NOT JUST BODIES -- PART 2

NOT JUST BODIES -- PART 2

More on Chaperones

In the first part of this series, I noted some strategies mentioned in the study, Not Just Bodies, that doctors use to help “desexualize” physical exams. One of those strategies is using chaperones -- a topic that Dr. Sherman covered well in the last post. I’ll add a few more observations about chaperones from the study.

In all but one of the interviews with doctors using chaperones, only female chaperones were used. “Many doctors believe,” the study says, “that the mere presence of a woman’s body in the examination room is comforting to patients.” This belief is articulated in The woman in the surgeon’s body (1998) by J. Cassell, who writes that patients' reactions to a woman’s body are “below the level of words,” and that these reactions are:

Shaped during the infant’s earliest interactions

with mother…A woman’s body comforts and holds;

a man’s body acts. A baby learns these distinctions

very early; a young child anticipates different behavior

from women’s bodies than from men’s; an adult is

impelled by the same embodied knowledge.

This belief may explain many of the gender attitudes and stereotypes, patients encounter in hospitals, -- why it’s just assumed that all or most men prefer female nurses. With few male nurses and chaperones available anyway, it could also be a rationalization for the status quo. This use of the word “impelled” in the above quote is revealing. Apparently, we have no control over this “feeling,” this “urge.” It has been imprinted upon us from birth. Following this reasoning, it would make sense for a doctor, male or female, to use a female chaperone when examining a male.

On the other side, the study quotes a female doctor who refuses to have any chaperone in a room when examining a male patient. “I can’t have a women in the room with me,” she says, “Plus I think it would be worse to have another guy in there…I just think it’s embarrassing enough for him already…” Even though she has male chaperones available, she believes it would be embarrassing for the male chaperone, too. I believe this response to be closer to the truth than most others because it supports a number of studies that say men just don’t want chaperones.

“Thus, female patients are protected by chaperones,” the study notes, “but men must be protected from chaperones.” Even J. Cassell (quoted above) argues that these feelings of childish dependency of mother, though acceptable for females may be emasculating for men. Any chaperone for a man, male or female, “could exacerbate his feelings of powerlessness.”

Why would the doctor quoted above think it worse for a man to have another man as a chaperone? This may be a power issue. Isn’t a man supposed to be able to protect himself? As the study points out, women are more often defined as victims than are men. Our culture sees women as in more need of chaperones. But men? A chaperone could be considered an affront to his masculinity.

A significant number, if not the majority of doctors and nurses, use chaperones primarily for their protection. Participants in this study gave three ways that chaperones protect them. First is the protection from false accusations of sexual misconduct. One male doctor called chaperones “cheap insurance.” It was generally agreed by those interviewed that “sexual allegations usually come from women.”

Are women doctors and nurses afraid of false accusations from their lesbian patients? The study didn’t show this to be a major concern, although one nurse said a complaint against a female doctor at her teaching hospital caused some others to use chaperones with their female patients.

A second reason for chaperone use, according to the study, is to protect doctors from sexual advances from patients. A female urologist said that many men (especially her Hispanic patients), are embarrassed because she is a women, and that they are “really macho” and uncomfortable with women in a “position of authority.” She was asked directly if she had ever had sexual incidents with male patients. She answered that she always had a chaperone in the room with either men or women. “I have a male chaperone with men, and a female with women.” To those interviewing her, it was clear that the purpose for the chaperones was for her “physical protection from sexual harassment or assault.”

The study noted that most doctors and nurses interviewed didn’t use chaperones for this purpose, but rather practiced other strategies. I’ll comment on these strategies as I go through this study later in the series.

A third reason respondents said they used chaperones was protection from their own sexual feelings. One male doctor talked about a female patient of his who he considered “gorgeous.” He had a difficult time examining her. “…I needed to use a chaperone." he admitted. "A chaperone not for her comfort but for mine.”

Although some female caregivers admitted that they sometimes “experience unwanted sexual feelings when examining an attractive man,” they said they didn’t use chaperones. They seemed more concerned with controlling the patient’s sexual desire. Interestingly, several believed that “men are expected to act on their sexual desires and women are not.” One nurse commented:

“Younger teenage girls, I would rather just female

nurses take care of them. I think we kind of discourage

male nurses from taking care of teenage girls. You don’t

want anybody to get the wrong idea. Teenage boys are

very comfortable with me, so I try to distract them, talk

with them, try to make them more comfortable.”

