Medical Students Learn About HIPAA Guest post by Estelle Schumann

Medical Students Learn about Patients’ Right to Confidentiality

Patient health information and privacy has been protected since 2003 under the Health Insurance Portability and Accountability Act, or HIPAA although it is something that both current and aspiring health care professionals  have always been aware of. Congress enacted HIPAA in 1996 as part of a broad health care reform effort. Initially, the emphasis was on promoting personal health insurance portability, but the emphasis changed to standardizing the process of sharing insurance claims with medical insurers.

Congress recognized a great potential for abuse of electronic health data, so they placed strict controls on its movement and care. Doctors and hospitals must comply with HIPAA regulations, and so must academic medical centers. Like all other staff of hospitals and medical centers, medical students must complete HIPAA training. Every health care facility must provide documentation of this training for everyone who has access to patients or patient data.

Protected Health Information (PHI) which is stored, transmitted, accessed, or received electronically is called ePHI. Under HIPAA, PHI means any information “that identifies an individual and relates to at least one of the following:

• The individuals past, present or future physical or mental health.
• The provision of health care to the individual.
• The past, present or future payment for health care.

Information is said to identify an individual if it includes the individuals name or any other information that could be used to determine the individuals identity.

To know the specifics of how to protect patient data, entering medical students must complete HIPAA training, which is generally administered online. HIPAA is site specific, and entering students, for example, at the University of Washington must complete training both for UW HIPAA and the Veteran’s Administration Hospital’s HIPAA prior to Orientation. The course for UW Medicine is web-based and takes approximately two hours. Students will receive a user ID, password, and web address for the training in an email, the summer before they enter medical school. Upon completion, they will receive a compliance certificate, one copy of which they must email to the school in PDF format, and one copy they may be asked to provide at clinical sites or to participate in research that includes patient data.

Some general HIPAA guidelines, according to the Medical College of Wisconsin Affiliated Hospitals, Inc., are:

• Access patient information only if you need that information to do your work.
• Share or discuss patient information only if it is necessary to do your work.
• Never share your identification number or password with anyone.
• Follow the hospital’s or healthcare provider’s policies on confidentiality and privacy.
• Log off your computer session when you are not by your workstation.
• Ensure confidentiality when you handle protected healthcare information.

In addition, MCWAH trainees are required to sign a confidentiality form.

Yale University is required to notify individuals within 60 days if the security of their PHI has been compromised. They must also notify the Department of Health and Human Services, and, if more than 500 individuals are involved, they must notify the media. Civil monetary penalties and criminal penalties have been established by HIPAA for knowing use or disclosure of identifiable PHI. An individuals own access to his or her health information is somewhat restricted under HIPAA, but generally the law protects the individuals right to privacy.

Doctors, medical students, and healthcare personnel, are trained and certified to follow HIPAA guidelines. It is an important piece of legislation that is vital to protecting patient privacy.

Estelle Schumann blogs at  http://www.healthscience.net/

The Mass Media & Men's Health by Joel Sherman MD

This article was chosen for reposting on KevinMD.

CBS Cares - About my prostate !

The mass media has a long history of covering medical dramas and rarely doing so with any realism.  We’ve gone from Marcus Welby MD to a host of shows dedicated to portraying medical personnel in the most salacious ways possible.  But at least with all these dramas it is understood that they are fictional.  There are now though a host of shows which pretend to show real life medical stories which are even more perverse. 

Some of the most egregious examples come from Untold Stories of the ER, a Discovery Health Channel production which is sporadically rebroadcast on The Learning Channel.  A prime example from this show is episode 4 from season 5, ‘Grandma’s Back.’  This episode can be downloaded from Amazon .    One of the incidents portrayed is that of a young man entering with priapism, an erection which won’t subside spontaneously.  This is a relatively rare occurrence as a side effect of Viagra.  But can also be associated with serious underlying clotting disorders and malignancies.  After an episode of priapism men are frequently left impotent.   In short, the condition is a serious one and anything but a joke.  It’s about as intrinsically funny as female infertility. 

The vignette portrays a young man coming in the ER with a prominent bulge in his pants accompanied by his mistress.  His wife later shows up and the two women fight as neither was apparently aware of the other.  The patient is portrayed as being in great pain and whining for relief while trying to fend off the two women who turn against him.   The whole episode is one of comic relief in contrast to the other 2 episodes in this hour show.  The other two tales in this episode concern critically ill women, one young and attractive, the other elderly but well preserved, both of whom ultimately do well.   Needless to say, both are treated sensitively as if a miracle had taken place without a hint of mockery.

The doctor in the priapism story is identified and I was able to call him.  He said the season was filmed in Vancouver, in a defunct medical clinic, which the network rented out for the month.   Of course all the patients and likely most of the staff are actors, but the identified physicians are real.  The priapism tale is one the physician suggested based on a real experience from his residency.  In commenting on the filming, the doctor said that ‘sex sells.’

A further episode portrays a man who came in with testicular pain.  A testicular ultrasound is ordered, but a mix-up occurs and an orthopedic patient is sent instead.  The patient who underwent the mistaken testicular ultrasound by a woman technician of course is later shown to have thoroughly enjoyed the exam.   Two other episodes make a point of showing men being embarrassed to be treated by female physicians or nurses.  Needless to say, I’ve seen no episodes ( though I haven’t seen them all) where women are portrayed in such a mocking disrespectful way.

The attitude taken on this show towards male health problems is reflected throughout society.  It is routine on TV and in movies for the portrayal of men being hit in the groin to be used as a comic event despite the fact that serious injuries occur.  The media treatment  of the John Wayne Bobbitt case is an extreme example.  There are many sites devoted to jokes about the incident.  It’s inconceivable that mutilation of a woman could be treated similarly by the media.

Men’s reluctance to obtain routine health care is also routinely treated as a joke.  Even physicians have done this.  An example quoted before on these blogs' is Dr Sharon Orrange’s article  on the 10 reasons men don’t go to the doctor including “you are afraid we will put our finger in your butt” and “you are afraid we will examine your balls.”   This same physician has never treated woman’s issues with levity. 
 

