Monday, November 24, 2014

Masculinity and Men's Health

Masculinity and Men’s Health Care
Doug Capra

            What does it mean to be a man? How do we define masculinity? What does a “manly” man look like, sound like? How does a real man behave?
            More importantly, who gets to decide the answers to these questions?
            The Movember Foundation is a respected global organization committed to changing the face of men’s health care.
How? By challenging men.  They challenge men to grow mustaches during November to raise funds and open up dialogue about prostate cancer, testicular cancer, and mental health issues. Since 2004, they have raised over $550 million and have funded over 800 programs in 21 countries. They are an honorable organization.
That’s why I was surprised recently to read a press release promoting this mustache-growing event that contained the following sentence:
“Most men aren’t proactive about their health because they’re ill-informed, lazy or scared. And that’s not manly.”
I’m not questioning the intent of the article. Getting more men to be more proactive about their health is an exemplary goal. But calling men lazy and unmanly?   And how dare a real man be scared. Real men aren’t supposed to be scared, are we? If we are, we’re certainly not supposed to verbalize it or show it in any way. On the other hand, realistically, who wouldn’t be afraid of the possibility of prostate or testicular cancer?
I couldn’t imagine this kind of language being used when the pink ribbons are distributed and women are urged to get checked for breast cancer? Why then do some believe it’s acceptable to use this language to convince men to get health care?
I immediately checked the Movember Foundation website  and read through it. I first went to their visions, values and results section under “about us.”  Everything I read showed tremendous respect for men, so I couldn’t imagine this language coming out of the Movember Foundation. So I sent an email to Movember inform them about this incident and asking if the press release came from them. I immediately got an email back from their representative, Abbie Rumery. She wrote:
“Thank you so much for reaching out. Was this a press release that was put out by a local community group, or was it in a news article that you read? That is not something we would ever say or promote on our website. Movember is all about getting guys to feel more comfortable talking about their health and breaking down stigmas and barriers related to their physical and mental well-being. If any organization is looking to promote their involvement in the Movember campaign, I would normally send them this digital press kit and the attached one pager and press release template. None of which say anything about men not being proactive about their health because they are lazy or scared and that it’s not manly.”
I hadn’t thought those words came from the Movember Foundation. That wasn’t their style. But then – where did that press release come from? I eventually found out, and I was further disappointed
I learned that what appears to be the original article is on a website belonging to the UMC Health System. They claim to be “the leader in comprehensive healthcare delivery in West Texas and Eastern New Mexico.” They say they reach “more than 300,000 patients a year,” patients that have “come to expect our dedication to service and the top-tier care we provide.” I’m not certain that this article originated there; it could have been reproduced from another source. But that’s not an excuse.
I sent an email addressed to four of UMC Health System’s top officials. I’ve not gotten an answer back from them and I note as I write this that the link that contains the sentence about men being lazy and unmanly is still up. You can find it here.   The fact that they haven’t returned my email is also disturbing. By ignoring controversies you just raise more disturbing questions. Did they think my email was from a crank? Do they consider my complaint unjustified or irrelevant? Or do they really believe that many men don’t get health care because they’re lazy and unmanly? By not facing the issue, they leave these questions unanswered.
I’m one of the men who is proactive about his health, and although I’m not a health care professional, I’m actively involved with health care issues. I frequently urge men who aren’t as proactive as I am to get checkups. But let me suggest that there are better ways to persuade them than by calling them “lazy”-- and saying that being afraid – a reasonable response to serious disease – is “unmanly.” Yes, many men are uninformed about health care issues – but not more than the population in general.
The real question – that is rarely asked and rarely researched – is actually why these men (and some women) don’t seek healthcare. And let’s not leave out that high costs may be one reason. Even with insurance, some patients can’t afford the deductibles.
