DOCTOR-PATIENT COMMUNICATION & THE MODESTY ISSUE

Dr. Maurice Bernstein and Doug Capra have co-written an article just

published by the American Medical Association in their amednews.com.

It's a fictional dialog between a doctor and a patient about communication

and modesty. Here's the link.

Sports Physicals Are They Needlessly Embarrassing?

Sports physicals are universally required in the U.S. on an annual or seasonal basis for students wishing to participate in sports.  All states have requirements covering public schools.  The reason for the exams is to ensure that the athletes can participate safely.   These exams are not intended to replace a regular physical.  There are no absolute standards for what should be included in these exams.  Most would agree that the emphasis should be on the cardiovascular and musculoskeletal systems.  The manner in which the exams are done is also not standardized.  Most schools will give students an option to see their private physician to have a form filled out; the private physician may elect to combine this with an annual exam.  Schools will usually offer a group examination which varies greatly in terms of how it is set up.  It could be one physician or nurse practitioner seeing the students one at a time; it could include multiple specialists seeing the students at different stations in a large area such as a gymnasium.  It often includes no provisions for privacy.

It is no secret that most children find these exams embarrassing as indeed they are likely to consider all exams.  But how embarrassing they are depends on how they are done.  All exams should include a full history form to be filled out to identify in advance any special problems.  Following that, every student needs BP obtained, a cardiac exam and basic check of skeletal muscular integrity.  Specific sports may require further checks, such for instance that wrestlers should not have any contagious skin diseases.
 
Girls usually have no further standard exams.  They do not have to take off their bra or panties for most exams.  Boys typically have genital and hernia exams done.  This is considered a standard of care by some guidelines.  The reason for this is unclear and the need for a genital and hernia exam is undocumented.  Though some information as to the child’s development can be obtained by a genital exam, the exam is usually not pertinent to the ability to play sports safely.  It is doubtful that asymptomatic hernias affect one’s ability to safely play sports.  A good history should detect who needs to be examined for this.  Indeed it is clearly recognized that the need for a genital/hernia exam is controversial.  There are no clinical outcome studies available which document the need for these exams.  In contrast, there are studies, especially in Italy, which have looked at cardiovascular screening to answer how many sudden deaths can be avoided.

These exams can be intensely embarrassing for adolescent boys.   This is widely recognized.  There’s even a small percentage of boys who refuse to participate in sports because of these exams.  I have seen women physicians blogging about how embarrassed the boys get during these exams.  Yet this problem is rarely addressed.   Reducing the embarrassment can be addressed in many ways.  For most boys, a male physician is less embarrassing than a woman.  But women who are a majority of pediatricians nowadays are often the ones who perform these exams.  As girls are fewer in numbers and not usually exposed at all for these exams it would be rational to give preference to male physicians.    Yes, modern medicine is supposed to be gender neutral, but patients, especially adolescents are not.   Increasing preference is given to female gynecologists for adolescent girls exams; the same preference should be granted to boys.

 Also crucial is the privacy which is afforded the students during the exam.  Although financially able families can take their children to private physicians, poorer students may only be able to afford school organized group physicals where privacy is routinely sacrificed.  But it doesn’t have to be.   All intimate exams should be done in private, behind screens if the exam is in the open, without any chaperones or onlookers directly watching.   Boys are embarrassed by any genital exam, but the embarrassment is intensified when there is an opposite gender chaperone watching.   That would never happen to girls; why is it considered appropriate for boys?  How would adults feel about such an exposure?  Even the military has stopped exposing young men during group physicals and now do the intimate parts one on one.  Better yet, hernia exams should only be done when the history indicates a possible problem.   The NCAA 2008-09 Sports Manual doesn’t even mention the word hernia.  There is no other need for genital exams to play sports.  If girls don’t need them, why should it have become a ritual for boys?  Embarrassing genital exams are best done during regular physicals by private physicians; there’s no need for them to be part of mass screening.  I have read many guidelines for sports physicals.  I have never seen one which gave anymore than passing lip service to privacy requirements.   I have never seen one which even mentioned the words modesty or embarrassment.

In summary, embarrassing sports physical have become almost a rite of passage.  That was perhaps better accepted in prior decades when boys were more accustomed to group nudity, generally taking group showers together in school.  But times and mores have changed.    Most kids have not been exposed to group nudity when they first try out for sports and an increasing number can’t cope with it.  Parents should be aware of this and be ready to intercede on behalf of their children.  Most are reluctant to lodge complaints with the school.  Given the total lack of evidence that routine intimate exams add to the safety of participants, the regular use of these exams should be abandoned.

Copyright © 2011 by Joel Sherman

This article has been chosen for reposting on KevinMD, a widely read medical blog.