Even when the motives are unquestioned, the media frequently uses humor and sex to try and encourage men to receive medical care.   CBS has run a series of public service announcements to entice men to receive prostate exams.  Some are directed to women rather than men, a common strategy.  Some of these ads use a young alluring woman to give the message with a smile (pictured above).   Can you imagine an ad to promote Pap smears using a young handsome man?  I don’t think you’ll ever see one.   Why not use an ad from a former athlete who may have had prostate cancer himself?  There are lots of them.  Johns Hopkins was featured in an ABC TV series in 2008 purportedly to show real life situations in medicine.   One episode featured a female urologist coaxing a minimally reluctant  older man to submit to an exam.  He is shown from the back lowering his pants for her.  There was no point to this episode except to introduce some sex and male embarrassment into the show.  There are many thousands of women physicians in this country who do thousands of exams on men every day.  Why feature men for embarrassment?  Women get just as embarrassed,  but that’s never a matter for humor.  That’s treated as a serious concern.  On an opposite but analogous theme, a play called, ‘Midlife Crisis, the Musical’ has one scene showing men sitting reluctantly in a doctor’s office waiting for their appointment.  But they are then told that the provider has been changed to a young pretty female physician, and the men now jump up with eagerness to get their exam.  So men are either reluctant to have an exam or eager, depending on what seems more humorous in the setting.

In short, the media has always portrayed medical situations in sitcoms and dramas in a way to sexualize and dramatize the entire episode.  It is highly variable whether any pains are taken to get medical facts correct; often they are totally inaccurate.    But at least it’s apparent that these dramas are fiction.  The so called reality shows are worse in that viewers are more likely to believe that they are actually witnessing valid portrayals of modern medicine.  Male patients are usually not shown as being capable of making intelligent choices about their health care.  They either need their wives to push them into it or the medical encounter needs a pretty provider to attract them.  Frequently they are embarrassed to seek help.  Now these characterizations do fit some segment of the male population, but why are they the only segment shown?  No humor is portrayed when women  need to be pushed into obtaining needed medical care.   The majority of men who need chronic health care, predominately middle aged and older men, would be better served by intelligent and factual reminders of what is needed.  Some professional organizations like the American Cancer Society do provide this, and there are serious health segments, especially on cable news, but in general the popular mass media fails miserably.  I see no organized protest about this.  Groups such as the AMA could improve the situation if they tried.

Modesty: Medical vs Societal Standards Guest post by Carolyn Knight

Medical Carte Blanche

If you go through security at an airport and are selected for a pat down, they will make sure that a TSA agent that shares your gender pats you down.  If you get arrested and receive a pat down before entering a squad car and an officer of your gender is not present, one will be called to the scene.  But, if you are in need of a urinary catheter at a hospital, you get no say in the matter whatsoever.  Oftentimes they are not even going to perform the insertion behind closed doors. 

Awaiting a prostate procedure

In today’s medical facilities, statistically speaking, catheter insertion is more likely to be performed by a female nurse. In fact, according to the U.S. Department of Health and Human Services, only around 6% of the nurses in the U.S. are men. Since some patients do not wish to be examined by a medical practitioner of the opposite sex due to cultural, moral, and modesty standards, this is a problem.

Some people believe that there is a general attitude in the medical profession that what gets in the way of a medical objective must be crushed and swept out of the way.  When it is cancer, then by all means, crush it and sweep it out of the way, but when it is human dignity people must advocate their rights. 

Dying female patients that are admitted to the emergency room that must have their clothes cut off and their breasts exposed for a chest tube or worse might not be too concerned about their modesty, but sometimes modesty is violated over matters of convenience and not collapsing lungs. 

People that enter the medical profession may not have the inherent tendencies to violate patient privacy. However, a total lack of modesty in training in school from LPN programs all the way to medical school and you have many practitioners that no longer have any boundaries. 

According to ABC news, men are less likely to visit the doctor than women because of factors such as modesty and a desire to not appear helpless. The price men pay for not seeking medical attention is tremendous. If those in the medical profession work to respect the privacy and modesty of their male patients, they would likely see a spike in men seeking help for their medical conditions. Men should, at the very least, be able to choose the gender of their doctors and nurses in the emergency room when they are seeking help for conditions that require extensive physical examination.

Of course, modesty and privacy concerns don’t just affect men. According to the American Medical Association, only around 40% of practicing OB/GYNs are women. And, according to the Canadian Medical Association Journal, around 50% of women prefer to seek help from a female doctor when it comes to childbirth and gynecological issues. So, women who desire to see a female gynecologist in the emergency room have less than a 50% chance of being able to do so. Women can, of course, choose the doctor that gives them a pap smear. However, they rarely have a say when it comes to which doctor sees them in an emergency room.

Male patients have a right to a male medical professional whenever exposure or contact with genitalia is a factor as much as female patients have the same right to be treated or handled by a female.  The lack of consideration for this right to privacy is not healthy for the trust of the patient in the practitioner, or for the aspects of truth, compliancy and giving forth of information and compliancy that is necessary for optimal treatment. 

As the accused have fought for the rights to be searched by the same gender, shouldn’t the same level of courtesy be given to those made vulnerable by their need for medical attention?

Author’s Bio: Carolyn is a guest blogger who writes about career advancement, LPN programs, and higher education.

Same Gender Maternity Care by Misty Roberts

Many people falsely assume that women don’t care about their modesty during childbirth because they are in too much pain, but that is simply not true. There are many women who feel that their modesty during childbirth is extremely important. Some women and husbands don’t want a male obstetrician / gynecologist (ob/gyn) or any other male medical professional to be present for the birth of their baby. All too often families have their wishes for modesty violated as they gave birth. The birth of your child should be a joyful time and it is tragic how violations of modesty have made birth experiences traumatic. Even female ob/gyns can be insensitive. 