Catherine E. Dube, EdD, has been doing research into men’s health attitudes for years. She and her colleagues published “Talking with male patients about cancer screening” in the Dec. 17, 2004 issue of the Journal of the American Academy of Physician Assistants. They wrote:
“Clinicians may hold certain assumptions about male patients that are not well founded. Clinicians may believe, for example, that men are immodest and unlikely to feel embarrassment during genital exams, don’t care about their health, are emotionally insensitive, and will seek medical care only if pressed to do so by a woman in their life. In our focus group research, however, we discovered that men were surprisingly modest about physical exposure in clinical settings, concerned about embarrassing exams, and interested in their health. We also learned that they desired closer personal relationships with their health care providers.”
This can be a sensitive issue that is worthy of much more discussion than I have time or space to offer here. Dube and her colleagues also wrote:
            “Understanding male communication and behaviors has become even more important with women entering the health professions at ever increasing numbers. Stereotypes held by practicing clinicians and handed down to trainees need to be challenged and adjusted to provide more effective care to men. Since men are less likely to be connected with the health care system than women, special efforts should be made to encourage appropriate preventive care, including age-appropriate cancer screening and early detection strategies.”
This article was published ten years ago, and perhaps we have made some progress – but not nearly enough. Indeed, the health care system is under even more stress today than it was then. Rising costs place a tremendous stress on efficiency. Safety, quality, standardization and patient experience issues dominate many a discussion in medical boardrooms.
And patient experience is an especially hot topic today. Some experts in customer service will tell you that the medical community, generally speaking, is twenty-years behind the times. In the early 1990’s a team from the Harvard Business School, Pine and Gilmore, published a book called The Experience Economy. Consumers were not merely after food or coffee or beer, they contended. They wanted an experience. That’s what they would pay for. They pointed out how Starbucks turned a commodity into a successful experience. Disney may have started the movement, or at least perfected it – but other businesses followed.
The patient experience begins with the patient’s first encounter with the system.
At the end of their book, Pine and Gilmore said that the experience economy has already peaked and we’re moving into what they called the Transformation Economy. Consumers don’t just want experiences, they want peak experiences that will transform their lives. We see that today especially in the tourism industry.
As we’ve consistently pointed out on this website, medical modesty and privacy are extremely important values for some patients and very important for many others. We’re not claiming that most or all men who avoid health care do it for modesty reasons – but certainly some do – as do some women. One of the key elements of American capitalism is choice. Patients in general, both men and women, should be offered the caregiver gender they feel most comfortable with, especially for the most sensitive exams and procedures. This may be one reason why some men and women don’t seek the care they need.
Certainly, we can push people into all kinds of behaviors by using name-calling and guilt. But that’s not persuasion. At its best it’s intimidation. At it’s worst it’s bullying. Of course, if one believes that the end justifies the means, than I suppose anything goes.
But the idea is to create lasting change, a “transformation,” -- not just one visit to the clinic where the experience may or may not be positive. The idea is to get rid of sexist stereotypes in both language and practice and start dealing with reality. Most men at heart want to stay healthy, not just for themselves but for their families as well. They may be afraid, but that’s natural. They may be strongly influenced by masculine stereotypes themselves and feel they can’t be afraid or embarrassed, or express their true feelings to health care providers. Certainly, telling them that this fear makes them “unmanly” is counterproductive and plain wrong.
But we’re not only dealing with the stereotyped attitudes some men may have been raised with.  We’re also dealing with attitudes from the medical community as Catherine Dube points out in her research.
As the month of November ends, let’s not drop the issue of men’s health. Let’s keep it open. And let’s all of us start taking openly about the issues that prevent men and women from seeking the health care they need to better their lives and those they love.

