Saturday, March 26, 2011

PRIVACY, MODESTY & STAFF BURNOUT

It is our pleasure to introduce this weeks guest columnist, Carolyn Thomas. Carolyn Thomas is a heart attack survivor and a 2008 graduate of the WomenHeart Science & Leadership Symposium for Women With Heart Disease at Mayo Clinic in Rochester, Minnesota - the first Canadian ever invited to attend this world-class training event. "Our Bodies Ourselves" of Boston named her one of their 20 "2009 Women's Health Heroes", one of 20 inductees from seven countries honored for community activism in women's health. She blogs at HEART SISTERS and THE ETHICAL NAG


A scene from the cable show, Nurse Jackie.


Does staff burnout lead to ignoring privacy considerations?

by Carolyn Thomas

As a heart attack survivor with an accordion file of ongoing complications, I’ve become a frequent flyer with my cardiologist, my longtime family physician, related specialists, the Pain Clinic, our local hospital, and in countless diagnostic procedure labs.

Many of these procedures – like a stress echocardiogram, for example – involve stripping to the waist and putting on the flimsy paper gown, but – in the case of a stress echo - with the opening at the front instead of the back to allow10 EKG leads to be attached to your bare torso during the test.

Not a big deal for male patients, but let me assure you – this is a very big deal to most women.

The last time I had a stress echo done, the experience was so profoundly upsetting that I not only filed a formal complaint to the departmental manager, but I created for her something I called Carolyn’s Top Ten Tips on How to Treat Your Patients.

It wasn’t the specific diagnostic procedure itself that was so upsetting that day. It was the appallingly poor social skills of the two attending technicians in the room. For example, when I entered the echo lab, one of the two techs present sat at a corner desk. He did not look up at me when I walked in, did not say hello, did not introduce himself. Was he the tech? Was he the doc? Was he the janitor?

As I later wrote to his manager:

“It’s not so much that these two people were openly rude – but it was their insufferable lack of people skills that pushed me over the edge. No introductions, no eye contact, no consideration of how awkward this test can be, no explanation of the test procedures or even the flimsiest effort at polite conversation.

“And by the way, next time I’m ordered to strip to the waist in front of a strange man, he’d better buy me dinner first.”

It has occurred to me during this and a few needlessly stressful medical encounters like it that the physicians, nurses and technicians who seem least likely to act like they give a damn may be the very staff who themselves are struggling with job burnout.

Burnout has been widely described as emotional exhaustion. The most conscientious people-helpers appear to be most vulnerable to burnout. Researchers like Maslach, Freudenberger and others dating as far back as 1977 gave the name 'burnout' to the special stressors associated with social and interpersonal pressures.

Dr. Arch Hart, who coined the term ‘compassion fatigue’, says burnout may include:

demoralization (belief you are no longer effective)

depersonalization (treating yourself and others in an impersonal way)

detachment (withdrawing from responsibilities)

distancing (avoidance of social and interpersonal contacts)

defeatism (‘why bother?’)

Dr. Christina Maslach has described burnout as “a state of physical, emotional and mental exhaustion marked by physical depletion, chronic fatigue and negative attitudes towards work, life and other people.”

She adds the following signs that you may be struggling with burnout:

decreased energy -'keeping up the speed' becomes increasingly difficult

feeling of failure in your vocation

reduced sense of reward in return for pouring so much of self into the job

a sense of helplessness and inability to see a way out of your problems

cynicism and negativism about self, others, work and the world in general

It was that last sign that should have waved a red flag (or at least a couple of EKG leads) in front of my face.

If a health care provider is feeling “cynical and negative about self, others, work and the world in general”, this person may no longer be capable of exhibiting even basic common courtesy or consideration about a patient’s potential discomfort or embarrassment during a clinical procedure.

Health care research on physician burnout by Dr. Evan Falchuk found:

“On days when doctors felt positive moods, they spoke more to patients, wrote fewer prescriptions, ordered fewer tests, and issued fewer referrals. However, when doctors were in a negative mood, they did the opposite.”

When I was casually told to strip to the waist by that stranger in the corner, neither he nor his colleague offered me a place to leave my clothing. Already feeling anxious and worried about this stress echocardiogram, I slowly pulled off my sweater and bra and clutched them tightly to cover up a bit while the two techs sat in bored silence, waiting for me to hurry up. One motioned to a chair in the far corner for me to place my belongings, and tossed me a paper gown.