Some female doctors have ignored women's wishes for privacy and allow medical students to be present for all parts of birth even when asked otherwise. At some hospitals, medical students strive to do as many pelvic exams as they can for their requirements and many women are taken off guard because they have medical students coming into their room uninvited doing these invasive exams and other procedures without asking.

A number of hospitals in the United States, especially rural areas, have mostly male ob/gyns and few or no female ob/gyns. This is a very serious problem because many women don’t want a male gynecologist to deliver their baby. Far too many hospitals cannot assure families that their desires for modesty will be met. All hospitals should offer this choice for women, to be able to birth with a woman. There are a number of wonderful all female ob/gyn practices in the United States that work hard to accommodate patients’ wishes for an all female team. Unfortunately, it is hard to find an all female ob/gyn practice in small towns so women who reside in those areas have limited choices unless they are willing to drive to a bigger city. Before 1990, there were not many all female ob/gyn practices so women's choices were very limited. About 80-90% of current ob/gyn residents are female so there will be an increase of hospitals that can guarantee a woman a female OB/GYN for the birth of her baby in the years to come. 

Home or birthing center births with a midwife attending is an excellent choice for healthy women with low risk pregnancies. You choose who is there with you – family, friends, or neighbors. There are no externally-imposed visiting hours in your home, before, during, or after the birth. Women's wishes for modesty in hospital settings are disregarded routinely unless they have worked out arrangements with the hospital to ensure that their wishes are honored.  Unnecessary medical interventions are common. The list is huge, but a few examples are: too many pelvic examinations, episiotomies and unnecessary C-sections. Midwives do fewer pelvic exams and always ask first. With respect for you as a laboring woman, you will reduce your chance of having these unnecessary interventions. 

If you choose an out-of-hospital birth, look for an appropriate back-up plan, preferably with an all female ob/gyn practice to deliver your baby. Always be prepared for complications that could happen that would require you to be transported to the hospital from a birthing center or your home so it is very crucial that you prepare a backup plan ahead of time. Make it clear to your midwife that you don't want a male gynecologist. Many midwives even do breast examinations, pap smears, gynecological examinations, and even some procedures for women who are not pregnant. 

For a planned hospital birth, (or unplanned as in the case of a transport from home or birth center), if a birthing mother wishes for an all female team and maintain that her husband is the only man present, she will need to choose an all-female ob/gyn practice that doesn't rotate with other practices of male doctors. Keep in mind that all doctors in a practice rotate. There are many wonderful female ob/gyns in mixed practices, but you usually cannot be guaranteed a female ob/gyn in a mixed practice. If you use a practice that has two female doctors and two male doctors, you have a 50% chance of having a male doctor deliver your baby unless you have a scheduled C-Section with one of the female doctors. 

Discuss with your ob/gyn your desires for an all female medical team for the birth of your baby. You should also visit the hospital and meet the nurses especially the nursing supervisor to let them know your desires. Remember that the team may consist of the female ob/gyn doctor, nurses, anesthesiologist and/or nurse anesthetists, and surgical scrub technician. If you need an epidural, you will need an anesthesiologist. It's best if your team consists of all females, a female anesthesiologist or nurse anesthetist. Many hospitals employ at least a few nurse anesthetists. Nurse anesthetists are often able to administer anesthesia without an anesthesiologist. If it isn't possible, speak to the doctor and nurses and request that they keep your private parts covered while the anesthesiologist or anesthetist is present to protect your dignity and modesty. If you must have a Cesarean Section, you will be required to have a catheter inserted. You should ask that the male anesthesiologist or anesthetist stay out of the room until all of the prepping for surgery including insertion of the urinary catheter has been done. 

Important Tips For Pregnant Women Concerned About Modesty During Childbirth: 

1.) Choose an all female ob/gyn practice that doesn't rotate with other practices that have male doctors. 

2.) Visit the hospital that the practice delivers at and ask to speak to the nursing supervisor or the manager for the Labor & Delivery unit. Discuss your wishes about who you want to be present and how the nurses can protect your modesty in case a male anesthesiologist or pediatrician is required to be there for some parts of the birth. Make sure you indicate if you don't wish for even female medical students to be there. Some women who want an all female team are open to female medical students observing them giving birth.

3.) Request that the amount of vaginal exams be kept to a minimum. Vaginal exams cannot tell you exactly how close you are to giving birth. They can increase the risks of infection even when done carefully and with sterile gloves. 

4.) Speak up immediately if you feel your wishes are not being honored. 

5.) Create a birth plan. Make sure that you include who you want to have present. If you don't want medical students or male medical professionals to be present, indicate that on your birth plan. Make sure you come up with a plan in case the unexpected happens. One web site that offers a good example of a birth plan is: BirthPlan.com. 

6.) Consider hiring a doula to provide support during your labor. She is an advocate who can help you to speak up for your wishes about modesty if you are birthing in the hospital.

Misty Roberts is the founder of Medical Patient Modesty (http://www.patientmodesty.org), a non-profit organization that promotes stronger patient modesty.

Teaching Medical Students about Patient Modestyby 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.

Young children and modesty by Holly Goodwin

Pediatric modesty is not a subject that is discussed often but certainly must be addressed. Recall experiences with your own children or your own childhood; at what age did the “good touch, bad touch” discussion happen? Healthy children will likely never have to have invasive pelvic procedures done to them and so it is likely not many people have experienced what it’s like to be a child who is forced into one of these examinations and procedures, but for those of us who were it can be a life altering event.

By the age of 5 I knew what a bad touch was. To my mind, it was anyone who wasn’t my parents touching my genitals. I was always told to say “no” if I felt uncomfortable with anything and I would be in the right. I suppose my parents didn’t expect me to begin having pelvic problems at such an early age.

My first episode with Interstitial Cystitis, a painful, incurable bladder disease, was when I was five. It was nap time and about time to go home when I felt the urge to urinate so I asked my teacher if I could go to the bathroom. After urinating I still had the feeling that I really needed to urinate bad but nothing would come out. I stayed on the toilet straining and confused for a long time before I got up and went to my teacher crying and saying it felt like I had to urinate but nothing would come out. Like most people, she assumed I had a UTI and let me go call home.

