Sunday, January 29, 2012

Teaching Medical Students about Patient Modesty
by Maurice Bernstein MD


  
I teach first and second year medical students how to take a medical history from a patient and how to perform a physical examination.  I have been at this task for the past 25 years.  When asked by Dr. Joel Sherman  to write here a commentary about how patient modesty is taught in medical education,  I replied that though medical school instructors teach students about patient modesty concerns  in general, such instruction is a background topic since most of the teaching time is spent with detailing the mechanisms of the physical examination in terms of developing productive information which will help to rule in or rule out suspected diagnoses.  It is not that we have knowingly diminished a concern for patient modesty but after presenting the general instructions to attend to modesty which generally deal with draping or undraping the patient, touching the patient and using the proper professional words, there is generally no further didactic activity on this topic. What remains is for the instructor to simply monitor the students for following the instructions.  Uniformly, we find they do. 
If you would like to know why first and second year medical students are so tuned to the concern for patient modesty leading to reluctance and caution in having the patient's body exposed is because virtually uniformly they show evidence of their own physical modesty concerns.  The student's personal modesty is apparent as they become patient subjects for their classmates to examine.  In my experience, I have never found a naturist medical student.  And this modesty is not student gender specific although as expected examination of the exposed breasts are uniformly permitted by males but not females.  Nevertheless, examination of their groins is seemingly a restricted area by both genders.  Some students will only allow same gender students to be their examiners. Students do not examine each other regarding genital or rectal learning though they do so with teacher-subjects.  
So, what do we teach? Undressing and dressing of a patient should be performed by the patient themselves in private if the patient has the capacity to do so. Otherwise, if unable, then the student would help but with the patient's permission.  We teach that draping of a patient of both genders  is important  both to prevent chilling and also for patient physical modesty.  We teach that removal of draping for examination of a specific area of the body should be performed  best by the patient him/herself and only at the time that area is to be examined. Afterwards, the area is re-covered.  We stress the importance of communicating with the patient prior to examination of each area of the body with regard to what the student intends to do.  We have followed the advice of our dermatology professors to instruct students that a full body skin examination for skin lesions should be  performed with the patient not standing in the nude but  covered and serially undraped in small segmental anatomic areas.  This technique not only supports modesty but also has been shown to improve physician detection of small lesions.
Draping and undraping patients and positioning them for genital and rectal exams is, as previously mentioned, taught by skilled teacher-subjects and with also particular attention to professional touching routines and appropriate verbal communication with patients during these examinations.  Male genitalia exams for an ambulatory patient is done standing and rectal examination with the patient bending over a table. Female pelvic and rectal exams are  performed with the patient draped but lying on her back on a table in the so-called lithotomy position.
What we haven't instructed our students is the need to specifically bring up the topic of that patient's physical modesty concerns prior to the start of the examination.  Prior to reading 6 1/2 years of visitor discussions on my bioethics blog "Patient Modesty" thread,  what we haven't taught the students is that there will be some patients who would sacrifice their health and lives in order to preserve their physical modesty and that healthcare provider gender selection and the provider's  environment and behavior are of great concern to some, if not many, patients.  It is my impression that  the gender selection issue and how it is satisfied by the medical system particularly with regard to the requests by male patients is really not a discussed issue in medical education amongst teachers and with students.  The concept that physical modesty will ever trump diagnosis and treatment of disease as a decision by a patient is also, I believe, one patient decision that all in medical  teaching or practitioners of medicine are unaware.   It will take specific education along with changes in the systems, not just of medical students, but also the physicians, nurses, technicians and all of those who run medical schools, nursing schools, hospitals and clinics, so that they can be made aware that all the undressing, draping techniques, positioning, touching and standard communication with patients are still inadequate to meet the emotional needs and demands of some patients with regard to their patient modesty.  


Dr. Bernstein has been teaching medical students for decades at the Keck School of Medicine of USC.  His bioethics blogs are well known.  He has had a discussion on his blogs concerning patient modesty for many years.



67 comments:

Anonymous said...

Maurice

I certainly hope all this negative banter dosen't have
you walking around all day with your head down and
feeling endless blame. None of this is your fault.

This entire problem is caused by female nursing
staff. You may have been teaching med students for
25 some years, but I've been around hospital nurses
for about 35 years and saw the problem from day one.

PT

Nekura said...

Good insight. Do you bring up the issue of male modesty issues? I also know the feeling of being willing to sacrifice my health for modesty all too well, especially when it comes to the issue of BC and forced paps. A friend got pregnant because of it and I had many scares.

Once I got IC it just turned into "my pelvis is so f'd up it doesn't matter to me so much" but I still find myself shaking afterwards. It doesn't hurt, its just the coercion and modesty violation combined.

Its not just the medical community -- doctors, nurses, schools -- but society itself lending to these problems. I was harrassed so much by "friends" calling me immature, child, too stupid to be having sex (as though letting one person touch me there meant anyone with a medical degree had the right) and these were all WOMEN!

Men share the blame too. As I mentioned in the comment section of my article my boyfriend scoffs at any man who has a modesty issue and says they just need to suck it up. I'll call it the "tough guy" problem.

Friends of the same gender verbally bash the patient, and there are those with the same sentiments in the medical community just because they're a member of this society.

I don't think you can fix society, but perhaps starting with medical students there could be some way to impart empathy even if they originally stood with the "bashers"?

Have there been any studies on the amount of deaths caused by patients who refused medical care because their modesty needs weren't met?

Good article.

Anonymous said...

Maurice, well done. It might be paramount in the teaching of medical modesty that something about the psychologically of the kinds of behavior that make patients (or anyone) feel degraded. Example: What amounts to public stripping, exposure in front of a group without explicit consent, etc.

Without the understanding of why, and perhaps asking each student to put themselves in the place of the patient, the awareness needed is not there.

We are not just a sum of our parts and articulating regulations is important but when the medical community understands the why, and the damage for noncompliance to the patients, it will make a profound difference in what's absorbed by those students.

Thanks for the article!
belin da

Maurice Bernstein, M.D. said...

PT, I don't feel "endless blame" rather I feel educated, perhaps now constructively knowledgeable to a banter never experienced by my colleague physician medical student instructors.

Nekura and Belin, unless you are actively engaged in the teaching of medical students, particularly in their first two years, you will have no idea of the degree of empathy and sensitivity and engagement they have with the patients they interview and examine. It is not unusual for us instructors to deal with a virtual if not actually weeping student after a patient encounter. In my long teaching history, I really have never experienced a callous student. Maybe I was just lucky but I suspect this is representative of the students we teach. What happens in later years when the work pressure increases and the responsibilities are loaded upon them and are learning from others is another matter. ..Maurice.

Suzy Furno-Maricle said...

“Nevertheless, examination of their groins is seemingly a restricted area by both genders. Some students will only allow same gender students to be their examiners.”

Dr. Bernstein:
Would this not be the perfect time to have the “gender’ discussion with these students? The time to reiterate to them that a big populous of patients are having the same gender struggle with intimate care situations that they are having? To catch a person at their most vulnerable time and say “this is how many of your patients will be feeling about your gender in this intimate situation” could prepare them for the patient discussions to come, and perhaps: lead to fresh thoughts as to how the medical arena could participate in the solutions beyond learning terms such as “professional” and “contextual”.
I have no doubt that when these times come, many are empathetic to the patient. They are still virtually in the patient’s shoes regarding potentially humiliating situations of giving or receiving intimate attention. They are a product of societal norms just as we are: they still have modesty, dignity, and respect boundaries based largely on society’s separation of genders just as we all do.
When these personal issues arise with students, do you attempt to have them view these exams contextually…or rather: allow them to seek what makes them the most comfortable in the patient/provider scenario? Specially what do you say when the gender issue does come up, as it seems for some...it does?

Joel Sherman MD said...

Excellent suggestion Suzy. It is apparent that most doctors have rarely considered how their patients feel in similar situations, yet they don't have to be told that they want their own modesty protected. Teaching it as medical students would make a point they would likely remember.

Nekura said...

Mr. Bernstein, that is really interesting to me. It backs up what I've always heard about why patients prefer NPs rather than GPs.. its like the medical setting eventually sucks away your.. empathy? I'm not sure what word to use for it.


What about you specifically? You've ran the gauntlet. What are your insights on the changes that occur through their careers?

Medical Patient Modesty said...

It’s great that you teach about patient modesty at medical school. A nurse informed me that patient modesty was not really addressed in the nursing school she attended. It is important that doctors, nurses, and other medical professionals constantly have training on patient modesty. Patient modesty should be constantly addressed in hospitals and doctors’ office. A number of doctors and nurses are insensitive. Some nurses have this attitude, “You have nothing I’ve not seen.” It makes no difference to modest patients about how many intimate procedures a doctor/nurse has done.