AN OPEN LETTER

Dear Juicy Nurse and Trauma Diva:

Unfortunately, I was introduced to your blogs recently. I found a reference to them on Dr. Maurice Bernstein’s bioethics website on the 38th volume of his thread on patient modesty. It’s the longest running thread on his entire site. You may want to contemplate why that thread has lasted for years, and why so many patients are concerned about modesty and privacy violations they and their loved ones encounter in medicine today.

My introduction to your blog, Juicy Nurse, was “unfortunate” because the poster who introduced it brought me right to your Monday, September 7, 2009 post entitled “Penis!” The poster, who signed it “Anonymous,” wrote this: “Here’s a blog from one of those gender neutral ‘angels sent from God.’ Note not a single comment calls this unprofessional.”

So, what’s the philosophy of your blog, Juicy Nurse? Here’s what you write:

“This blog is designed to give nurses an opportunity to listen to funny, embarrassing, truthful, sad, and happy stories. I plan to talk about things that don’t get discussed! The truth! This is a forum to be honest about the challenges of nursing! God knows we have challenges. Let’s talk about them!”

Yes, Juicy Nurse, let’s talk about the “truth.” (This goes for you, too, Trauma Diva). Here are a few “truths” for you to consider:

1. Your blog, although aimed a nurses, isn’t read by nurses only. It’s read by the whole world. That’s the nature of the “world-wide” web.

2. What’s “funny’ to nurses is not necessarily “funny” to a good number of your patients. Oh, yes. I know. You’ve got to have a sense of humor. That is true. But you need to realize that what’s “funny” in your work place, often depends upon whether your dressed or in a gown, whether you’re in pain or not in pain, whether you’re exposed or covered, whether your laying on the exam table, or standing over it.

3. You want to talk about “things” that don’t get discussed? Okay, then -- Read the rest of this essay.

You extend your philosophy a bit more, Juicy Nurse, with this explanation:

“Let’s Talk Juice! Being a nurse is rewarding…True, but it is also pretty funny, disgusting and really trying at times. Let’s share the stories that we can not share at work, at the dinner table, or with people that are not in health care. Let’s talk about the unspeakable! No judgements (sic.) here! Enjoy!”

If these are stories you can’t talk about at work, what makes you think they’re appropriate here for everyone to read? Here’s another truth: You did actually share your “Penis” story with those not in health care. And many of them didn’t think it enjoyable, entertaining or funny.

By the way, Juicy Nurse. Words have connotations, and I would suggest to you that the title “Juicy Nurse” sets the wrong tone from the beginning. It seems to encompass all the unhealthy stereotypes about naughty nurses that we see in the media.

My introduction to your blog, Trauma Diva, was “unfortunate” because the poster who introduced it brought me right to that wonderful “Trauma pic of the day.” Readers, go to the bottom page of this link. It shows a naked male patient in the ER, his belly opened up completely, his pubic hair and penis clearly visible. The first question that came to my mind: “Did you have the patient’s permission to post this?” I located your apparent answer in another spot on the page It’s titled “Diva Disclaimer” and reads:

“BTW, all posts are HIPAA compliant. Any event, picture, person or thing that resembles real life in any way is a figment of your imagination. All persons, places and events are purely fictional. Yah?”

How respectful of human dignity, patient privacy and modesty! Your philosophy and purpose for your blog? Here’s what you’ve posted:

“Howdy! Step into the nurse’s lounge of a big city ER. Prop your feet up! Talk is cheap. Gossip, great ER stories, and gross trauma pics are always welcome. This is the spot to dish about worthy trauma trash -- actually trash or dish of any kind will do.”

So -- suffering, hurt, patients in pain are “worthy trauma trash,” or “dishes” of any kind? Yes, talk is cheap, and so is your exploitation of human suffering for the entertainment of the public.

You see, Juicy Nurse and Trauma Diva, here’s my problem with what I’ve seen on your blogs: I have I’ve spent considerable time defending nurses against accusations of unprofessional behaviors, accusations that come from men like the one who found your “Penis!” post and called attention to it. Or, like the man, Trauma Diva, who found the photo you posted for public “enjoyment.” Some of these men clearly are misogynists. They neither like nor respect women in general and nurses especially. They’ve been hurt, insulted, embarrassed, humiliated, shamed by female nurses and they’re not in a forgiving mood. There’s probably nothing we can do to change their minds.

But not all of these men are misogynists. Some of them are good men. Men with wives and daughters, mothers and aunts. They respect women. But their unprofessional treatment has alienated them from female nurses in particular and the health care system in general. Now they’re angry. They don’t trust you.