I cannot remember if I actually had an infection or not when I had to do the pee-in-the-cup test. I’m not sure if this was in the same visit or not, but I know that eventually it was discovered there was no bacteria in my urine anymore (if there even had been any) and the doctor wanted to perform a pelvic exam on me. I was already afraid of doctors from a series of treatments for my lazy eye which eventually ended up being a painful surgery that left me blind for what felt like days.

When I was asked to take off my pants and panties I was confused. I said I didn’t want to because my doctor was a boy. I expected a girl to come in because I was always taught not to let boys touch me there if I was uncomfortable, and of course I was uncomfortable given the setting. With my mom’s aid, they forced my clothing off me while I was screaming and crying for a female doctor. That useless argument that we women always hear came up, but most heart-breakingly, from my own mother – that “He’s seen so many it’s not a big deal” speech. Regardless, I had been told to say no if I didn’t want to be touched there, and I did say no. I screamed no. Despite my struggling, I was too little to fight them off. The doctor didn’t penetrate me with anything but he looked at my urethra and inside my vagina and said he thought I may have a yeast infection causing the problems. He brought a cream out and slathered it all over my genitals and it burned. 

After I put my panties back on all I could feel was that cream slurping around in my privates and making me feel very humiliated, as though I had wet myself. My mom kept making me use the cream at home despite it burning and not helping, but because the doctor said so she made me do it. As to why the doctor insisted on putting the cream on me himself inside the office instead of allowing my mom to do it there or later at home with the prescription I have no idea, but it made me realize I truly had no say-so or autonomy when it came to matters with my body and doctors regardless of everything I’d been taught during my 5 years of life. I was ashamed and depressed, but didn’t know how to express these feelings in words. In the end the cream did nothing. I had Interstitial Cystitis, not a yeast infection. In fact, the irritation of the cream likely made it worse. After that experience I stopped telling my mom when I hurt and lost a lot of trust in her.

A study done by Child Abuse & Neglect: The International Journal says that a child’s ability to recognize a bad or good touch depends mainly on age and if they were educated. Before being educated in the study, 5-year old children were most likely able to distinguish a bad touch from a person of authority, who was usually considered “good,” than 4- or 3-year olds. After being educated over 90% of both 4- and 5-year olds were able to determine a bad touch regardless of its source (Maureen and Wurtele). To me, what had happened had been a “bad” touch despite the position of authority he held since I was old enough to recognize that I was uncomfortable with the idea of a man I hardly knew touching me there. This study shows that children as young as 4, and even some at the age of 3 can have a sense of genital autonomy and social taboos about it as well as knowing about saying “no” to bad touch. To a child, a burning cream forced onto him or her could definitely count as a “bad touch.” A child’s sense of personal autonomy over his or her own body during the years of preschool and elementary school is very strong. They are often modest, have a strong sense of ownership in regard to their bodies, and often may insist on privacy, even from their own parents. The ability to maintain comfortable boundaries is important for a child’s dignity, self-esteem, and a healthy sexual development later on in their lives (Popovich, 12). Children are very vulnerable to psychological disorders caused by the helplessness of hospitalization or invasive procedures (Popovich, 12).

Despite my own experience with the lack of care towards a child’s modesty preferences I had it lucky. If I actually did have an infection then I could have experienced the VCUG [voiding cystourethrogram] . A VCUG is performed to test for kidney reflux in children 5 and younger. The procedure is that the child must disrobe, lay on a table with a gown, have catheter placed through his or her urethra and have dye pumped into the bladder. The child is then forced to urinate on the table while pictures are taken while voiding. Not only is this exam invasive to privacy, it includes painful penetration, and as an act of losing all dignity, the child must pee on themselves in front of a medical team during an age where most have just proudly became fully potty trained. The pamphlets given to parents absolutely do not prepare either the child or the parent for what occurs during the exam (Phoenix Children's Hospital). It mentions discomfort, not pain, and describes the catheter as a “soft like a spaghetti noodle.” Anyone who’s been cathed will likely disagree with this statement. The first step to patient modesty is telling them the truth, especially to parents. Because of the child’s developmental issues at such an age, their feelings of shame or guilt are intensified when he or she is forced to expose the body and experience hurtful, invasive procedures. Children are also very frightened when doctors or other personnel focus on their bodies in ways only their parents have done. Preschool-age children react to this through regressive actions such as crying or thumb sucking. Even worse is for cases when parents are not allowed in the room; children may feel they are “bad” for allowing themselves to be touched, prodded, and probed (Popovich, 13). 

There are pediatric nurses trained for such cases, but evidence suggests that they hardly practice what they were taught due to personal attitudes or a tendency to be reactive instead of proactive. With little research there are few cases to cite, but in 2000 Popovich found that pediatric nurses had knowledge of a child’s physical needs but lacked knowledge in needs relating to psychological growth and emotions (13).

Many studies have concluded that the levels of anxiety experienced by children in a medical setting is unknown, but regressive behaviors like anger, sleep disturbance, and bed wetting is considered “normal” by nurses and doctors while a child is in the hospital. There is no published research on hospitalized children’s need for privacy, modesty, and self-esteem (Popovich, 14). 

The most hurtful thing for me to read are the stories written by mothers about the treatment of their children during the VCUG. Obviously, a good advocating parent will ask for treatment for the pain the child will feel, assuming they researched online rather than just using the hospital’s pamphlets, but nurses and doctors often try to talk parents out of using anesthetics like Versed. General anesthesia cannot be used evidently because the child must pee on him or herself for the test to be complete. As to why anesthetics like Propofol cannot be used I have no idea since it is an extremely short lasting form of general anesthesia commonly used for outpatient procedures like colonoscopies. 