It is important that medical students be educated about reasons some patients don’t want certain parts of their bodies to be seen or touched by the opposite sex. You can find a list of some reasons why women don’t want a male doctor/nurse for intimate procedures. Many modest men are simply uncomfortable with female doctors/nurses seeing certain parts of their body because they feel their wife or future wife should be the only woman to see and touch certain parts of their body. Male modesty is not a weakness at all.

I heard of one incident where a male patient spoke to his male doctor about how he didn’t want any female nurses to be present for his vasectomy. There were no male nurses available so the male doctor did everything by himself. Dr. Sherman mentioned in one of his articles that male doctors used to do some urinary catheterizations on men years ago. Why has that changed? It would be great if male medical students could be encouraged to step in and do intimate procedures on male patients who are uncomfortable with female nurses.

Medical students should be taught to always ask a patient for her/his permission before being involved in her/his care. A medical student should always respect patients’ wishes. Patient’s wishes should be priority number 1. All medical professionals should always respect patients’ wishes. If the facility is not able to accommodate the patient’s wishes, they could always refer the patient to another facility.

It would be great if hospitals made a new policy requiring all nurses ask both male/female patients about their preferences for same gender nurses for intimate procedures. Patients are often made to feel guilty or silly for raising questions about the modesty issue. It is almost as if they should be comfortable with anyone doing anything to them as long as it is in a healthcare setting. This needs to change. All patients also should be asked about their preferences for bathing. Many patients prefer that their spouses give them bath. This is a good way to make patients more empowered. Patients are paying customers who should be able to get their wishes.

Dr. Bernstein: It’s great that you have worked with medical students who are sensitive to patient modesty. Do you think that many of them become desensitized after working with some doctors and nurses who are insensitive to patient modesty?

Are you aware that some medical students are encouraged to do non-consensual pelvic exams on patients under anesthesia without their consent? I am not sure how often this happens. ABC News aired a show about non-consensual pelvic exams a number of years ago. You can see the information. We need to make non-consensual pelvic exams illegal.

Medical Patient Modesty said...

Dr. Bernstein: You mentioned that some of your medical students were hesitant about doing intimate procedures. Do you know if any of them are hesitant due to convictions they may have?

Have you ever had any medical students who expressed that they felt that they could not participate in certain procedures due to convictions or other reasons?

Medical Patient Modesty received an interesting email from a Christian nursing student who has strong convictions that she should not do certain procedures on male patients. You can find some of the things she said below.

I am a Christian, and both my husband and I only see doctors/nurses of the same sex. We feel strongly regarding patient modesty that intimate procedures should only be performed by the same sex health care professionals. Right now I am in a dilemma though because I am also a first semester nursing student. Right now I am learning intimate procedures that are meant to be performed on both male and female patients. I have spoken to my professors asking if I can only perform these skills on female patients and so far have stared at me like I have two heads. When did it become okay for health professionals to perform intimate procedures on the opposite sex? What are some tips I could use to advocate same sex procedures?

I am aware that doctors can choose to not do certain procedures on opposite sex due to convictions. There are some male family practice doctors that refuse to do gynecological examinations. I noticed that according to Medical Student Section of the American Medical Association (AMA) that students can object to doing certain things. You can find information below.

"Just as physicians can object to providing services due to their ethical and/or religious beliefs, medical students can have conscience-based objections to participating in educational activities" according to Medical Student Section of the American Medical Association (AMA). See more information. It doesn't mention intimate procedures on the opposite sex, but I believe that conviction against doing intimate procedures on the opposite sex is certainly in the category of conscience-based objections.

Has anyone ever heard of any nursing or medical students who were successfully able to get through medical or nursing schools without having to do intimate procedures on opposite sex human beings? Mannequins don’t count. Some medical and nursing schools have mannequins that students can practice on.

Joel Sherman MD said...

Medical Patient Modesty, if you haven't read the article by the stressed medical student, you should.
Although I have no doubt that there may be some medical schools that will make full allowance for religious and cultural beliefs, the large majority would give the student a tough time. And there are national guidelines and probably state guidelines as well as to what a medical student should learn, and this would include intimate exams irregardless of gender.
I'm sure Dr Bernstein could give a fuller answer.

Medical Patient Modesty said...

Dr. Sherman,

Yes, I read the article by the stressed student. Unfortunately, she didn't finish medical school. I appreciate a lot of issues she brought up. There are some medical schools that are more accommodating than the medical school the stressed student went to. She definitely would have made an excellent doctor. She is very sensitive to patients' rights.

I would love to know of cases where medical and nursing students successfully graduated from medical or nursing schools without having to do certain procedures on the opposite sex due to convictions. Are there any cases? If so, how did the students succeed?

Doug Capra said...

"I would love to know of cases where medical and nursing students successfully graduated from medical or nursing schools without having to do certain procedures on the opposite sex due to convictions. Are there any cases? If so, how did the students succeed?"

That will probably be very difficult to find out. My thoughts are that, the ones who made it, unless they've reached a significant status position in the profession (and even then) may be very reluctant to talk about it. Unless they've become patient advocates. It is not a popular position to take within the profession, and I really believe, would reduce their status among their peers of others found out. It may already have done that.

Suzy Furno-Maricle said...

"I would love to know of cases where medical and nursing students successfully graduated from medical or nursing schools without having to do certain procedures on the opposite sex due to convictions."

MPM: I am curious: when you say convictions if you mean how the student feels about giving opposite gender intimate care or how the student feels the patient may feel about recieving opposite gender intimate care? Of course it could be both, but one would be the primary reason.
Without really opening the religious or moral/ethical door my question is just the basic:
Would this be a student who has a problem with touching and/or viewing the nudity of the opposite gendered patient, or a student who believes the opposite gendered patient has a problem with them?
It could mean the difference in how the student is approaching handling the curriculum dilema, and how to advance the "advocacy" after fullfilling said curriculum.
Example:
In crafting my own advocacy education (since there is no standard to date) I would believe it necessary to go through some sort of CNA or pre-nursing education. Now, as an adult woman, I have no problem with male nudity. But as an advocate I am well aware that many men would have a problem with me....that is afterall a cornerstone of the advocacy movement.Am I willing to be a hypocrite believing that the end will justify the means? Despite my husbands rather balanced urgings, I am not. Putting men through the humiliating circumstances that I am advocating against? Just can not justify it....
So, I would be curious as to which point of view the students you are asking about would be coming from because it may mean the difference between a workable solution or a concession of beliefs.

Medical Patient Modesty said...

Suzy,

I am referring to nursing and medical students who have strong convictions that they should not do intimate procedures on the opposite sex due to their own convictions. Some people feel that their spouse should be the only person they see naked.

As you saw, we received an email from a Christian nursing school student. The reason she felt strongly about not doing intimate procedures on male patients was due to the fact she felt that her husband should be the only man she sees naked. I think she really treasures her relationship with her husband. Many people feel a special bond when their spouse is the only person of the opposite sex that they see naked (after puberty).

There are definitely a number of medical and nursing school students who have strong convictions that they should not do intimate procedures on opposite sex because many of the patients may be uncomfortable. As you know, the stressed student was disturbed by about how many unnecessary invasive procedures were done.

Maurice Bernstein, M.D. said...

I am sure all medical students are aware of potential modesty issues related to intimate medical examinations and this concept is reinforced in their second year when they perform such exams on teacher-subjects. I don't think this concept fully disappears during their later training except it may fade a bit during periods of need for heightened patient medical or surgical responsibility to be accomplished in very limited time later in their careers. It certainly has not disappeared from my concern. But as I have written on my blog also, it does require for all physicians some reinforcement by the patient speaking up to the doctors or institution with regard to specific issues of concern.

I think all medical students have varying degrees of personal physical modesty when dealing with the healthcare system but they are more specifically sensitive to physical modesty issues in their physical exam exercises with their peers and with the attention to patient modesty issues which they are taught. What role "faith" or other moral issues play generally is uncertain though I know that other instructors have had students from other cultures where moral or faith issues had to be attended to.

To me, the "stressed student" experience and view and response by a medical school is particularly perplexing since she never intended to be involved career-wise in the examination techniques she was required to learn before graduation. Perhaps schools should tailor curriculum more specifically to the goals of the special students rather than the goals of medical academia. ..Maurice.

Suzy Furno-Maricle said...

MPM:
Thanx for the clarification. I must admit that I usually look at this from one of two perspectives:
How the patient feels about exposure and the role that gender plays, and then the provider and how he/she feels regarding the entitlements to that degree of exposure. Rarely do I consider the providers response and/or feelings about opposite gender intimate exposure.
Thanks for the third point of view.