Both could not possibly have demonstrated less respect for modesty even if they had deliberately set out to embarrass me. Afterwards, I described my impressions to their manager:

“To them, I was merely their 1 o’clock appointment, the obstacle between them and their next coffee break, just a piece of meat on a slab – but worse, an invisible piece of meat.”

In fact, it was this odd and inappropriate behavior of both these techs that first made me think: “Something is very wrong with you people!”

People suffering from severe emotional burnout could easily treat other human beings the way I was treated that day. Even saying a simple “Hello, my name is…” apparently required too much effort of them. They simply could not care less.

I was unable to identify this at the time, but when I read Dr. Hart’s list of burnout symptoms, a number of them leaped out at me to describe my stress echo techs: depersonalization (treating yourself and others in an impersonal way), detachment (withdrawing from responsibilities), and distancing (avoidance of social and interpersonal contacts). Check. Check. And check.

The most damaging part of this encounter was not the procedure itself. I’ve had many other far more potentially embarrassing medical procedures (sigmoidoscopy, cystoscopy, not to mention that I’ve delivered two babies the old-fashioned way) but none left me feeling as distressed as I felt during and after that stress echo.

Why? It just happened that the health care professionals who administered those other privacy-invading procedures had been universally kind, gentle, friendly, approachable, careful to explain what was happening, and solicitous of how I was doing throughout each test.

The good news: after receiving my complaint – tellingly, the second in the same week about the same people! - the cardiology departmental manager told me she felt quite alarmed to hear this about her employees. She not only spoke to the people involved, but then read my Top 10 Tips On How To Treat Your Patients aloud to all her staff at their next weekly meeting, posted it on their staffroom bulletin board – and even submitted it for publication to the hospital’s monthly internal newsletter. You can read it here at “An Open Letter To All Hospital Staff” on my blog Heart Sisters.


26 comments:

Joel Sherman MD said...

As a cardiologist involved in stress echocardiograms, the description of your test is startling. Rude uncaring personnel can happen anywhere (though it shouldn't). But a basic principle of dealing with patients is that you let the patient dress or undress in privacy. If the room doesn't have a separate area for this, privacy screens can be used. Most women are uncomfortable undressing even in front of other women, let alone 2 men. In our hospital, the female ultrasound techs ask the patient to change in an adjoining bathroom. Male ultrasound technicians are certainly not rare, but you would think they'd go out of their way to avoid embarrassing situations. In my experience men are often more conscious of these situations and better dealing with them than women. They know they are very likely to precipitate a complaint if they don't.

Carolyn Thomas said...

Thanks, Dr. Sherman. You'd think so, wouldn't you!? When I spoke to their manager after this procedure, she expressed surprise, saying "He's usually pretty good!" But how on earth would she know that unless she is also in the echo lab for each test?

Also, the fact that BOTH techs seemed equally distant and uncaring is a key point in this not-uncommon tale. You might imagine that if only one were merely having a 'bad day', at least his co-worker would step up to the plate and treat patients with courtesy and politeness.

Thanks for running my essay here.

Cheers,
C.

Doug Capra said...

Very interesting article, Carolyn. As you point, many patients, if not most, are not in any shape, emotionally and/or physically, to confront a situation like this head on while it's happening. It would be interesting, though, to see what would happen if a patient did. Because of the emotions involved, an immediate comment might prove counterproductive. But...what might happen if a patient could remain calm and civil and say something like:
-- Let's sit down and talk about how I feel you're treating me before this test begins...OR
-- Before we begin, I'd like to establish some ground rules.
Depending upon the answer, the rest of the exam or test could go in varied directions. The patient could ask to talk with a supervisor. The patient could still reserve the right to report the incident in writing, including the results of the discussion.
Having said all this, I do agree that a significant number of patients would just want to get test over with and deal with a complaint later. But, as I've written in other posts -- immediate confrontation may be the most effective in terms of changing behavior. The letters could stil be written. But, to some caregivers, there's nothing like the shock of savvy patient who can actually clearly articulate the basics of patient rights, core values, dignity and respect. I believe the incident would live in the minds of those techs for years to come.
Doug Capra

Anonymous said...