I would suggest a few points about this last comment. First, this is not an uncommon attitude today among a significant number of female caregivers. Indeed, how many male nurses steer clear of these encounters for their own professional safety? Secondly, how accurate is this nurses assessment of her male teenage patients -- “Teenage boys are very comfortable with me…” How does she know? Has she asked them if they would prefer a male nurse? Although homophobia, especially among boys, may be a factor -- a common assumption seems to be that most boys are homophobic and would prefer female nurses or doctors. Is this assumption backed up with any research? Certainly it makes it easier for the medical system to base their practice on this assumption, since they are unable to accommodate most men or boys who would prefer same gender intimate care.

But, as the study points out, the attitude of the nurse above is that, even if the teenage boy wanted a male nurse, a man replacing her may give people the “wrong idea.” Men, as this attitude suggests, are sexual beings not in control of their feelings. Females are more to be trusted. “Just as women are more likely to be cast in the role of ‘victim,’ the study states, “so are men likely to be seen as sexual aggressors. These beliefs are internalized by some health care providers and institutionalized in the patterns of chaperone use.”

The assumption, unstated, is quite clear. Men are not in control. They will act upon their sexual urges. Women are in control. They won’t. A female nurse, talking about catheterizing men, said: “If a male patient wants a male, that’s fine. Some male patients are hesitant about anyone catheterizing them.”

Isn’t it also true that “some” female patients are hesitant about anyone catheterizing them? I would suggest that most patients don't "want" to be catheterized. Another attitude that seems prevalent in health care is that men just don’t want anything done to them. Men just don’t want to be there and don’t really care about their health. I would suggest that most patients -- male and females -- are uncomfortable with people doing intimate procedures to them.

But back to chaperones. As the study points out, attitudes toward and practices regarding chaperone use are embedded in assumptions about men’s and women’s sexuality. “Men are powerful; women are sexually vulnerable. Women’s bodies are comforting and soothing, but they also elicit feelings of childish vulnerability.” This vulnerability is acceptable in women but not in men. Men should be strong, shouldn’t complain.

So -- what does all this mean to patients who may face the use of chaperones at a clinic or hospital? Here are a few points to consider:

-- Be aware of the various uses of chaperones. Be honest with yourself and with your caregiver about what’s comfortable for you. Unless your comfortable with it, never allow a chaperone to just be present without being “offered” to you. You do have a choice.

-- Be aware of note-takers and other “assistants” whose real purpose is that of chaperone. This is simply dishonest and needs to be challenged. Ask the medical reason for the extra person in the room.

-- Some caregivers will offer to place the chaperone behind a curtain or have them turned away. Consider the ridiculousness of this. Can you imagine a chaperone sitting on the witness stand in court being asked, “What did you see?” and answering “The wall.“ or “All I could see was a white sheet.”

-- Some practices are continued for no medical, legal or even logical reason. They’re done because that’s how it’s done. No one thinks anymore about why. Not too long ago, I had to have a pre-surgery EKG. The nurse took down some information, told me to take off my shirt and handed me a gown. It would be fine, she said, to keep my pants and boots on. “Do I need to put on the gown?” I asked. “It would be best,” she said. I went along out of curiosity. So there I was -- shirtless, with pants and boots and wearing a gown. The tech came in, a young female, and did the EKG. The only reason I could see for this inane gown request was for the possible protection of the female tech. Would she feel more comfortable with me in a gown? Would it help me control my sexual urges? As patients, we need to be alert to these behaviors. Don’t be afraid to ask questions and demand medical reasons for these behaviors. I let this slide because I often act as a participant-observer and, in this case, wanted to see where this was going.

-- Men need to be aware of how some female caregivers may view them -- the perceptions, assumptions, stereotypes. Remember, it’s not just about their comfort. It’s just as much about your comfort. Don’t hesitate to speak up.

-- If you agree to a chaperone, be very alert as to her status. Is she a nurse? A medical assistant? A nurse assistant? The receptionist? And, of course, don’t hesitate to request a chaperone whose gender you feel most comfortable with.

-- If you don’t want a chaperone, or are faced with one of the opposite gender, don’t feel forced into having one. Doctors who required chaperones need to place that requirement up front. It should be mentioned at the time you make your appointment; it should be placed on their web page. Don't be ambushed. Don’t be afraid to file a complaint, several complaints. Doctors in private practice have the right to run their business they way the want to. They don’t have the right to accept you as a patient without making clear their chaperone polices. Of course, you’ll find that most if not all doctors and hospital have no written polices for chaperones. Having nothing in writing makes it easier to just do things they way they do things. You’ll find that, nationwide, there are no standards for use of chaperones by the medical community.