Some grown adults can’t even handle this procedure, me included. Now imagine being a 4-year old child being prepped for this procedure, but you don’t really understand why they need to do this to you. Your parents likely told you what they read on the hospital’s pamphlet about it being “slightly uncomfortable” because it’s the only information they were given, and once you felt you were ready to cope with the embarrassment you find out how agonizing a catheter really is. At this point you may start to fight, but will be held down even as you scream, certainly not giving consent to be touched “there.”

The following are posts from parents I’ve come across during researching pediatric modesty, and especially about the VCUG which not only destroys a child’s privacy, but is actively penetrating their urogenital area and causing severe pain:


"Update: I'm still a little agitated after yesterday's experience and

trying to figure out how I feel about the way things went, so forgive
me if I ramble a little, and vent a bit. But, first of all --
everything's fine. My daughter's tests showed perfectly normal
kidney/bladder function; that's a big relief.

The ultrasound went well-no problems there. However. When the
office staff went to send back the orders for the VCUG, they
found that the ped's office had sent the script without sedation.
Not what we, including our daughter, were prepared for. They
could not get through to the doctor's office (8:30am), and the
voice mailbox was full. Great. I got out my cellphone [sic] and
hit the lobby...within 20 minutes (mostly spent on hold), I had the
office staff faxing the correct prescription. In fact, by the time I
got back to the Radiology waiting room, I was getting the thumbs
up from the office staff. Good.

Then, once in the room, the "intervention" nurses talked us out of
sedation. I believe at first they thought she was going under general
anesthesia, but even when told it was oral Versed, she persisted in
trying to persuade us that the risks were not worth the benefits --
that the catheter would be easily done and that the testing would be
simple. Ok, fine. We're all for less risk.

However, the catheritization [sic] was not simple. Not pain free. Not
un-traumatic. It took 4 nurses/techs to hold her down and get the
catheter in (after 3 tries), and this is with DH and I at her head
talking to her and holding her arms. NOONE [sic], and I mean
NOONE [sic] prepared us or her for the fact that she was going
to be asked to pee on the table. She's 3. She's recently
potty-trained. She doesn't pee on the table. Meanwhile, the
Radiologist is being a screaming cheerleader, which is pumping
up her anxiety level and he WON'T SHUT UP.

Egads. It was really quite the experience. I'd probably feel really
differently if we'd found out something was really wrong, and I
know I'd feel differently if we'd done sedation and something
had gone terribly wrong, but man...I just am so torn about the
process. I'm so pissed that they didn't give us all the
information we needed BEFOREHAND, despite my persistant
[sic] and detailed questioning. It's the things you don't anticipate
that get you.

We've tried to use the experience to continue teaching the ever so
important lesson that it's ok to object to people doing things to your
genitals that you don't like. That it's ok to say no. That it's ok to
scream and yell and put up a fuss if someone is trying to hurt you,
all the while reinforcing that this was a necessary medical procedure.
Such a fine balance. She was so offended, and so hurt that we didn't
do more to protect and defend her. Breaks my heart (Garden_of_darwin)."

Another commenter replied:

"My just turned three year old dd [sic] is going to have to
do the ultra sound and the VCUG. I had reflux from age 2 to age
10 and outgrew just before surgery was going to be ordered. I
had the VCUG procedure done no less than five times
WITHOUT sedation. At age 35, I am still traumatized and
would choose child birth over the procedure any moment of
any day. I INSIST that my dd [sic] has sedation and I think
that the nurses that guilted you out of it are no less than
monsters for doing so. Our pediatrician wants sedation,
which surprised me as I thought I was going to have to
sell her on it, but she insists as well. It is like an ancient
torture method without, believe me. I am soooo [sic]
sorry it happened that way for you and for your daughter.
We all do the best we can and as parents, of course we
don't want to risk our children. However, oral sedation
is not as dangerous as IV/general anasthesia [sic] and I
don't think they must have even had good motives in
scaring you out of it."

On another forum I read that the mother's girl was screaming to get it out of her. How this doesn't qualify as medical rape, I have no idea. I just know that only having a male doctor look at my privates against my will still haunts me and those paper gowns just make me want to die. It's like they take the last defense mechanism you have and toss it away, giving them complete power over you. There needs to be a major overhaul with how children are treated by medical professionals.

Propovich suggests the following enhancements to pediatric care:

· Preschool and early-school-age children are quite vulnerable to feelings of shame. Help them avoid such feelings by providing children with physical and psychological privacy, preparing them appropriately for procedures, and asking permission to look, listen, and touch. Providing for their privacy and respecting their sense of modesty convey to children a recognition of their inherent worth.

· Perform baths, assessments, and procedures with curtains drawn and doors closed.

· Use treatment rooms when appropriate to ensure protection of the pediatric patient’s self-esteem and self-concept.

· Spend time talking to children and walking them through procedures and stressful events in advance.

· Since children of this age group usually do not want to be seen crying, nurses can assist them by encouraging them to express their feelings, taking care not to deny or negate their expressions of fear and shame, and not criticizing out-of-control behavior.

Likewise Rosen-Carole, a helpful family practitioner, wrote about how she deals with pediatric modesty. Last year a pediatrician was charged with 471 counts of sexual abuse towards minors. Delaware Attorney General Beau Biden said, "These were crimes committed against the most vulnerable among us—those without voices (Quinn)." Rosen-Carole says that we have to rethink what we teach our kids in regards to “good touch, bad touch” as doctors are usually seen as being the “good” and parents may mention them as the exception, but from the study posted at the very top of the page it takes education to give a child the power to truly tell the difference. She shared her method of reinforcing the “good touch, bad touch” in Contemporary Pediatrics:

“As I listened to the news reports, I thought back on my own practices and realized that the following clinical pearl might be useful to others. Any time I examine a child more than about the age of 3 (and less than, say, 13) below their underpants, before I pull down their underpants, I point at them and say, "So, who is normally allowed to look down here?" The child will sometimes point at a parent, sometimes shrug, look blank, or even point at me. I look to the caregiver for guidance here and say, "Is that right? Only mommy/daddy/grandma (etc), right?" Then I ask the child, "Can doctor look?" and mostly get yes as an answer. I then answer myself, "NO! Only if mommy or daddy is in the room, right? If mommy or daddy went outside, I couldn't look anymore, right?" I wait for acknowledgement from caregivers and children at this and generally get it. Sometimes, if the child or family doesn't appear to understand yet, I go further and say, "What if someone tries when mommy or daddy isn't around? You say no and kick and shout and run away and tell mommy or daddy, right?" The caregivers look sometimes surprised, but mostly relieved. I think the relief might be that I have brought up a sensitive topic and have shown them how they can bring it up with their kids, too.” Rosen-Carole also mentions how the parents are surprised when once she asks their child the question they seem to not know the answer regardless if they have talked about it or not (Rosen-Carole).