Your unprofessional little essay, Juicy Nurse, about various penises you encounter helps these men justify their position. Your infantile description of the “peek-a-boo penis, smelly penis, dirty penis, oozing penis, uncircumcised penis, young penis, old penis, swollen penis, uncomfortable hard every time I walk in the room penis, paralyzed penis, white penis, Jewish penis, Asian penis (not good)…”

Your reference to African Americans, is particularly offensive if not racist:

“It is true what they say about the black man. I have seen A LOT of black man (sic) penis and it is NEVER small. From the time these penis’s (sic) enter the world they are HUGE. It is UNBELIEVABLE! The little black babies have penis’s (sic) that actually flop up over their belly buttons. When I worked in pediatrics, I was shocked at the head start that these little black babies get…they are ahead of the game from day 1!”

I do want to apologize to my readers for even quoting this offensive nonsense -- but some of you won’t bother reading the penis article or looking at this blog (I don‘t blame you), so this at least gives you an idea of this kind of disrespectful, shall we also say racist, misandry.

And you, Trauma Diva, with your wonderful, exploitative photo. Is it any accident that you selected a male for this photo? Would you have selected a female with her breasts and genitals showing? Perhaps. Bad judgments goes both ways gender-wise. But many men see a double standard here. Are they wrong?

Can you imagine how people would react if a male nurse wrote a piece like yours, Juicy Nurse, about the various breasts he encountered? How about a male nurse writing about all the different kinds of vulvas and vaginas he encounters every day. Take the quote I provided above -- you know, the different kinds of penises -- and replace penis with vagina or breast. I would suggest that this would never be accepted.

That brings up the double standard regarding how respect for men and men’s modesty is treated by a significant number of medical professionals. As an example, I refer you to web column by a Dr. Sharon Orange called “The 10 Real Reasons Why Men Don’t Go to the Doctor.”

Reason number 1 -- “You are afraid we’ll put our finger in your butt.”

Reason number 2 -- “You’re afraid we’ll examine your balls.”

A significant number of men found her tone and language offensive, patronizing. They wondered how it would have been taken if a male doctor had spoken to female patients using that kind of language to describe their private areas. Sexist? Some suggested that any male doctor who wrote like that to women would find his license and/or job in danger.

The irony -- I’m sure Dr. Orange wants to help men. I don’t think she was meaning to be offensive. She exercised poor judgment, stereotyping men, perhaps, believing that by entering into the old boys’ club and using this kind of language she’d score points. One needs to be careful.

Juicy Nurse and Trauma Diva -- Do you see what I’m talking about?

I must say this to my readers. This material is so offensive that it’s hard to be positive that it’s authentic. Are these real nurses writing these blogs, or is this a sad joke? I’ve read everything on both blogs, and it’s clear to me that these are real nurses. All the posts are not like this. Some are actually decent. I’ve run these blogs by other medical professionals who agree that they are authentic. I'm convinced that Juice Nurse and Trauma Diva are real nurses.

Now, Juicy Nurse and Trauma Diva, I challenge you to respond to this post. I’ve read both of your blogs, all the way through -- not just the offensive material. There’s good and bad there. The sad thing about all of this is that I can see that in many ways you’re both kind, caring individuals. I’m also sure you probably have fine skills as nurses. But I question your judgment.

The spider that prowls the world wide web has captured you, wound you up, stung you, and put you to sleep. You think you’re in your own little world rather than exposing yourself to the whole wide world. You’ve forgotten what it means to be on the other side of the gown. You’ve lost your empathy.

I spent a long time writing this piece, and made sure I ran it by my co-moderator, Dr. Joel Sherman. It’s not pleasant for me to attack two nurses. If you read my many, many posts and articles over the years, you’ll see that I have great respect for the vast majority of nurses. But too many today are getting trapped by their Facebook pages and blogs like yours. I don’t think you realize the damage you can do to your profession with some of the posts you write. I don't think you realize how quickly you can alienate your patients with blogs like yours.

So, before you challenge me, note this --I’m writing under my real name. Neither of you, Juicy Nurse nor Trauma Diva, are writing under your real names.

I wonder why.

NOTE -- Readers: If you, too, are offended by these blogs, consider filing a complaint with the American Nurses Association. Email to ethics@ana.org.

NOTE 2 -- "Apparently," and I use this word for a reason, the real person behind Trauma Diva is this person. On the Trauma Diva blog, under Sunday, April 18, 2010, you'll find at post titled "Writer Out of the Closet" where she gives sends readers to the link above. So, she isn't hiding. She has identified herself. She also

started a amateur radio talk show about popular culture, TV trash and trauma cases. The first, and perhaps the only episode, can be found here. It's mostly dedicated to a shallow discussion of an episode of the reality show, The Bachelor. One caller participated in the show. Near the end, she says future shows will include trauma cases, all of which will be HIPAA compliant, she says.

I mention all this because this nurse is right out in the open. Although she uses the title Trauma Diva, she has made her identity known. I have to give her credit for that. But I see no educational or professional purpose to either her blog or her radio show. It's all about gossip, popular culture, and trash TV. And by mixing in trauma cases with all this, she denigrates the patient experience and patient dignity.

(c) 2011 Doug Capra