Friday, April 11, 2014

Medical Scribes, an Evolving Threat to Patient Privacy

by Joel Sherman MD

Medical scribes are a burgeoning field with many institutions and practices exploring their use while the many commercial enterprises who lease out scribes are pushing for their widespread acceptance.  There is no accepted definition of what scribes do or what their background or training should be.  There is no mechanism for licensure of them in any state.  They are poorly defined medical assistants.  The field is in its infancy and its ultimate role in our healthcare system is unclear.

The usual use of a medical scribe is to follow a provider around in their clinical tasks for the purpose of data entry.  This may or may not involve being present for the history and physical exam.  Most commonly they are physically present in the room and witness the entire encounter.  The need they fill is a function of our ever increasing mandates for electronic medical records (EMR).   Before EMRs, the use of data processors in examining rooms was quite rare.  Thus federal mandates have created another whole class of employees who are placed in the middle of health care interactions increasing the potential cost and complexity for all.   Some practices will clearly be tempted to use the scribes for as many uses as possible including assisting with minor procedures which I’ve seen advertised and acting as chaperones, which I know happens. This can help to ameliorate some of the extra cost involved in their employment.

The background of scribes is not standardized.  The minimum requirement appears to be competent data entry ability which translates into typing speed at a terminal.  Some advertisements require applicants to have a high school diploma or a year or two of college.  Many make no mention of education at all.  Some commercial sites train the scribe for a period varying from a few weeks to months.  At the high end, some advertisers require an existing knowledge of medical terminology with the preferred candidate being a medical student or premed student.  This is more often the case when the scribes are being used by academic institutions that have much greater access to people with these qualifications.  The majority of practices will not have access to premed or med students.  The scribes are mostly young and it is likely that few will choose this as a permanent career.  Thus they constantly have to train new ones.  The advertised pay rates vary from a minimum wage of about $8/hr up to about $20-25/hr.  The work may be full time but often is part time.

The touted benefits of scribes are to increase the efficiency of the practice by allowing the physician to see more patients while having a more personal interaction as they are freed from data entry.   It is advertised as a money saving strategy though a practice I discussed this with wasn’t at all sure that it saved money in their practice.  Scribes are a possible solution to the imposition of EMRs whose benefit to the patient and practice are frequently unclear or negative to begin with.  The dangers to patient privacy are clear but not often emphasized.  How much of a concern this is depends on the practice.  My ophthalmologist uses them without difficulty.  Few would object to an assistant hearing your ophthalmological history.  But many patients of general practitioners or internists would be inhibited from giving an intimate history by the presence of an assistant.  A few have the assistant outside the room for this perhaps making the patient more comfortable.  The presence of scribes during intimate physical exams is a further situation where many patients would be uncomfortable.  One article by urologists studied this and found no problems with acceptance, but the study had many caveats which the authors document[1].  This took place in an academic setting with medical students used as scribes.  The majority of the scribes were in fact men.  The one female urologist in the practice with a predominately female following refused to be part of the study.  I think the results would have been different in a urology practice in a private non academic setting where scribes were predominately young women without a medical background.   The routine use of opposite gender scribes would certainly make many patients uncomfortable in a private urology practice.  The most common use of scribes to date is in emergency departments where there are certainly many issues of patient privacy.  But in emergency settings patients are less likely to be concerned about their privacy.

The accuracy of scribes has not been studied to my knowledge.  The results would depend greatly on the background and training of the personnel.  But I do not see how anyone with a high school background and a few months of training could possibly understand all the medical conditions covered in a general practice.  The physician is responsible for signing off all records of course, but if the record is full of errors, it would be of limited use.  If premed or med students are being used, the results should be better, but this is partially mitigated by the fact that there would be immense turn over and new people would always need to be trained.

In summary, the routine use of scribes in a general practice has many potential problems of privacy and accuracy.   I don’t see how scribes without a medical background could ever be competent to understand a general medical history.  It would be far more accurate to have patients fill out detailed questionnaires on the initial visit and then have data entry performed on this later by scribes.  This would also permit a far greater feeling of patient privacy.   Patients have always understood that their medical records may be processed for administrative purposes.  The presence of scribes during intimate histories and exams should be very limited and only done with the express permission of the patient.  They should not be used as chaperones or multipurpose medical assistants without further special training.  In the long run the use of scribes is likely to be a temporary answer to a cumbersome system of mandated EMR which can still cause as many problems as it solves.  There is no intrinsic reason why EMRs need be so intrusive that their use requires a staff of intermediaries.  This makes it increasingly impossible for solo physicians and small groups to stay in practice.

[1] Koshy S et al, J. Urol. Vol 184, 258-262, July 2010.

This article has been re-published on