Fellow Interstitial patients have also mentioned experiences with such procedures, stating that they held off diagnosis for years out of the terror that remained since their childhood after having these procedures done without any pain-killers (Interstitial Cystitis Network). I myself held off diagnoses for 3 years simply because of how violated I felt as a child anytime I went to the doctor. Even at age 12 I recall my doctor, who was female, not ask or say nothing to me before grabbing my shirt and looking down the neck hole of my shirt to examine my breasts. I was so shocked I couldn’t say a thing and my mother made no comment. I felt extremely violated as I was very sensitive about the changes happening to my body at the time.

I now struggle every year when it’s time for my annual pap smear. Just knowing that I have to have it done to get birth control turns my mind into a wreck at having my bodily autonomy once again taken from me through this “carrot on a stick method.” I have a wonderful, caring doctor now that I had to seek out for myself but I cannot get rid of those feelings of complete helplessness and bodily violations, especially with the current birth control policies most clinics have.

Preventing iatrophobia, the fear of doctors, starts at childhood. I plead to anyone with children to advocate for them and never leave the room. Listen to their gender preferences if they need to disrobe, and always research beyond what pamphlets the doctors hand out about pediatric procedures. There are many support groups online who will tell it like it is without any sugar coating from the medical community. Research, research, research, and if the doctor or hospital will not provide adequate emotional or physical pain relief then walk out and find one who will focus on what’s best for the child. In the end, it is you who must make the decision. Doctors can only recommend and perform procedures, not tell you what is best for your child and family. They are trying to look after themselves when the issue of pain relief comes up just as you are trying to look after your child’s well being, emotional and physical. Research if their methods are standard and get a second opinion, and even if their method is standard and you disagree, there will always be another doctor who will have a different view on how to diagnose, dispense medication, and treat conditions.

----------------------------------

Works Cited

Garden_of_darwin. "Vcug Renal Us for 3 Year Old: Seeking Information (long) - Kitchens Forum - GardenWeb." That Home Site! Forums - GardenWeb. 7 Feb. 2006. Web. 29 Dec. 2011. <http://ths.gardenweb.com/forums/load/kitchbath/con0212390014095.html?27>.

Kenny, Maureen C., and Sandy K. Wurtele. "Children's Abilities To Recognize A "Good" Person As A Potential Perpetrator Of Childhood Sexual Abuse." Child Abuse & Neglect: The International Journal 34.7 (2010): 490-495. ERIC. Web. 17 Dec. 2011.

Laura. "Interstitial Cystitis Network : Patient Stories : Della." Interstitial Cystitis & Overactive Bladder Network - Overactive Bladder, Bladder Pain Syndrome, Painful Bladder Syndrome, Hypersensitive Bladder Syndrome Information & Support For Patients & Providers. Interstitial Cystitis Network, 29 Apr. 2005. Web. 29 Dec. 2011. <http://www.ic-network.com/patientstories/laura.html>.

Phoenix Children's Hospital. "VCUG." Phoenix Children's Hospital. Phoenix Children's Hospital. Web. 29 Dec. 2011. <http://www.phoenixchildrens.com/PDFs/patients-visitors/VCUG-1.pdf>.

Quinn, Rob. "Pediatrician Earl Bradley Indicted on 471 Counts of Child Sex Abuse." Newser | Headline News Summaries, World News, and Breaking News. Newser, 23 Feb. 2010. Web. 29 Dec. 2011. <http://www.newser.com/story/81556/pediatrician-indicted-on-471-counts-of-sex-abuse.html>.

Rosen-Carole, C. "Good Touch, Bad Touch: Teaching Your Patients Whom To Trust Can Keep Them Safe." Contemporary Pediatrics 27.7 (2010): 66. CINAHL Plus with Full Text. Web. 17 Dec. 2011.

Holly Goodwin is a student who blogs about her personal experiences with interstitial cystitis.

Nursing Violations of Patient Privacy by Doug Capra & Joel Sherman

Nursing history emerged from a tradition of nurses as angels of mercy, selflessly devoting their working hours to care of patients.  Although modern nurses don’t like to view themselves that way, there is much truth to that image, even today.  We would trust our care to the large majority of nurses we have known.  But like all stories, there is another side to it.

Physicians have been criticized for releasing too much patient information on their blogs.  Nurses do the same.  Allnurses.com claims to be the largest online nursing community with over half a million members, the vast majority of whom are undoubtedly active nurses though membership is not restricted.    A recent thread on allnurses.com  reveals many disturbing anecdotes.   The thread is called “Nine things nurses don’t want you to know.”  The first item is: “Yeah, we look......and no, we're not above whispering to our co-workers, "Psst! Did you get a peek at the guy with the foot-long whatsis in 216?"   Now the poster said after being challenged that this was a tongue in cheek comment, but other posters in this thread make it clear that similar incidents do happen.  Although a few do condemn this as being a serious infraction (probably many more than posted that point of view), still too many seem to consider this behavior just part of the culture.  