Medical Patient Modesty said...

Dr. Bernstein: I think medical education is too general. I feel that medical schools should reduce the number of intimate procedures students have to do in order to graduate especially if they are planning on becoming doctors that will never do intimate procedures when they actually practice medicine. There are so many medical students who already know what kind of specialty they want to go into. Cardiologists, neurologists, radiologists, podiatrists, optometrists, otolaryngologists, and orthopedic surgeons do not do any gynecological or urological procedures. Medical schools should be able to exempt medical students who want to become certain types of doctors from doing intimate procedures due to convictions. A future female gynecologist will not work with male patients in the future so it will not really be important for her to learn to do prostate exams on male patients.

Do medical schools have general medical education curriculum for all medical students regardless of the specialty they plan on going into because many of the students are undecided about what they want to specialize in? I would be interested in hearing about the history of how the medical school curriculum was set up.

Steven Marcus said...

I am a older physician and medical educator. I have dealt with student physicians for over 40 years. I am interested that you state your students examine each other. At my medical school they do not. I have asked the dean's office why, and was told that it is for their modesty. When I ask the studets, they think it would be a good idea, but it doesn't happen, at least not in any sanctioned way. The few standardized patients that students get to examine during their first 2 years is totally insufficient for them to achieve any degree of copentency in doing a physical examination. How fair is it to the "real patients" they start examining as 3rd and 4th year students, let alone residents?

I have always tried to teach respect for patient's rights of all kinds, physical, mental, etc. This is not just limited to their external physical bodies. I understand the beliefs of many posters and respect them. We do try to accomodate the requests to the best possible extent, but there has to be a point at which care trumps "modesty."

I was just recently admitted to a hospital after an unsuccessful ultrasonic lithotripsy. At the time of my admission I was passing bloody urine and was in absolutely the worst pain I could ever imagine. It is hard for me to think that anyone in my position would worry about modesty, but the ED staff did a great job isolating me from other patients, etc. What did amaze me, was that regardless of the sex of the staff, my chest was never examined without a gown on, and, believe it or not, my external genialia were never examined. I can only call this sloppy medical care, something which continued throught my stay. Twenty four hours into the stay it was decided that I needed to have a stent placd into my ureter by cystoscopy. That required a device to be placed through my penis and bladder and up to the kidney, obviously while I was sedated. I was taken to the OR for the procedure. Interestingly the operating room was all male except for one lone female nurse. When the anesthesiologist was getting me prepped, she stated that she would leave and "give me some privacy." I thanked her for her thoughts, but that this was a ridiculous gesture given the fact that her help was needed and in the operating room my genitals would be exposed for everyone to see anyway. So she stayed and helped apply the various leads, probes and devices which would help insure my safety through the procedure. Would I have been embarrassed/upset if she had seen me nude by accident outside of the medical environment, you bet. In the situation I was in, I WANTED her there, I could care less if she got to see my naked body.

The est of the hospitalizatio continued a cat and mouse approach to my body. The care taken to assure my modesty onenight when I awoke completely drenched from head to toe in sweat and needed to have my gown and bedsheets replaced was literally painful. I finally said to the nurse, please let me get out of bed, strip off these cloths and get new ones on me and then you can get the bed remade. She looked at me a if I was nuts. I said, look, I am not an exhibitionist, I would just like to get this over and get back to sleep. The rest took minutes and I was back to sleep.

So i understand and appreciate the beliefs/feelings, but respectfully hope that those people do understand the fact that th health care system's responsibility is to give good care. I think I also show that my attitudes translate to how I act, not just what I preach.

Doug Capra said...

Dr. Marcus:
Thank you so much for sharing your story with us. I only wish we had more doctors and nurses participati g in this discussion.
But I have a question, and I ask this with all respect. If you go back and look at some earlier articles on on blog, you'll find one by Dr. Steven Z. Kussin, author of "Doctor, Your Patient Will See You Now: Gaining the Upper Hand in Your Medical Care." In the intro to his book, he describes his automobile accident and his hospitalization. What in part inspired him to write his book was that he recognized that his treatment wasn't "ordinary" treatment. Because he was a doctor, a medical professional, his colleagues went out of his way to give him the VIP treatment. One of the goals of his book is to help "ordinary" patients learn the system so the can get more than just ordinary treatment.
So -- my question. Looking back, in retrospect, do you think you were treated any differently than ordinary patients because you were know as a medical professional -- not just your technical medical care but also your modesty. I'm not suggesting that medical staff consciously divide patients into other medical professionals and regular patients. I'm suggesting that there is a concept in all professions called "professional courtesy." I would suggest that few doctors needing an appointment would be told that it would take two or three weeks. They would get an appointment right away from a fellow doctor.
Thanks again for your thoughts.

Maurice Bernstein, M.D. said...

Dr. Marcus, I would agree with Doug's comment that possibly you were treated as a VIP ("very important person")particularly if the hospital was one in which you practiced or previously practiced and have been known there. VIP treatment is usually not in the best interest of the patient despite an occasional benefit.

I also agree with your concern about a medical school not allowing students in the first and second years to examine each other. The advantages of students learning on each other are multiple. Beyond the opportunity to develop the techniques to obtain needed information on the physical exam, techniques which may need repetition during the exam to do them correctly (which might not be tolerated by a real patient), there is the matter of the understanding how to "lay on hands" but with patient modesty in mind before attempting to do that on a real patient. This practice on each other as they go through the various systems (such as respiratory, cardio-vascular, musculo-skeletal, neurologic and so on) prepares them for doing the same correctly and effectively, along with professional supervision. on the 10 or more patients the 2nd year students will examine during that year at my medical school. Standardized patients (actors)are occasionally used for physical examination subjects but, of course, the use of students themselves puts no additional cost to the school.

By the way, I agree also with what I think you implied that it is wrong for medical providers make assumptions regarding the patient's view of "modesty vs the need for an essential and effectively performed physical exam" and not first ask the patient and listen to their response about their view and requests, if any, regarding that relationship. ..Maurice.

..Maurice.

Steven Marcus said...

I don't think I received much in the way of VIP treatment. It was not my major hospital, often the nurses and physicians remarked that they did not know that i was a physician.

Joel Sherman MD said...

Dr Marcus, I'd agree that you were given special treatment. It is highly unusual that a nurse would offer to leave the room while you were being prepped unless perhaps you knew her well. I've been treated in the hospital where I'm best known several times and have always been treated with respect, but never to that extent. I once needed to be catheterized at night after surgery. The nurse never offered to have someone else perform it. I would agree that it is usually disadvantageous to request special treatment, especially for surgery or special procedures. I'd never do it.
Doug, you exaggerate. I'm frequently given an appointment for several weeks or more in advance unless I say it's urgent. It varies greatly on the office.

Doug Capra said...

Joel: I really don't know, Joel. It might not be the norm today -- but here's where I'm coming from:
There's an interesting article by Trisha Torry on her Patient Advocate forum about the definition of "patient." Who or what is a "patient?" What does it mean to be a "patient?" On the one hand, everyone is a patient at one time or another. But that's only one way of looking at it. It might be better to ask, what is the "patient experience" and how does it differ on a continuum from those with no medical knowledge,experience and status to those with much medical knowledge, experience and status.
I would suggest there can be quite a difference in the patient experience when you compare end sections of the continuum. A rule of thumb is that those with knowledge, and especially power, don't often recognize their power. They don't often see it. Those without the power see it clearly. So, I'd suggest that patients without medical knowledge, experience and professional clout, will often experience their their "patient" context much differently that those with medical knowledge, experience and professional clout.

Doug Capra said...
This comment has been removed by the author.
Doug Capra said...

I needed to edit my last comment for typos. That's why it's gone. Here's my corrected version:

Let me add another perspective that may be overlooked in medical training. I can understand why most non medical professionals concerned with modesty consider it hypocritical for medical students to be trained using standardized patients for intimate kinds of exams.

I can also understand why it's important for these students to learn the technical process in a non threatening way. But these standardized patients by the nature of what they've agreed to do are most likely not expressing modesty. I've had some tell me that some asked to act modest, but unless they've won an academy award for their acting abilities, I question how effective that would be.

If these medical students, in addition to dealing with standardized patients, also had to examine each other -- even if they were personally modest and didn't want opposite gender care -- that would teach them many things. I wouldn't force them to be examined. But here's what they might learn.

It would give them immediate empathy associated with the discomfort of how that "feels." Yes, it's about emotions.
It would teach them how uncomfortable it is to try to negotiate with the system about this issue, from a patient point of view.
It would, within the hierarchy of medical schools (students being on the lower end) -- teach them how "power" plays a role in the medical system.
If those medical students who were not modest showed distain for or ridiculed those students were were modest -- it would teach them what not to do with the patients they encounter in their practice.
I would suggest, that for those especially modest medical students -- it would provide them a lesson they would never forget.
I'm not sure how it would affect those who are not modest. Perhaps both perspectives could be discussed in class so each could gain empathy for the other.
I'm not a doctor. But I have had extensive experience as a teacher and trainer in the field of communication. And what I described could be an effective teaching technique.