Patients should be allowed to undress in privacy whether it be behind a screen or with staff stepping out for a few minutes to allow the patient to disrobe and put a gown on. This is standard with opposite and same gender care. Very odd that didn't happen here. It should have. Hopefully that is now policy at this facility.

Jan Henderson said...

Great post, Carolyn. I had a simple EKG last year. Was told to lie down on a table. The young male tech proceeded to lift my t-shirt, without telling me what he was going to do. (I didn’t have to remove my bra. Still.) You may be onto something there when it comes to burnout.

Doug – It would be great if women and men could role play speaking up before they find themselves in a situation where they feel somewhat intimidated by an authority figure, plus vulnerable and subordinate because they’re sick and without clothes.

Anonymous said...

Certainly,this happens to male patients more so than to
Female patients due to the high number of female nurses,ultrasound,echo,radiology and nuclear med techs.

Pt

The crabby skeptic said...

Carolyn, I was a cancer patient when I was in my 30s. There were no dressing rooms, lockers or even a privacy screen for patients who had to undress for radiation therapy. Five mornings a week for a month, I was forced to strip to the waist next to the linear accelerator while the techs were prepping for my treatment session. At least they provided a chair and a hook on the wall where I could hang my clothing. After the session I then had to get dressed again quickly and leave because the next patient was waiting. Gotta keep up with the schedule, you know. I should have complained vociferously, but by then I was so beaten down by months of chemotherapy and complications that I didn't have the mental energy.

There will be ice skating in hell before I ever agree to do cancer treatment again.

From comparing notes with other patients, I don't think this situation was all that unusual. And as far as I know, none of the other patients at my radiation oncology center ever protested.

Staff burnout? I'm sure this was part of the problem. Worse than this, though, was that I sensed they were all completely tone-deaf to how patients might feel. You know the attitude: "This is how we do it, so suck it up."

Thankfully, they now have dressing rooms, lockers and even a separate small waiting room. Better late than never, I guess.

Joel Sherman MD said...

I think 'crabby skeptic' is correct, that modesty standards have indeed improved over recent decades. It's just an impression though. Perhaps our experts on the history of modesty have some harder facts for us.

Anonymous said...

When are women going to realize that NO MALE, esp. a tech or a male nurse, should be able to see your most private areas, and that you probably have a case of sexual assault against them if you tell them you don't want them doing any intimate procedures on you against your will and they go ahead and insist on doing it anyway!!!!!! Who do these guys think they are?????

Joel Sherman MD said...

Obviously anon, male techs and nurses have the same 'right' to view your private parts as female workers do. They only lose the right if you refuse their care. My guess would be that less than 10% of women exercise that right, and much fewer men exercise that right when opposite gender care is offered.

MarĂ­a said...

All fine and dandy, but the problem is that patients don't complain, especially male ones. Maybe they just think it's not macho.
Beside what it's enraging here is that "burnout" cannot be used as an excuse for laziness, rudeness and not giving a damn. I don't care how poor or inadequate the facilities are. There's just no excuse for that kind of behaviour, and it does also happen even with state-of the art equipment and the work, although proper screens, rooms and the like may minimize the impact somewhat. I believe I wouldn't do anyone any favors by putting up with their crap and complaining later.
Sadly, I am convinced that some techs don't really get it until one patient refuses them, and maybe not even them. If at least a couple decline, especially during a period of bad burnout, it may register with them.

Anonymous said...

I agree with Maria on this one.Burnout is no excuse to
be unprofessional and I'm sure it's just a tactic that the
nursing industry uses. Complain and do it aggressively.

PT

Anonymous said...

Don't assume most ekg techs are female. Most are male; check the records of any medical vocations school. So are most respiratory techs,X-ray, and a lot of sono. Guys mostly still become techs, women become nurses, unfortunately that's the way it is.

I think America has become de-sensitized to women's breasts, perhaps because of all the poor women who have to suffer through breast cancer; it's become accepted to talk about breasts and bare them for all sorts of procedures; at the hospital where I work a male phlebotomist performs all the pre-op ekg's and he has no ekg training at all.

Why aren't breasts treated as the private, sexual parts they are?

I dread the day when I will have to have a stress test and I guess run naked on a treadmill with a bunch of male techs around? And I know girls that were told their echo's had to be done bare-breasted.

I myself am still recovering emotionally from having a MALE perform a breast sonogram on me with no offer of a chaperone. I felt as though I'd been sexually violated.

Joel Sherman MD said...

