Sunday, January 29, 2012
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.
Posted by Joel Sherman MD at 3:17 PM