Maurice Bernstein, M.D. said...

Doug, you will never see a medical school in the United States demanding students to perform intimate exams on each other with penalty if refused by either student. Compulsive pelvic exams by one nursing student on each other in decades past are gone (or should be gone) now according to my reading. I can tell all that such an approach to teaching modesty for medical students or nurses is not only unethical (students as well as patients should have autonomous control over their bodies) but will not be of additional educational merit since all students as well as physicians are made aware that examining or performing procedures on a patient without their permission except in certain emergent situations is not only unethical but also legally prohibited. What is important is that all healthcare providers are attentive that they have been given such permission. ..Maurice.

Doug Capra said...

Maurice -- You wrote: "Doug, you will never see a medical school in the United States demanding students to perform intimate exams on each other with penalty if refused by either student."

I wrote: "...that would teach them many things. I wouldn't force them to be examined. But here's what they might learn."

Of course it wouldn't be required. I never suggested it be demanded. But students who don't want to go along might be asked to explore their values to understand why they feel the way they do. Might there be pressure to go along with the program? Peer pressure? Perhaps. Might that be similar to the pressure patients sometimes feel to go along with the program regarding their intimate care? Perhaps. Is this a tough kind of training? Perhaps. But I don't expect anything less for students who want to become physicians -- such an important vocation. Medical school is already a kind of boot camp in its own way.

You write: "What is important is that all healthcare providers are attentive that they have been given such permission."

Yes, that's important. But what in their upbringing or professional training helps this "attentive" stance? I'm suggesting that it's empathy, and that there needs to be a strong connection between the intellectual aspects of their training and the emotional part of their being. To some extent, perhaps a large extent, empathy can be taught. Isn't that one major purpose of the humanities -- to help us connect with the rest of humankind emotionally as well as intellectually?
That's what I'm suggesting. And I'm just suggesting. I clearly recognize that I'm an outsider. But sometimes an outside point of view is worthwhile.

Steven Marcus said...

I have a problem in the use of the term "intimate." Is examining a chest intimate? How about the abdomen? We are not speaking genitals here, which is another subject. Never once during my recent hospitalization did anyone examine my chest bare! The attendings all listened through my gown. What is that showing me about their education in how to examine a patient. Unless I am really a dinosaur, I guess as a senior citizen i deserve to be called on that one, then I think we teach students, residents to examine the chest by observation, palpation, percission then auscultation. I have no idea how one accomplishes those without at least moving the gown around an sequentially drapping and undrapping the examined part. Does modesty trump a good physical examination? If not, how do we teach the students to do an appropriate examination?

Doug Capra said...

Dr. Marcus -- You bring up an interesting theme that I've found on several threads, i.e. the modesty of doctors and nurses and how that affects patient care. Or is it their modesty? Is it a time-saving technique to examine the chest, for example without asking the patient to remove clothing? Yes, there are modest patients who object to or are uncomfortable with the gender of their caregiver for specific exams. But there are also modest caregivers who have never really become comfortable with certain exams or procedures.
I have noticed this to some extent in my own care over the years and wonder whether it's a question of saving time or caregiver modesty. Frankly, if I know I need my chest examined, I'll take off my shirt on my own without being asked. I expect that kind of examination.
As I've mentioned in previous posts, there are several studies about how doctors and nurses deal psychologically with bodies -- not just nudity, but terrible injuries and wounds. There are different kinds of psychological mechanisms they use to do the job they have to do. What I find interesting is that some of these mechanisms work for them but may not work psychologically for the patient. These mechanisms protect the caregiver psychologically but may even harm the patient psychologically.
My take on this, and I could way off, is that medical students are most often taught to just "deal with it." Are they really taught how? How much metacognition is involved with their education on this subject? Are they encouraged to examine their own thinking in this area, to examine the various mechanisms to see which ones they would tend to use and how they would affect patients?
I don't know. What do you doctors have to say about this?

Maurice Bernstein, M.D. said...

I ("we instructors") teach the students that inspection (viewing) means to view the anatomy and skin bare. How can one visualize the anatomy and skin otherwise? It means to auscultate (listen)to the skin bare. We know that clothing diminishes the sound but also may add confusing adventitious sounds.
It means to palpate (feel) and percuss (tap) on bare skin. To do otherwise diminishes the sensation received. Now, bare skin doesn't mean partial nudity since as I have previously written, unnecessary exposure of skin can lead to chilling of the patient and shivering and increased muscular tension (unwelcome exam responses) and also may be unpleasant to the patient from a modesty point of view. So, students are told that all observations should be on bare skin but the patient should be draped and undraped in necessary segments of exposure. They are told this and we continuously monitor them that they follow this procedure. Yes, of course, at first there is modesty concerns for themselves and the patient and hesitation by the students to make bare a stranger for whom the student thinks that the student is not contributing to the patient's well-being and health by this action. So they are repeatedly told to avoid examining through clothing. The main thing we teach the students is to inform the patient what needs to be done and await some "OK" or acknowledgment. Once they are taught and remember what needs to be done, I think that later on in their experience and career, listening through clothing mostly has to do with limitation of time and the assumption that covered skin will not interfere with an adequate examination. It should be rare that a physician continues to be squeamish about visualizing or touching the patient's bare skin.

In response to Dr. Marcus: Yes, the students would consider examining female chest with breasts exposed as an "intimate" procedure. A male chest exam is not "intimate". That is why sequential partial uncovering is an effective technique to teach the students.

Doug, don't wait for true "empathy" in the student or physician's management of modesty issues of the physical exam procedure. Empathy (if you mean experience by the student or physician of their very own experience with modesty issues of their own body) but now as part of a physical exam technique of a patient. is something which will be different between examiners and if such empathy is too overpowering, the examination may be inadequate to meet the goal of diagnosis. No.. we need not teach empathy for the physical, we need to teach one point: don't examine a patient (except in a life-threatening situation) without the patient's informed consent. If you do.. it's illegal! This instruction takes care of everything! I am not discarding empathy but, if true empathy (a situation involving the patient but similarly experienced by a physician personally or within the family)is present it should be how the physician generally communicates with the sick patient and the goal being therapeutic and not interfere with a goal of the physical examination: to establish the correct diagnosis of the patient's symptoms. ..Maurice.

Maurice Bernstein, M.D. said...

Doug, one other point for clarification: the difference between true empathy and sympathy. Sympathy expressed by a physician would represent a non-personally experienced issue similar to the patient for which the physician is attempting to provide some comfort through awareness that the patient is uncomfortable. Sympathy can leave the physician still to act objectively and not deviate from the beneficent goal through his or her own emotions. True empathy on the other hand, the physician having a direct personal knowledge of the suffering, can cause the physician to act subjectively and perhaps fail to attend to the details to lead to the most beneficent goal. Some say that empathy can be "taught" and then the understanding expressed to the patient. But the use "taught empathy", which may preserve a physician's objectiveness is not true empathy and is simply acting and I don't think doctors should be "actors" when they expressing feelings to their patient, despite the attempt to preserve objectivity. Anyway, this is my view of "teaching empathy" ..Maurice.

Doug Capra said...

Good points, Maurice. I don't think we really disagree. I think we humans sometimes create dichotomies where they don't exist. I see sympathy and empathy as part of a large web or circle or continuum.
1. On one end we have empathy so strong that the individual can't be objective in any way -- empathy so powerful so as to make the individual ineffective.
2. On the other end we have the sociopath, the individual who has no feelings, no sympathy, no empathy. It's all about him/her.
3. As you move from #1 to #2, and as you get closer to the middle, you begin to develop sympathy.
4. The middle may represent someone who perhaps hasn't had the precise experience, no direct experience -- but who can still move beyond mere sympathy to the feeling of being in another's shoes. Don't underestimate the power of imagination, how it can be used to represent reality in a positive way. Perhaps this middle area is what I'm talking about, where you can still keep your objectivity yet begin to show empathy as well as sympathy without losing your effectiveness.
Maybe I'm complicating this -- but it's not the simple use of words to nail down definitions. These concepts are fluid. And a good dose of the humanities can -- I don't want to use the word "teach" us -- but can move us toward empathy.
Most of the doctors I've known have been much more than technicians. They've been philosophers, like you. Or linguists, or lovers of literature and music and art. We must never lose that part of what it means to be a physician.

Maurice Bernstein, M.D. said...