Thanks for the comments, anon. Most sole ECG techs are female but multitasking techs in general labs are more likely to be male.
You don't have to worry about having a regular stress test while bare breasted. I've probably done over 10000 in my career and never seen it. Being bra-less would add to the motion artifact on an ECG and there's no reason for it. But make sure the bra has no metal in it and is relatively narrow or it may interfere. A stress echocardiogram is different and you would likely be topless for that though always covered by a gown during exercise.
Unfortunately if you are uncomfortable with a male tech, you really need to speak up before hand. That's not ideal, but it's really not feasible to have male techs and nurses chaperoned for every female encounter. They should ask, but most don't.

Anonymous said...

I'm a clinician and I'm now also a heart patient. I am female. I've had many lovely hospital experiences. Some quite appauling actually. The EKG tech who did'nt share his name..and proceeded to RIP open the snaps on my gown openly exposing my breasts, with my room door ajar. That was uncomfortable..and thinking then gee I have a chaperone when I do a rectal on a male pt. But being I felt bad..I did not speak up or complain...and I know the "you see one breast you've seen them all" mentality too amongst clinicians..STILL I felt violated. The "open" toilet in CCU with no simple curtain or knocks when you need to urinate, forget BMs..at a teaching hospital with lots of vistor traffic...violated again. Yet the male EMSin back with me who announced , "one of your leads came undone, I need to reach under your gown to replace it"..I praised this EMS employee. How NICE to at least tell the pt. WHAT is happening or needs to happen, not to catch them off guard. And the male EKG tech at another hospital who took the time to do an appropiate 12 lead EKG..yet cover my breasts with a towel, behind a privacy curtain too..THESE are the providers I desire as a patient and how I treat my patients as well.

Joel Sherman MD said...

Thanks for your comment anon. If I understand you correctly, you say that you use chaperones to do rectal exams on male patients, I assume women chaperones. If so, could you please explain your rationale for that.
You might look at the chaperone thread here.

Anonymous said...

I am and have been a male echo tech for 20 years. I look at peoples hearts and evaluate them, men and women. it is truly a privilege to do so. I see nothing sexual whatsoever in my job, have a great relationship outside of work.
I ALWAYS explain my procedure, I ALWAYS keep my patients covered and assure them of that before starting the procedure.
What about a male going for exams?
Don"t women think we have privacy issues with med exams?
As far as a chaperon, if a person has issue with my gender, and after many years it happened recently.
there are people with ethnic backgrounds where it is so objectionable to them to have a male see their breasts, I feel the tension and respond appropriately.
First I ask if there is any objection, if there is I assure them they will be covered. Still an objection? I get another tech.-for any reason.
I want to tell you, I see what other techs do. I have a wonderful bedside manner, I go out of my way every day to make my patients feel comfortable throughout their experience. Again, it is a privilege to serve.

StayingFit said...

In his recent radio program, Dr. Zorba Paster mentioned a study, concerning the impact that burn out has on the behavior of medical students. At present, this show can be heard here, but I don't know for how long this link will be active:

http://www.wpr.org/webcasting/play-wma.cfm?FileName=zph111029.wma&pagename=/zorba/listen.cfm


Here are some interesting points that Dr. Paster gleaned from this study:

Among those students who were burned out, up to 43% engaged in some form of unprofessional conduct
Unprofessional conduct included stating that part of a physical exam was normal, when the student never looked at that part of the body, and talking about patients in a disparaging way
The students who were burned out did not believe that they, as physicians, have a responsibility to society (i.e. they lacked a sense of altruism with regard to the practice of medicine)

The full study can be found here:

http://jama.ama-assn.org/content/304/11/1173.full#T2

This study supports the idea that stress among medical professionals leaves these people less likely to be concerned with, or sensitive to, certain aspects of patient care. For instance, it seems unlikely that caregivers who make disparaging remarks about their patients would then concern themselves with issues such as the modesty of those same patients.

Anonymous said...

I would love to hear from a representative from a MEN'S Health Organization, if any exist.

Anonymous said...

I'm female and think women really need to get over it. Breasts... Big deal. Grow up , this isn't playing doctor. I couldn't care less abt my breasts being bared!! I am, after all, there to get my heart checked. Prudes.

StayingFit said...