Next in the series, we’ll look at what this study, NOT JUST BODIES, has to say about the strategy of “Objectifying the Patient,” and why, even though this may work for the caregiver, it may not work for the patient.

(c) Doug Capra 2010

Chaperones Do They Reassure or Disturb Patients?

By Joel Sherman MD

Chaperones are increasingly recommended for routine use in Western medicine.  There are semi official recommendations in both the UK and USA.   The AMA has long had this policy.   

The rationale for using chaperones is twofold.  In theory their primary purpose is to protect, comfort and assist the patient.  In reality though, the usual purpose is to protect the physician against claims of sexual assault or harassment. 

Preferably chaperones should be real professionals, ideally nurses, female or male.  They should function as a patient advocate and their presence should reassure and comfort the patient.  Medical assistants are far less able to do this and should never be used without them being given special training.  Unfortunately, many offices use anyone who’s available at the moment.  This could be secretaries or clerks.  They could be experienced at their jobs or young girls just out of high school.  I have never seen data delineating just what type of personnel each office uses as chaperones and how they are trained.  This information is sorely needed to evaluate the topic.  It is also not clear what percentage of these chaperones are introduced as such.  It is probably more common to pass them off as ‘assistants.’

There is no doubt that male physicians feel that they need to offer chaperones when doing pelvic exams on women.  Over 80-90% use them in the US. (Ehrenthal et al, Chaperone Use By Residents J GEN INTERN MED 2000;15:573–576) and Rockwell, DO et al,  Chaperone Use by Family Physicians During the Collection of a Pap Smear Annals of Family Medicine 1:218-220 (2003).  For other intimate exams, ie breast, male genitalia and rectal, the percentage drops off.    Not surprisingly male physicians use chaperones at a much higher rate than women do for opposite gender patients.   Women physicians plan on using chaperones for male genital exams no more than 20% of the time.  The use of chaperones by male physicians is driven by legal concerns.  This is not as evident for women physicians (Ehrenthal, ibid).   They more often site patient comfort and their need for assistance with the exam.  In truth what is the real legal risk for women physicians?  Suits and complaints against male physicians are common enough.  State medical boards deal with them every year.  However complaints against female physicians are nearly unheard of.  Their risk is so low that the presence of chaperones cannot be justified to protect the physician in my opinion.  Some women may use them not to protect themselves against suits, but to ease their own discomfort with the patient.

It’s clear however that many patients aren’t comfortable with the presence of chaperones for a variety of reasons.  Surprisingly nearly 50% of women don’t want chaperones present even when male physicians do a pelvic exam.  For men, the figure is 80 to over 90% refuse chaperones when given a choice in most studies.  That is hardly surprising when you consider that almost all chaperones are women.  Men are almost never hired as medical assistants in an office setting.  In part, that’s because they won’t accept the low pay scale, but many offices won’t hire men because they can’t readily be used as chaperones for women patients whereas female assistants are generally used with both men and women.  Few men feel that the presence of extra female eyes is reassuring.  One statistic that is not readily available in the US is the percentage of physicians who actually ask their patients whether they want a chaperone present.  If the chaperone’s  presence is driven by legal concerns, many doctors don’t ask  as they plan on using them anyway.  Some women physicians may use them because they feel at risk of inappropriate behavior from their male patients.  Patients turn down chaperones for many reasons.  The presence of extra people watching intimate exams increases the embarrassment factor for many patients.  There is also a loss of privacy that patients may resent.  It is harder to discuss intimate problems when strangers are present. Factors such as the familiarity of the patient and physician come into play here.  New patients are less comfortable in these situations.   In short, it must not be assumed that patients want chaperones present.