Doug, believe it or not, physicians are taught starting in medical school the biopsychosocial model and we follow the same model in our medical school. Our aim is to move away from earlier medical teachings that look only at the disease and not at the patient as a whole who presents and is comprised not only of the pathologic process (bio) but also has components of emotional (psycho) and social issues, all of which together play a role in what the physician is faced with as he or she evaluates and treats the disease but also the patient. (See a description of the pros and cons of this model in Wikipedia.
What I am getting at is that we don't teach our students a mechanistic "treat the disease" concept but a humanistic "consider and treat the whole patient". All I can say further is that we are attempting to encourage, by attention to emotional and social issues, something more in the interaction with the patient beyond simple whining sympathy.. perhaps toward some degree of empathy. And this should include attention to patient modesty and needs beyond just what prescription to write.

It seems to me that some folks think that in medical school teaching we are ignoring humanistic medicine. I don't believe we are. Unfortunately, the medical student as he or she progresses through the career are influenced by other forces, since they are only humans, and their behavioral outcomes may be not exactly what their teachers had hoped for. But we try. ..Maurice.

Doug Capra said...

Maurice: I'm not one of those who think humanistic medicine is being ignored in medical school. As I said, my experience with doctors has been mostly positive and I've been impressed with their vast knowledge in areas outside the technical aspects of their profession. I wonder, though, how much of that is from their medical education and how much is just due to the kind of person that tends to go into medicine, usually very intelligent individuals, often gifted, who have interests and curiosity in many areas.

As you suggest, we're all under the influence of outside forces in our culture. The question we've brought up -- and this applies to all education in all professions is this: being taught the biopsychosocial model is one thing, which I don't question. To what extent is that being modeled not just in medical school but as the student moves along through the system and later thru the profession? In some cases medical students may quickly may realize this biopsychosocial model as the ideal which really doesn't fit in to the current way medicine is being deliver in this country. What happens to doctors who want to practice this way but can't due to the economic stresses within the system? Stress? Burnout? That seems to be a big problem today.
I'm less concerned with physician education. It's extensive and pretty thorough. I'd like to see the standard for nursing be the BSN which would give more time for some humanities and more emphasis on the biopsychosocial model. I'm much more concerned with nurse assistant training, cna's, med assts, etc. -- which is mostly task oriented, i.e. get the job done. These are the people doing most of the bedside care today and often they have more contact with the patient than do the doctors and nurses.

Maurice Bernstein, M.D. said...

Doug,If what you read below is really going on (I don't want to publicize this "school" with a link!) then how on earth would the humanistic and BPS models be truly taught and students evaluated over the Internet? ..Maurice.



"Earn A World Class Nursing Degree Online...
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Earning an advanced nursing degree online provides the competitive edge you need to keep up-to-date with the rapidly expanding educational needs of today's nursing profession. Online nursing degree programs give today’s nurses the ability to advance from LPN all the way through Doctor of Nursing Practice entirely online. Reshape your nursing career while you work with no classes to attend, no traffic or parking to worry about. Earn an accredited nursing degree online when and where you want, 24/7 from the nation’s leading nursing schools. Success in your nursing career is just a click away!"

Doug Capra said...

Maurice: Yes, but I'm surprised to see a nursing program listed as all online. It's very common to see training for cna or medical assistant or some tech positions. And some courses come from non accredited "colleges" or training schools. I've some experience with online classes. They can be good for some things, and extremely poor for others. I don't see how a complete course in nursing can be done online effectively. There often needs to be the give and take of discussion and debate, the natural discourse that happens in a real classroom.
Unfortunately, we're going to see more and more of ads like the one you posted.

Maurice Bernstein, M.D. said...

What is missing from these purely "online" healthcare provider "teaching" programs is I suspect the total lack of "patient hands on" monitoring and formal examination of student skills and behavior. Specifically, I suspect these programs have no OSCE (objective structure clinical examination)in which the students are challenged to interact and examine a trained actor in the presence of a observing teacher and who along with the actor evaluates each student's performance and provides direct feedback and grading. The actor will look directly, as the patient, at how the student behaves in the professional vs patient relationship and the teacher evaluates this also but from the professional requirements point of view. The use of the OSCE provides a teaching program formal insight into the knowledge and clinical practice behavior of the student far more than any written exam on paper or by computer. ..Maurice.

Anonymous said...

I'm male, early 30's, decent shape.

I've had no tramatic experiances ( that I recall), but I'm incredibly shy.

I haven't been to a beach since I was 12, and haven't had a "general checkup" since I was 16.

My only encounters with doctors for the last 15+ years have been for stitches in the ER a couple times. (forearm and shoulder.)

I'm literally terrified at the idea of some random stranger thinking they have the right to touch me.

After reading several stories over the years of what med students do to sedated patients, I honestly think I'd decline surgery rather than risk being a "play thing" for a dozen students learning to do rectal exams....

I have a friend who's a nurse, and I always hear " It's nothing we haven't seen", or "there's nothing to worry about... doctors are trained" as an argument to why I should "suck it up" and go for a physical.

I am SOOOO sick of them parading out that line of gibberish.

I don't care what some strangers job is... my body is just that... MINE.

So yeah... male modesty does exist.

Anonymous said...

I am a male in my early 60s, and have had cardiac by-pass surgery. I find this whole issue of patient modesty interesting in light of what I experience in my visits to my doctors. I have a female primary care physician, and generally a male cardiologist.
My normal quarterly visit to the primary care physician is for the purpose of checking blood pressure and reviewing blood work, and medication issues. She usually listens to my chest and back, but always through my shirt, unless I voluntary undress to the waist, which I sometimes do in the interest of a good exam. The real problem is the annual physical. Although I am told remove all clothing except for underwear, and am given a gown to wear, she would do almost the entire the exam through the gown--the only exception is the prostate rectal exam.
This bothers me, since she never does an visual assessment. I have never had a male breast exam, and she never inspects or examines my genitals (I asked once for a hernia check--but I had to ask). I have tried to find another doctor (unsuccessfully), but previous physicians were not all that different.
May I offer my view as a male patient? I am fairly modest, but when I enter the examination room, modest is not an issue. The doctor is trined to deal with the human body of either gender. Frankly, I expect to be instructed to undress completely, and it doesn't bother me at all. In fact, I feel that the gown (usually paper) is a waste of money. I will gladly sit, completely naked, on the table for as long as it takes for the doctor to do a thorough exam. I expect a female doctor to do a full genital exam, including visual assessment (what about STDs?). And when I am just having a periodic visit (not a physical), I still expect to have to strip to the waist--and again, gowns are unnecessary.
Fully assessing the unclothed patient is just good medicine. Or so it seems to me.

Joel Sherman MD said...

Anon, every patient has different preferences which you can make known. But I believe you are in a distinct minority; not many patients are comfortable sitting around naked. Beyond that, most physicians are not comfortable interviewing and examining naked patients, especially opposite gender. Many patients would complain and the doctor potentially faces a liability risk. And beyond that in many offices, you never know who might enter uninvited.
And gowns don't interfere with an adequate exam. It has been shown that uncovering one section at a time may even help the physician to focus on that area better.
If you want a thorough exam, tell your physician and discuss it. If he/she won't perform one to your satisfaction go elsewhere.

Doug Capra said...

Anon -- I don't think anyone on this blog contests your right to have the kind of exam you desire. If you feel comfortable that way, fine -- if, as Dr. Sherman commented, you can find a doctor who is also comfortable with that also. On this blog, we are advocating for you to have an exam your way, and others to have it their way if they have problems with opposite gender care or complete nudity. Patients are different and have different backgrounds and values, and the medical community needs to pay more attention to that -- especially regarding gender preference.
I do agree with you that a full exam is a full exam and should happen. But, as Dr. Sherman indicates, it doesn't require the patient to be fully nude all the time. Draping is probably suitable for most patients.

Anonymous said...

this is going to drift a bit off topic, but an active conversation often does, so here goes...

Anon posted "May I offer my view as a male patient? I am fairly modest, but when I enter the examination room, modest is not an issue. The doctor is trined to deal with the human body of either gender"

Great, good for you that you're able to flip a switch and shut off aspects of your personality / self.

From my point of view, I don't care how many years they've been trained to deal with naked folks, or how many naked folks they see with in a year.... it's not about them, it's about me.

~I~ am not comfortable undressing for a stanger, and ~I~ don't make a habbit of lying on a table, naked, being prodded.

I was talking about this with my girlfriend after my previous post (I'm the anon who hasn't been to the beach since I was 12)...

I gave her the analogy of... People who work as camera operators in the porn industy also see lots of naked people, so it's no big deal.... people who frequent porn websites have also seen many, many naked people.... so does that mean you're willing to go be in a porn that gets posted online?