Anonymous, I think it's great that you aren't bothered by exposing yourself, in a medical situation. As it happens, I am not overly troubled by this, myself. At least, not if it is done with good reason, and if those involved are there with my permission.

So, I suppose that, compared with us, people who have this issue are, to use your word, "prudes". As in, they are more modest than we.

Then again, when compared with nudists, exotic dancers, or porn stars, I'm sure that you are a "prude". I know that I certainly am!

So, whose standard is correct? Whose comfort is worth considering, and whose should be disregarded?

That's all that these folks are saying. Let the level and manner of exposure be determined by the patient. Medical professionals need to ascertain what that level is, and act accordingly.

That seems a more reasonable approach, rather than dismissing these patients as "prudes" who need to "grow up".

chris said...

to anonymous 20 years in the job echo tech. i was a 4 year partner to a young woman who lost her fight with cystic fibrosis, her name was roseanne , and let me tell u something ,while you may ensure us that you have a great standard of practice and moral ethics , and have witnessed how other techs operate , you need to be aware of how many inappropriate techs there are in your profession ,yes i have been in a room while a gentleman such as yourself has handled the necessary tests and both roseanne and myself found no grievance, not only that but made a few friends also :) .BUT that is best case scenario .we were also confronted by male techs that actually lay"d roseanne on the exam bed and attempted to remove her shirt and bra without explaining what was happening to her .now put that stress on top of not being able to breathe properly and you have a very scared young woman ,and a very pissed off 6ft partner that walks in to the middle of it just as they were laughing about the fact that with her condition she should be used to this by now. they didnt even see the tears in her eyes or hear the fear in her voice . needless to say after walking in on that the 2 techs needed medical attention themselves and after our case are no longer allowed to be alone with a female patient . now i realise that i just mentioned the worst experience roseanne had ,but only because you only mentioned how good the experience can be with a professional , but guess what there are atleast 5 bad experiences for every 1 good professional appointment . and after well over 1oo appointments i can say thats a dam poor average , and mr joel sherman i applaud you for putting your name to your posts ,but you must realise that YOUNG multi tasking interns are not so bright as to think about the consequences of taking advantage of a given situation .<<< chris. email csilczak@yahoo.com.au

Anonymous said...

chris - Roseanne was so fortunate to have you with her through it all. Did you really smack 'em? If so, there's such a succinct beauty in it, (and of course I must state that this would be wrong - I guess). There seems to come a point where it is obvious that the level of callousness is so high that only direct action will cause "awakening."

_____

As to keeping breasts/chest covered, imagine when a patient, (me), states that, during an exam, she wants the physician to actually look at her skin, causing physician to flush red and get nervous. Skin tells quite a story. When it's all covered up, there are a lot of things to miss. But there is a line drawn.

I am prompted to file a formal complaint against the hospital I use that has nothing to do with privacy. I have difficulty getting up from a supine position. Multiple medical personnel will stand around while I struggle to right myself. Nice, eh?

I'm very tempted to cancel my upcoming appointments, which, one way or another, are only going to make me feel worse. At best, I'll walk out at the first sign of callousness. Then they can add a "noncooperative patient" note to my "permanent blipping record."

Anonymous said...

Why is it this subject comes to light only when it happens to a doctor, nurse, or some other medical person? How many other blogs, BBs, etc. have complained about dignity of patients?

Despite the fact that the medical community marginally admits that this happens, there is no admission that this causes long term (mental) trauma.

Consider this as a point of reference (I know it will never happen and may seem ridiculous); how different would exams/procedures be if medical personnel had to be in the same state of (un)dress as the patient?

Think of this scenario similar to people who say WWJD (what would Jesus do).

Anonymous said...

It is difficult for me to comprehend how some people don't respect another' desire to retain dignity and privacy.

What part of dignity do medical persons not understand?

Anonymous

Medical Patient Modesty said...

I wanted to encourage everyone to check out a new video by a man who is concerned about male patient modesty, Male Modesty In Healthcare Setting by Argh IMO

I really appreciated the white sign that a man holds over his private parts (you cannot see anything at all) around 3:38 of the video that says “This Area is Off Limits ….. Please Send a Male Nurse. Thank You.” This was a great idea. I think that this guy did a great job addressing how important it is for nurses to respect male patients’ wishes for modesty and male nurses.

I really appreciate him encouraging people to check out Medical Patient Modesty’s web site for patient modesty issues at the end of the video.

Misty