Comments include a poster who said that she might not comment upon a man’s body parts but knows nurses who do.  Another said nurses have always engaged in shop talk and always will, but added that it’s reasonable as long as it is not done in public.  After a protest, the original poster commented that it may not be nice to discuss the anatomy of a patient over coffee, such as the guy who needs an extra long Foley, but it happens and it doesn’t help to get upset over it.  Another poster recounted having a pre-op woman up in stirrups, and people coming in to view her shark tattoo between her legs.  She doesn’t say whether the patient was under anesthesia at the time though that is likely.

In this long thread there were initially no complaints registered but slowly a negative reaction occurred, mostly from posters who are probably not nurses. Two posters challenged the female nurses to consider how they would have reacted had a male nurse written a similar statement about female patient body parts. Others warned that allnurses.com is not a private blog, but goes all over the web and is read by some who look for just such evidence to condemn nurses.

To be fair, a few nurses commented that anything like the first item (the foot long whatsis) had never occurred in their career.   We believe both of them.  Incidents like this are very individual; they may occur on one floor of a hospital and never in another.   It only needs one person to offend.  We have never been made aware of an incident like this, but it’s unlikely any nurse would confide this to a physician.  What perhaps is most disturbing about this thread is that very few people would be willing to criticize their fellow nurses for actions like this, not to mention report them. This demonstrates a very unhealthy culture of silence at some hospitals where nurses and nurse assistances fear retaliation for reporting incidents like this. It is further reinforced by a recent thread on allnurses titled “And it’s all going to be your fault."  Look below this post to see how many nurses agree with this view. In some hospitals, nurses feel they are at the bottom of the pecking order and are scapegoats for whatever goes wrong. They fear any challenge to the powers above.

These gross violations of privacy described in the original post titled “Nine Things” are against the law, but they are not covered specifically by HIPAA.  We don’t think the feds have ever brought an action against providers for physical encounters or oral breaches of privacy, though oral transfers of protected health information are covered.  HIPAA is almost all centered on digital and printed information protection, not on personal encounters.  Yet likely all states have laws regarding personal privacy in healthcare that would cover it.  Certainly taking an unnecessary peek at a patient’s genitals is considered sexual misconduct which could result in the loss of license in every state. 

There is reluctance in every profession to report one’s comrades.  This happens with physicians as well as nurses.  A New Mexico otolaryngologist, Dr. Twana Sparks, was disciplined by the state board following years of operating room misconduct wherein she would fondle the genitals of male patients under anesthesia in the presence of the OR staff, making derogatory comments about the patients.  The hospital was aware of this and did nothing until one nurse filed a formal complaint.   For years the hospital laughed off the incidents.   There have of course been many incidents over the years against male physicians though there is perhaps less reluctance to lodge complaints against men for sexual misconduct.

In the initial ‘Nine things’ thread, some patients commented that they avoid medical care because they’d get demeaned because of their obesity.   It’s not uncommon on allnurses to read what are called “rants” about obese or otherwise stigmatized patients. This is not to say there are not “difficult” patients who can be rude and overbearing. But some of these rants offer no benefit to the vast majority of nurses who treat patients with respect not only in the hospital room, but also in the break room. It’s hard to reassure anyone that their fears are unwarranted, especially if they have an unusual anatomy or disability. 

It’s astounding to us that so few nurses looked upon divulging prurient tidbits about identified patients as a serious infraction.  They seem to think that as long as it stayed on the floor or in the coffee room it was business as usual.   It is widely accepted now that no information should be divulged unless there is a need to know.  Regulations mandate that all hospital staff must be instructed on patient privacy concerns.  It seems like they do a very poor job of it.  JCAHO should mandate reforms.

Modesty, A Woman's Perspective by Nicole Lee

From their website.  Click on to read.

Nicole Lee is the creative director of Stirrups and Stories.   She has worked in the area of sexual and reproductive health for over five years: taking sexual histories, training others to do the same, working in HIV prevention, and providing quality control for clinic and agency management.

The word “modesty” is loaded with too much emotional and cultural connotative meaning to be a neutral concept.  Who is saying the word, and how, and to whom, and for what purpose?  Is “immodesty,” with all of its attendant frightful connotations, the shadow defining the edges of modesty?

In the context of health care provision, modesty is a double-edged ideal:  on one hand, respecting patient-initiated modesty enhances our ability to serve patients.  Some of the ways we do this include:  acknowledging and responding to the cues our patient gives us about her level of comfort; by asking for permission and consent before touching her; by echoing the language she uses; by avoiding unnecessary, invasive procedures; by acknowledging the legitimacy of her family structure.  We do this by listening – and hearing – what she is saying to us.  By explaining in language she understands why we are asking intrusive questions, and working with her to procure the necessary information.  By respecting a denial of consent and fully honoring the process of informed consent.  By seeking training on cultural competency specific to the populations we see.    

Such a type of respect requires our acknowledgement of the wholeness of the patient in front of us, including the soul and the heart that embraces that modesty.  No longer is she a composite of parts and organs and symptoms, a medical puzzle waiting for construction (or deconstruction):  her embodied self is not our disembodied medical task.  When we as health care workers are respecting a woman’s own sense of modesty, we are helping to make more visible the value system in which she functions.  Significantly, that value system is fundamental to the context in which our palliatives, prevention, and education must succeed, and is a potentially key part in identifying pathogens or risk.

On the other hand, if a health care worker or policymaker enforces modesty, the relationship between patient and provider is inhibited.  Such a dynamic can silence a patient, leaving health care workers without knowledge that may prove vital to providing care for a given woman. 

The enforcement of modesty is rarely overt, but instead typically a thoughtless perpetuation of a set of cultural norms that liken immodesty to being unladylike.  It provides a prescription of acceptable behaviors and appearances for women to assume, and defines the dimensions of space women are allowed to occupy.

Is it immodest and unladylike for a woman to disclose the number of sexual partners she has had?  To choose not to shave any particular body part?  To use abrupt or rough language to describe her experiences?  To talk openly and unashamedly about her partner(s), who may be of the same sex?  To speak of her abortion with sadness and no shame, or with no sadness at all? 