If not, why not? if the sole argument for "turning off your modesty" is that the other person / people in the room deal with lots of naked people all day long, then by all means, explain the difference.

I'll assume someone will go with "doctors are there to see to your health and help you live longer"... but that doesn't work as an acurate answer, since as stated previous, gowns don't hinder exams, and ... if you've ever talked to someone who works in a trauma center... it's "policy" to strip you naked regardless of the apparent injury. (spend 10 minutes on google, and you can find a forum where nurses talk... keyword search "exposed", "modesty", "covered" or any such related word, and you'll get hundreds of stories of hospitals showing a COMPLETE disregard for the patient being naked.... one story in particular, a nurse was telling how where she worked, it was routine for anesthetized patients going to surgery would be wheeled on the gurney from pre-op to the OR, completely naked on the cart, no sheet or anything... down hallways and in elevators where they passed visitors to the hospital. it's rediculous)

Anonymous said...

Dr. Maurice Berstein in “Teaching Medical Students about Patient Modesty,” writes the following: “Male genitalia exams for an ambulatory patient is done standing and rectal examination with the patient bending over a table.” The internist with whom I did business for sixteen years never had me “bend over a table” when he performed a transrectal prostate examination. A nurse would ask that I replace my clothing with a gown. The nurse would leave and the physician would enter the examination room and have me lay on my left side with my legs bent at the knees. He then draped me before performing the examination. This was not my experience with a female urologist whom I visited. She had me undress in front of her and bend over a table, as described by Dr. Berstein. In an ice-cold voice she proclaimed, “You have a lump” and when I asked her what that meant, she responded, “Cancer!” This shocked me, given I had just had a PSA and prostate exam with the internist a couple of months earlier. So, I asked him if bending over a table would make it easier than lying on one’s side to detect a lump on the prostate. His response was, “Absolutely not. But in case you are concerned, I’ll do it her way.” He did so and felt nothing out of the ordinary. After speaking to a number of physicians and patients, I came to the following conclusions: Requiring patients to bend over a table to conduct a transrectal examination unnecessarily adds to the indignity of an already undignifying procedure. It is done in lieu of draping patients and asking them to lie on their side because the latter is less convenient for the physician than asking patients to bend over the table. Furthermore, according to social constructionists, the bent-over patient with a physician behind him sticking a finger up his rectum carries a more powerful symbolic meaning than treating a patient with greater dignity. This symbolic meaning, which I am sure is clear to all of us, reinforces the asymmetrical power relationship that exists between doctor and patient. If my assessment is correct, it would follow that those who give instructions to medical students and are concerned about patients’ dignity should themselves be taught how to perform a transrectal examination that minimizes the indignity of an inherently undignifying procedure and encouraged to transmit what they have learned to their students.

Anonymous said...

"If my assessment is correct, it would follow that those who give instructions to medical students and are concerned about patients’ dignity should themselves be taught how to perform a transrectal examination that minimizes the indignity of an inherently undignifying procedure and encouraged to transmit what they have learned to their students"

If those students themselves learned such intimate procedures by having them performed on themselves first, by their fellow students... at the front of the class with the entire class watching, it might help them appreciate the least exposed and most dignified way the procedure can be done.

(and after all... if it's no big deal for a med student to see your naked body, then it shouldn't be a big deal for a med student to see another med students naked body, right?)

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George T said...

I hace had 3 TURP operations and 3 transurethral bladder neck operations. Each time I have asked that the prep work for my operation be done by a MALE nurse ans I was always accomodated but once. I had spinals so was canscious for the prepping. At a hospital I went to in a nearby big city I had called to make sure I make my desire known. On the day of the operation a female came to my room and dis lots of things, all I was comfortable with. WHen it appeared that no male was comming before the OR trip I said NOTHING PERSONAL but I'd like to have a male prep me in there--I was informed that SHE Would be doing it and I was dumbfounded. I had been assured by the hospital that getting a male in for that ONE thing would not be a problem. I even wrote out my wishes and had the paper laying on top of me. I was in shock. Once in the OR the room was full of folks involved in what wouild happen to me and I just laid there with tears in my eyes as she preped me. While being operated on a woman cam in to see her as she satg at a desk by the or table and the two of them had a conversation in sight of my undraped body. I was MORTIFIED that this othe rwoman who had nothing to do with my case just walked in. WHen I had to have the same operation again in 15 months i used a different doc and a different hospital and trhe urologist assured me that he woudl prep me HIMSELF--He also posed a sign on the OR door that said NO ADMISSION once operation begins. In medical offices when I have to be uncovered for exams I have NEVER been offered a gown to put on. WOmen have walked in to see the femalw nurse working on me and thought nothing about it. There are NO male nurses at the urology practice I go to who counsel men on ED issues or use of a vaccum device (Peyronies disease damage)--Imagine a woman showing a modes male how to do all that? There was no other option fo rme but to just do it but I am still bothered that males are given no consideratin usually on modesty issues. I bet there is not a single female gynocologist in the US who has all male nurses--nobody would go there I guess.

Anonymous said...

Hello. I am an undergraduate college female and hold strongly to my beliefs in Christianity and values of physical intimacy. Two years ago, I was molested. Recently, I have been having lady problems and have to go to a gynecologist to get it looked at. This is my first gynecologist visit, and I am struggling greatly. I have had multiple panic attacks and severe depression in light of the upcoming exam. I am not scared of malpractice occurring in the gyno's office, but rather of the procedure that is medically acceptable. It is exactly the same thing that happened to me when I was molested and this time I won't even be wearing clothes. May you please tell me how you deal with patients like me and how you teach your medical students to calm patients like me. Thank you.

Maurice Bernstein, M.D. said...

To the undergrad female from today:
First, one doesn't need to claim Christianity to hold strongly values of physical intimacy. To various extents this is a common property of many cultures and religions and certainly is not something one should try to hide from or avoid.

Secondly, I think it is reasonable to suppose that your reaction to the upcoming gyn exam can be explained easily as a post-traumatic stress consequence and is unlike some other women based on uncertainties from hearsay, yours is primarily based your traumatic experience. The best approach to help ease the symptoms is ventilation of your experience and concerns with, (who else?), the physician who will perform the examination. Make an appointment for a preliminary visit to just talk to and listen (no exam yet) to the doctor who you have selected. Talk about your molestation and reactions and see if the doctor's response is supportive and comforting to you. Use your reaction to the doctor's responses as the criteria for whether you want to continue and be examined by this doctor. Don't go into the examination, unless emergent, without this conversation since you don't want to simply add to the trauma. If I was a gynecologist, I would want first to talk to the patient just as I do in internal medicine and as we teach our first and second year med students to do. Every patient comes with some concerns of one sort or another and not always purely pertinent to some disease or symptom. The students are taught in the first days of medical school, well before they learn physical examination, the professional job of communication with the patient. So you should start with communication with your doctor and look to see that he or she responds and provides the confidence and support you obviously need. ..Maurice.

Medical Patient Modesty said...

Dear undergraduate college female student,

Dr. Bernstein made an excellent suggestion that you talk to a doctor about your concerns first before allowing an exam to take place. You should find out if she has worked with sexual abuse victims before and how she works to make them comfortable.

You should also ask her to explain to you what kind of exams she would recommend for your condition and how much exposure will be required. You also should ask her about alternative procedures that may protect your modesty best. For example, if it is suspected that you may have an ovarian cyst, you could look into having a pelvic ultrasound that would only expose your lower abdomen.

If you do not feel that the doctor you meet with is sensitive enough to your concerns, you should look for another doctor. I strongly recommend you read this article: Tips For Sexual Abuse Victims.

If you have any more questions or concerns, please feel free to contact Medical Patient Modesty.

Misty

Nancy Bowling said...

I have been living with my common law husband for 23 years. He recently suffered a stroke, and I was mortified to see this nurse change his diaper and expose his genitals while his exwife was sitting only a few feet away. I want to persue legal action for this breach of privacy and decency. Do I go straight to the administrator or the AMA?

Joel Sherman MD said...

You might look at the thread about privacy complaints.
The AMA does not generally deal with personal complaints of any kind, but in any event would not act on nursing violations.
I would start within the hospital. They will have a protocol to listen to complaints. Of course if you desire legal action you'll need a lawyer, but it's doubtful that any would take the case given what little monetary damages are involved.

Cryptoreformer said...

This is an interesting subject. I have been in the medical field for 40 years and now am semi-retired. I have been a Navy Corpsman, lab tech, LPN and RN. I have done about every intimate procedure on both men and women. Most men are not draped for prostate exams or genital exams, while women are placed in a tent like contraption to hide the mystery of the vagina and the breast must be covered as well.

