and believes they should all have to change their views to assimilate to those of the majority. That is something that has always bothered me.

I hope Dr. Sherman and Dr. Bernstein continue to raise awareness for patients to know and exercise their options and legal rights regarding sensitive medical exams. And as a woman, I hope American girls and women start to explore alternative practices and philosophies about their bodies and reproductive healthcare outside of the rigid setup traditional modern gynecology has to offer. I could never accept non-emergency care from OBGYNs now that I know how they are trained. If I ever wish to have a baby, I will not think twice about home-birthing with midwives because I do not want to be a woman who receives demeaning and dangerous interventions when unnecessary and often harmful to both her and her baby. And I am ecstatic to see that American women are becoming more informed about their birthing options, thanks to documentaries like "The Business of Being Born" by Ricki Lake.

Much of what I wrote here ties into various medical modesty and ethical concerns discussed on Dr. Bernstein's Blog. That is why I agreed to publicize all of it here on his Blog. I also do not mind publicizing this story further anywhere else if it might prompt a change in some of the problems I detailed.

I wanted to end by saying that I believe there should be a requirement at the national level that students are explicitly told about these exams when they apply to medical schools, which should not be laborious to implement because students all use the same application website. I contacted several individuals last fall, told them my story, provided them with news articles about students fainting and crying, and none of them took me seriously. Some of the people I contacted included the "Senior Director of Student Affairs and Student Programs at AAMC" and the "LCME Assistant Secretary". These people told me they thought most students knew about these exams beforehand. First, I have never believed that "most" is ever enough; it does not validate the fact that the system currently tramples over a minority of young students. Second, I do not know where they got their flimsy statistic that "most" know about these exams anyway, since most students have never visited the proctologist, and at least half have never visited the gynecologist. These people also told me different students face different "challenges", and so they cannot cater to one "challenge" over another. I do not believe these intimate exams are "challenges". I believe any exam that could be construed as sexual (and sexually violating) must be fully explained and consented. Otherwise, it could be serial sexual abuse and rape.

I also want to report the OBGYN faculty for not following the law that women can get birth control without pelvic exams, as well as report both him and one of the ECM instructors for not properly educating students about the BFOQ patient modesty law. These individuals are teaching and encouraging hundreds of future physicians each year how to be insensitive about sensitive exams, and I want to do something about that. The problem is I do not know how to report these authoritative figures, unless there are freelance lawyers any readers out there might know about who advocate for patient rights.

I look forward to reading any comments and suggestions from readers.