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?


Maurice Bernstein, M.D. said...

I fully agree with Dr. Kussin. In our teaching first and second year medical students the process of the physical examination, sequential draping and undraping is stressed both for patient modesty and to avoid chilling. I must say, in addition, with regard to "leave your socks on", we do emphasize for the student to remember to have the patient finally remove their socks since inspection of the condition of the feet, palpation for temperature, tenderness,skin lesions and masses and adequate examining of the arterial pulses in the feet should not be done with the socks on. Just to indicate how sensitive these medical students are to patient modesty and dignity is that virtually all my students have to be reminded, as I watch them perform, to have the patient's socks removed.

I want to make one additional comment and that is about "properly chosen" senior physician role models. Yes, they should be "properly chosen" since some degrade the humanistic view of patients that those of us in the first two years are attempting to teach. Because of limitations confronting the students' freedom to "choose", they may be faced with senior physicians who, as deliverers of the "hidden curriculum" and really should not be chosen. ..Maurice.

Joel Sherman MD said...

Dr. Kussin's comments are appreciated. This article and his book show an empathy for patients which is not easily found among modern hard pressed doctors. He combines this with an unmatched ability to advise patients how to seek the care they need.
His book, Doctor, Your Patient Will See You Now: Gaining the Upper Hand in Your Medical Care is highly recommended reading. As a physician I was surprised to see the many valuable reference sources he gives to research your illnesses and find a doctor and hospital. I was not aware of many of them. His book will certainly help you find the right doctor for yourself, though I think few of us will ever find the elusive perfect physician to care for them.

Anonymous said...

I have just recently heard of this book. I just ordered it online. To see these types of comments by someone from "within the system" is encouraging since he not only recognizes the issue, but knows the system. I am looking forward to reading it.

Doug Capra said...

I want to thank Dr. Kussin for taking the time to write this article for us. I found his book to be very helpful, and I highly recommend it for patients who want to become more of a partner in their medical care. Dr. Kussin has many good suggestions. I believe there are more doctors and nurse out there who have had experiences as a patient with privacy and modesty. I urge them to advocate for patients in print like Dr. Kussin has here, and to remind their colleagues when they see these kind of violations occur.