To day I did an EKG on a young woman, I asked her permission first, and then had an female LPN assist me. The LPN covered the lady;s breasts with a drape which I moved slightly to place the ekg leads. I saw nothing and touched nothing I did not need to. I did the ekg and left. The LPN assisted the lady after that. As a professional I respect patients modesty and boundries. After this I assisted a Nurse Practitioner with a pelvic exam and pap smear. I set things up, and stood with my back turned while the breast exam was done and the pap smear taken. I put the specimen in the bottle and left. The NP assisted the lady out of the stirrups.
Last week, I had a complete skin check done, from head to toe. The RN took me to the room and told me to strip to my skivvies and cover with a drape. I skipped the skivvies and covered my lap with the drape. The MD was a woman and did a thorough exam. She found 2 precancerous lesions and froze them
off. I was asked to lower the drape for the genital exam and again she did a good examination, Nothing was sexual on either part.

I respect patient boundaries at all times. Me, I try to educate nurses and MD's that it is no big deal to exam another human being who is naked. Boundaries must be respected and permission gained prior to the exam or procedure.

This past year I have had two surgeries, and plenty of exams of my genitals, mostly by women, and it does not bother me. I am just matter of fact and let them get their job done in a timely manner.

I think nursing students and medical student should be sexually desensitized to nudity in the medical setting. One way to do this is for them to practice exams and procedures on each other. That is just my opinion.
Thanks, Gary, RN,MS

Doug Capra said...

Thanks for your comments, Gary. It's interesting getting your perspective. I'd like to challenge that perspective a bit, respectfully.
In your comments about your skin exam, you make some assumptions that I think many medical professionals make -- assumptions that I think are not necessarily true. "Nothing was sexual on either part," you write. It's often assumed that patients who prefer same gender care are afraid of the provider's sexual thoughts, that this is the driving issue. But their embarassment isn't necessarily due to that. I believe most patients accept the fact that these kinds of exams are not sexual in nature, on either end. Just because the doctor or nurse has no sexual feelings, doesn't justify ignoring a patients desire to have same gender care.
Are you assuming that your response to your skin exam is the "right" response, the "norm," the way men should respond? You represent the "gender neutral" attitude that's often been discussed on this and other blogs. I read your experience as if you somehow represent the way things just should be for all patients, men and women. How you feel and accept being treated is your business. How others feel and accept being treated is their business.
The way you describe how women are treated as compared to men shows that women are provided more respect than are men. I can't quite tell whether your comment about the "mystery of the vagina" is in jest or not. Why not the "mystery of the penis?" And I do understand the cultural and historical significance of your comment about women's bodies. But what about "gender equity?" What does that really mean?
Why didn't you have a male LPN to assist you for that EKG? Most female doctors and nurses will use female assisants to treat men in cases like the one you describe. Why is that? Are the men asked how they feel about that? Are they given a choice? In the case where you assisted the female NP, did anyone ask the patient whether she prefered a female nurse to assist the NP? Or was it just assumed she wouldn't mind.
I do agree with you that medical students and nurses should practice exams on each other.The fact that many won't and are offended by such practice just shows the hypocracy here. But the fact that they need to be desensitized to nudity, does not mean that all your patients must be desensitized by the profession to their nudity. Their level of sensitivity is a value that they deserve to maintain. There seems to be a notion on the part of some medical professionals that it is their job to desensiticize patients to nudity, to resocialize them. I would suggest that this is not within the scope of their practice, nor really any of their business. That doesn't come within "patient education."
But I do respect your opinions and really appreciate you coming on here and expressing them. I wish more medical professionals would come on blogs like this and really engage in the discussion like you did.

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Math Teacher said...

Thank you all for sharing your thoughts and experiences.

I'm not sure where the disconnect between training and practice occurs, but I can tell you first hand it does.

Two years ago I needed gynecological surgery. I was very concerned about both my modesty and being sedated (and thus unable to know what was happening to me.) I made my concerns very clear to my doctor, anesthesiologist, and nurses. All assured me they would take "good care" of me.

After surgery I learned I'd been sedated without warning (I have no memory for about 7 hours, the surgery itself lasted only 1.5 hours) and that my doctor had both a male nurse and assistant working with her--removing my gown, prepping my vagina, inserting the fingers and other objects into my vagina and even performing a pelvic exam. I was, and still am, mortified. Her response was that everyone involved in the procedure was a professional and I shouldn't worry about what they saw or did.

Since then, I have not been able to bring myself to allow any provider to examine me. A couple of months ago I went to see a dermatologist for acne and to check some moles on my thighs. The panic I felt seeing the examining table prevented me from showing her the moles. I couldn't get out of there quickly enough.

I know for certain a colonoscopy or mammogram are out of the question, at least for the time being. The point is that not only should providers be trained on how to honor patient desires for modesty, they should also be trained on how to listen when they make "mistakes." Though there is nothing I or the providers can do about what happened, a simple "I'm sorry, I should not have allowed that to happen" would go a long way. Justifying or rationalizing treatment is not "patient-center." Worse are comments like, "I'm sorry YOU feel that way," because it puts the blame on me rather than their choice to ignore my requests.

Patients should be treated in the manner they expect/ask. Efficiency and arrogance (in the form of "the doctor knows best") should not drive decisions of heath care workers. Further sedation does not negate norms for respect for patient wishes.

Cryptoreformer said...

I previously commented about my experience of 40 years of dealing with nudity in e medical context. What I was writing about was my experience. I am not trying to prescribe how all people should feel about this. When I did the EKG on the woman, I did have a female LPN assist me, as that is our policy at the Free Clinic. Also, there were no male LPNs available. When I assisted the NP, with the pelvic exam, the patient was first asked if she minded a male nurse assisting the NP. The was was given a choice here and nothing was forced upon her. I was the only nurse on duty that day also. If she would have said no, a lady in the office would have had to help the NP. ALso, I had to chaperone that same NP later in the day when she did a gentical exam on a male patient. It is the policy of the clinic.

I do try consciously not to offend people and to protect their privacy. I always ask permission first before a touch a person, either male or female.

After 40 years, I am desensitized to nudity in a medical context. I do not know what the female dermatologist or her RM were thinking about me when they did their skin check. My examination was professional and thorough. That was the point of the examoto look for skin cancer. Nothing more, also I am not a "feast for the eyes". I have seen female nurses in the past talk about the mans' penis they just catheterized and I thought that was in appropriate. I have had to catheterize females of all ages in the past. To me, it is anatomy and a procedure to do to relieve a problem. I always asked permission first. When a woman said "no", I got one one my buzy LPNs to do the job, while I passed the meds for them.
Respect is the main concern, and always ask permission first.
Thanks, Gary RN

Cryptoreformer said...

I would like to share the past couple of years (2012-2013). I realized I had some erectile problems. I went to the local MD, who happened to be female. She asked if I minded her examining my genital area and doing a prostate exam. I said no, as this is not an issue for me. She did a thorough exam from head to toe, then asked me to raise the gown after standing up. She examined the testicles for any pain or masses, and examined the penis for abnormalities. The exam was efficient and done in a professional manner.
Then she did the prostate exam. She did a good exam and told me that was normal.

Okay this was my first exam in a long time by a female MD. It meant nothing sexual to me, as I was just a patient in need.

A few years later, I was a patient in the hospital where I worked. I was too ill to even stand. When I had to urinate, the nurses (my friends) had to hold the urinal for me. I was just grateful for their help.

Years later, the ED got to a terminal point. I went to a local Endocrine MD who was in my insurance loop. I went to see her and gave her my history of ED. She asked to examine my testicles and penis , and asked if I was offended. I said no, just do what is needed. She apologized for her female nurse who had to chaperone her, that the MD told me she always turned her back to the wall. I said OK and the kind doctor did the exam and asked questions. She was wonderfully professional. She also knew I was an RN, so she was less nervous examining me (as she said).
Okay that done.

I asked for a recommendation to a urologist. I got one and it was awful. The guy was just out of his residency and had an attitude problem. He looked at me as he walked in and said "Drop your drawers." I did and he examined me for a minute or so. He said:"There is nothing I can do for you, as you are just a fat baby boomer." He then whipped out his RX pad and wrote me a prescription for Cialis, and said: "See if this works, if not, I can not help you."
I was shocked by his behavior, his curt exam, and his whole attitude.
I asked for a second opinion. He said okay, "Call this man at UVA. He is one of the top guys." I said thanks, got the number and left.

I called the medical center and got an appointment with the MD for 6 weeks later. When I got there, I was greeted by his Fellow, a female urological surgeon, who had already completed her residency. We talked about my history, rugs, etc. She asked if I minded her examining me, and I said no. (She was an attractive young woman, but at the time there was no sexual feeling on my part).