Is it unladylike for a woman to challenge our authority as medical care providers?

Women are faced with a variety of messages that often boil down to one – the feminine ideal is to be a lady, so avoid an immodest exposure of self.

Are our offices spaces where women can expose the necessary parts of themselves without fear of sanction?

If they are not safe because we (or our staff) judge our female patients for not abiding by the standards that we, possibly unconsciously, have for women, it is nearly impossible to conceal.  Our biases are conveyed in a plethora of ways both subtle and overt, including how we ask questions (and which questions we choose not to ask), our body language, our double standards for men and women.

Conversely, by ignoring a woman’s own unique modesty and sensibilities, we are imposing on her an authoritarian message of subservience and disrespect.  Without thinking, we risk telling her that “her body is ours” and that she has given up certain rights merely by seeking health care.  This encourages a retreat from visibility for many women and a reduced ability to successfully communicate with her health care provider.

What and how we communicate, and how we receive information given, can contribute to a woman’s reluctance to seek prevention or cure for any number of health concerns.

By respecting her values and that which she chooses to conceal or protect, we are inviting her to reveal more of herself to us.  In that exposure is the human for whom we are charged with caring, and in this new relationship is the true potential for health and healing.

By refraining from imposing our own values of modesty on our patients, we open up the possibility to clearly see our patient in her own context.  In that exercise of self-awareness and self-restraint, we lay the groundwork for a respectful and deeply therapeutic relationship with her.

The narrow channel between what we subscribe to and what we prescribe for others is a tricky space to navigate, but that is exactly what we must do. 

Feathered Boas and Your Dignity

It is our pleasure to introduce Steven Z. Kussin, M.D. to our blog. He is the author of, Doctor, Your Patient Will See You Now: Gaining the Upper Hand in Your Medical Care, (2011) published by Rowman & Littlefield. Dr. Kussin was a practicing physician in New York for more than thirty years. He has published several journal articles, and has taught at Albert Einstein Medical College and Columbia College of Physicians and Surgeons. He has founded The Shared Decision Center, one of the only free standing independent community based Shared Decision Centers in the country. Dr. Kussin blogs at MedicalAdvocate.com.

Feathered Boas and Your Dignity

by Steven Z. Kussin, M.D.

“In war, truth is the first casualty.” (Aeschylus, celebrated Greek dramatist)

“In medical care, dignity is the first casualty.” (Kussin, unknown American physician)

Whether critically ill in the hospital, or fit as a fiddle in a doctor’s office, an individual’s dignity is an issue dear to me because of a memory. The memory of a mentor. Doctors learn from journals and texts. The best of us also learn from mentors. Rivaling only the military, medicine is a highly hierarchical system. When young doctors find a senior physician who has fulfilled the dreams of how we someday wish to be and be seen, they become our mentors. These role models, properly chosen, can influence not only our knowledge but our attitudes. Most doctors will identify only one or two whose impact is so significant, that their lessons are destined to last a life time. One of my mentors left a circle of young physicians in awe of his knowledge and in shock in the wake of his death. We all knew he had cancer and was to die. But to me, it was his treatment near death that left the lasting message.

During his final hospitalization, I entered his room often finding him fully exposed. His gown thrown aside and with sheets askew he lay there for all to see. Dementia had claimed the mind all were in thrall of. I spoke with the staff and his doctors. Could we close the door? Could we pull the drapes? Could we secure his gown beyond his ability to remove it? Apparently not. So, a cadre of his acolytes, including me, guarded him during his final days.

And so it is today. So let’s talk a bit about your dignity, privacy and how it is so casually and gratuitously subtracted from your care. You may need your own night’s Knights Templar when you are stricken. Neither your family nor your doctors should restrain you physically or chemically when you already have enough to deal with. To maintain the dignity you will surely lose, you need what, in my book, I have called ‘Designated Sitters’. Family who are constant and consistently present. To protect your body from soulless comments delivered in your ‘absence’ demands their help.

But how about when you are well? Gowns that are side tied (available at your hospital supply store or on line) prevent the world from regaling in either of your nethers. Better yet, bring your own PJs and robe.

You should demand a private room because they are, well, private. Privacy is where dignity starts. Privacy increases the quality of your consultations. The bonus is the possibility of entering your doctors’ circle of empathy. Your doctors would prefer death to a semi-private room. When you are bivouacked in a private room, your domain becomes bespoke. Fill it with photos of you when you were your doctors’ age and litter the room with upscale magazines. Architectural Digest or even the Robb Report comes to mind. Let them see themselves in you. Being stared at, jaw agape, by your providers, let alone the ten year old guest of your roommate just adds to your woes.

And the physical examination? Enter the pictured feathered boas. How can it be when physical examinations are almost a relic of the past you nonetheless find yourself with your sundry body parts needlessly defying gravity, dangling in front of your providers? Breasts, gonads and penises swinging free for all to see. Well it’s precisely because physical exams are a lost art that you get to show your parts. Back in the day, boa dancers could remain fully demure even when they had nothing but diaphanous throws to throw about their bodies. The art of using examination sheets as skillfully as boas is a rarely used remnant of a lost medical culture. Moving these drapes down the torso artfully and gracefully leaves nothing unseen, while paradoxically, leaving nothing revealed.

“Strip to your underwear. Leave your socks on.”

Why, is there something wrong with my feet? And I refer to both the modern and biblical use of the word feet. Cotton gowns that are clean only by inference and as threadbare as dishrags do you no service. Paper contrivances that, when you sit, bend or recline, ride up and down like a roller coaster prevent any attempt at preserving your status much less hiding your quo.

What to do? What to say?

“Doctor, right at this moment, if I was examining you I’d make sure I’d be seeing a lot less of you than you are seeing of me. Can you spare a drape? Thanks.”

It’s kind of funny, kind of pointed and kind of you too. Let the doctor know that you are being dissed and dismissed by being needlessly and carelessly revealed.

Will you say that? Wait, you’ll find out the next time it happens. When is your next appointment?