She examined very thoroughly and the exam took more time than the male urology doctor. She said we should try the medical route first. I said okay, and tried the Cialis for a few months with only one erection. I called back and had another appt. with her.

This time was for a penis ultrasound. I got there and she said she had to inject a drug into my penis for an ultrasound. They had a male tech do the ultrasound, as he had to physically handle my penis. Then she injector me to give me an erection for part 2 of the ultrasound. It did not work. She said a second injection was needed. She had her female resident hold mu penis, while she injected me on the other side. Again, it did not work. After that, she injected my penis with normal saline and there was a large erection. They ultrasound was performed. She results were "terminal ED".

Okay, we talked about surgery. That was scheduled, and on the day of the surgery, her boos did the surgery, as she was at a conference. I was disappointed, as she had been very kind and professional. I met her boss for 60 seconds before I went under. The last thing I remember was he was giggling about the surgery. That was very odd.
Anyway, that was one of my experiences as a male patient with a female urologist. It did not concern me, and she was professional and kind. She gave me hope.

Thanks, Gary RN

Anonymous said...

Dr Sherman,

I have enjoyed your insightful blog on patient modesty. And while I have never had a problem with female nurses I do have a question that you may be able to shed some light on.

We hear stories all the time about female nurses discussing the size of their male patients anatomy. Not all do this, of course, but it happens more then we would like to admit.

What I would be interested in knowing is why?

If nurses get past the nudity early in their clinical training, are comfortable around it, can perform all procedures from top to toe, and if it is really "seen one seen 'em all" then why would any nurse feel the need to comment on any part of a patient's anatomy?

I've also heard of nurses discussing things at the nurses station that would make a sailor blush.

I know that nurses are people and, as such, are prone to the same failings that we all have. But in this line of work, there is appropriate and inappropriate behavior. And I just don't understand why a nurse--being the professional that she is--and being used to the nudity would ever comment on a patient's size or even lack thereof.

My guess is that it is a maturity thing.

Sure, they are human. Sure, they have to do assessments and they will see the human body in all of its glory. But what they do with what they see is another issue entirely.

Nurses say all of the time that the care that they give is not sexual in any way. Then how would we classify a comment on a patient's size? Pure anatomical interest?

I'd appreciate any feedback someone may give.

Anonymous said...

We all want anyone involved in our health care to be professional, courteous, and able to do everything needed within the scope of their professional practice.

Both male and female providers treat patients of both genders every day. When we complain about modesty issues and concerns over opposite gender care, I think what we are really looking for is something that nobody can guarantee.

I'll explain...

One of the big reasons that women want a female caregiver is because of distrust of the male physician. It isn't that he isn't capable. He is just as qualified as his female counterpart. The reason is because of fear over what the doctor might be thinking.

I read another post where the poster asked if a doctor, after examining a female patient, would say that she was so good looking she should be in a magazine?

Questions like these show concern not about what the doctor does professionally in regards to the patient but what the doctor might say after the patient leaves his place of practice.

We question the use of chaperones because we believe that they violate the privacy of the patient. I believe they would be a violation only if the patient does not want them as part of their exam. We also balk at the idea of a chaperone being a receptionist rather than, say, a nurse.

But here is the gist if the matter...

If all that is required of a chaperone is to witness the exam, a receptionist could do this as well as a nurse could.

So, what's the difference? As patients we expect that with the level of training a nurse receives she will view the exam differently than a receptionist would. Or in other words, we as patients have more confidence that the nurse will THINK clinically about our exam and attendant nudity more so than the receptionist would.

But is this a guarantee? If you dressed the receptionist and the nurse in scrubs with no identifying badges and had two exams, both the receptionist and the nurse would come in, view the same exam, act professional doing nothing inappropriate, and then leave. You as the patient would not know the difference. The only difference might be in how they *thought* about the exam. However, what a caregiver or medical professional thinks is beyond your control.

What if the nurse looked at your exam with a sexual view but the receptionist was a very moral person, married with kids and attended church? How would you know? Which would you rather have?

I believe that the higher the qualifications and training, the better the chance of a professional mindset. But it is no guarantee that they will have "professional" thoughts that only you would like.

That doctor examining you may have a thought that if you knew you would be offended or ask "Why did they think that?"

In the end, we do not control what a doctor, nurse or chaperone thinks in their heart nor can we control what they say or think after we've left the medical center.

In the big picture, what a caregiver thinks, or even says about a patient after they leave the building is not only out of your control, it does not affect the patient one bit.

Is it right? Of course not--not any more than it would be right to talk about people "behind their backs" so to speak.

But the person being spoken of, being blissfully unaware, is in no way affected. In fact, the only ones being affected would be the people doing the talking.

So while we can demand changes, the changes that need to be made are at the "heart level" and are changes over which we have no control.

We can demand certain kinds of behavior... but we have no right to demand certain ways of thinking.

Joel Sherman MD said...

Anon of September 27, 2014 at 12:34.
I agree that it is a 'maturity thing.' The vast majority of providers outgrow the need to discuss unneeded patient tidbits. If they don't, they don't belong in their field.

Anonymous said...

Dr Sherman,

This raises an obvious question: how do health care providers control themselves around the nudity of their patients? Doctors, nurses and others in the medical field see body parts all the time--parts that some people, sadly, buy magazines to see.

In addition, some patients would be surprised by some of the outside activities of their health care providers. Some which we could question as to how it would affect the provider's view of nudity in the medical environment.

We are all sexual beings--doctors and nurses being no different. Most of us are not so naive as to think they have a special gift, or flip a switch at the hospital door and turn their libido off. Neither do most believe that doctors and nurses are always just one step away from misconduct either.

Is it context? Is it the professional relationship to the patient? The environment? How can a nurse or doctor view body parts at home and enjoy normal sex and then go to work and remain professional with not even the slightest hint of arousal or temptation? Or are they human and just good at hiding it?

Anonymous said...

My father had bladder CA a few years back. As these modesty blogs have observed the urology practice where my dad went only had female assistants for all prepping including cystoscopy procedures.

My father explained what was involved with the prep and it is very intimate to say the least. I think some may be nurses but in all likelihood most are medical assistants or even just assistants specially trained for the task.

While I have no problem with this and I thank God for them being there for my dad to assist in his care (and he said they were very professional) one can only wonder what goes through these women's mind when they are prepping these males? I would hope that their thoughts are only clinical.

Also, it makes one wonder what their (the female assistants) motivation was for getting into urology and doing these kinds of procedures in the first place?

Not implying that they were less than honorable but it would be interesting to hear from some as to why and what they think about their work.

Anonymous said...

"If all that is required of a chaperone is to witness the exam, a receptionist could do this as well as a nurse could."

Receptionists don't have the training to recognize what is appropriate or not. Additionally, IMO they (CNAs, techs, and assistants) lack the professional distinction to witness either a male or female intimate exam. Which is why all patients should inquire about the professional title, level of education, and why their needed before agreeing.

Ed
Ed

Anonymous said...

Ed,

I understand that a receptionist would not necessarily know what is proper medical procedure and what is not. More often than not the doctor using a chaperone just wants another pair of eyes there to either protect their license or to discourage any kind of misbehavior on the part of the patient. Trust plays a big factor here.

As to a chaperone having the professional distinction to witness an exam, if you are talking about knowing what is and is not medically permissible, I agree. If by professional distinction you mean that the medical professional will only have clinical thoughts about what they're looking at, there are no guarantees.

See, we trust those with professional credentials behind their name. And we have every reason to believe--based upon prior experience--that we will be respected and treated appropriately at all times during the exam. We sort of trust these people because of their "professional distinction."

But no matter how educated someone is, there are no guarantees that the "professional" is not having thoughts about the patient that the patient would resent.

As humans, we judge even though we shouldn't. Doctors are not exempt from this.

Which brings us back to my comment.

While I would rather have a nurse who is clinically trained observing my exam, if all they are doing is being an extra pair of eyes, then a receptionist could do that...professional distinction or not.

Professional distinction in this case would not change the outcome, nor guarantee that everyone in your medical exam would be thinking happy thoughts about you.

On one level, I know where you are coming from. On another level, the reality is that 90% of all health care workers are female. If us males want a same-gender team to care for us it will create a logistical nightmare as well as no guarantees that our requests will be met.

And while it is noteworthy to raise the issue to providers about the double standards which exist on several levels in our health care system, sometimes, you just have to go with the flow at the moment and deal with it.

Don't want to sound like I am giving in or anything. I have never had a problem with female health care providers and do not feel threatened by their presence in my exams--provided they are a necessary part of the team.

So, 90% female or not, I don't have anything to worry about. But I do understand the men whose modesty issues require same-gender care.

At the present time, the deck is still stacked against those men who desire same-gender care.