Adolescents are a special case as they are more prone to embarrassment than adults.  Boys are particularly subject to embarrassment when the physician (male or female) brings in a women chaperone to watch.  And the chaperones are almost always women.  Doctors do this again for legal reasons as they are concerned about charges of assault.  At least one state, Delaware now mandates the presence of chaperones during intimate exams given by pediatricians.  This law was passed after an egregious case of a pedophile pediatrician who assaulted many children over the years.  The case is not unique; Connecticut had a similar case and I’m sure there are others.  Delaware’s law is unusual in that it does state that same gender chaperones should be used ‘when practicable.’  However in the average office, it is never practicable.  Pediatricians’ offices almost never have any male employees.   I believe the law is an overreaction to a rare problem; bad cases make for bad law.   This law forces the presence of women as observers to watch the exams of older adolescent boys, many of whom would be severely embarrassed.  Using a parent, usually a mother, would not be much better in many families.  In short this law substitutes inflexible provisions for common sense. 

In my opinion, sensible provisions for chaperone usage should include:

1.)     Chaperones should be offered to all patients for intimate exams.

2.)    They should always be voluntary.  The AMA regulations above make no mention of this allowing physicians to use them against the patients’ wishes.  This is wrong.  If the physician is worried about liability, he/she can have the patient sign a waiver or refer them elsewhere.

3.)    Chaperones should be professionals.  The use of secretaries and clerks is not acceptable.  Medical assistants, i.e. unlicensed ‘professionals’ need to be specially trained.

4.)    Chaperones should not be present during history taking segments of the visit, only during the intimate exam.

5.)    Chaperones should be introduced as such, not labeled as assistants when none are needed otherwise.

6.)    Chaperones should be same gender as the patient.   This always happens for female patients and almost never for men.  Any exceptions should be made clear ahead of time with the patient given the option to refuse.

In summary I believe that the large majority of chaperones are used solely to protect the physician without the patients’ wishes being taken into account.  They are a hindrance to patient privacy and betray an underlying lack of trust on either the physicians’ or the patients’ side.  I believe they are greatly over used in our litigious society.

Further references on chaperones can be found in the thread on my discussion blog.   They are embedded throughout the near 250 comments.

This article has been chosen for publication on KevinMD, a widely read medical blog. 

Addendum  4/26/11  I note with pleasure a just released set of chaperone guidelines from the American Academy of Pediatrics which does allow both  for patient choice and same gender chaperones.

Not Just Bodies

DEAR DOCTOR AND NURSE: WE’RE NOT JUST BODIES

By Doug Capra © 2010

A few years ago, I came across an interesting article while surfing the web. It’s title immediately attracted my attention -- “NOT JUST BODIES: Strategies for Desexualizing the Physical Examination of Patients” It can be found in by Patty A. Giuffre and Christine L. Williams. Both authors are sociologists, not medical professionals. I noticed the study wasn’t published in a medical journal, but in Gender and Society put out by Sociologists for Women in Society.

Since doctors and nurses routinely deal with naked bodies, the study asks how these professionals avoid or deny their personal sexual feelings. How do they deal with patients who show sexual feelings toward them? Polices and professional ethics standards guide them in many ways. In medical and nursing school they are taught to desexualize the human body, to hide their feelings, avoid emotional involvement and to use scientific, technical language, But these are often strategies taught in the “academic” curriculum. Students then go on to learn and develop many other strategies in the “hidden” curriculum as they enter the profession. Most of us have experience this “hidden” curriculum. You’re given training, then you get on the job training, then you start working, perhaps with a mentor. “This is what you learned in school,” they tell you. “But this is how we really do it.” Or, the message isn’t even verbal. It’s taught silently. You just watch and learn.

In medicine, the “hidden” curriculum can be extremely powerful since it gathers its strength from medical history, tradition and culture.

In discussing “patient” modesty, we are sometimes missing the other half of the equation -- that is, doctor and nurse modesty. As human beings, these medical professionals bring with them into the examination room just as much emotional baggage as do patients. Doctors and nurses have certain feelings and values associated with bodies and nudity. They don’t leave these issues at home.

But -- the big difference between these medical professionals and most patients is the years of experience they have had dealing with naked bodies. Nudity becomes routine to them. They may still have the feelings and attitudes they began their professional experience with, but the report “Not Just Bodies” found that “With few exceptions, the men and women in this study reported that they were uncomfortable performing examinations in the early part of their training but that they became more comfortable as they progressed through their careers.” The report goes on: “Several physicians and nurses noted that they ‘see 20 patients a day and everybody looks the same’ and that they ‘have been doing this for so long’ that they never get uncomfortable.”

Why? Because they have developed strategies to deal with this. At the very least, these strategies make them feel comfortable.” That’s the key, and it makes sense. To do a any job competently, one has to feel comfortably competent.

The more empathetic, experienced and talented doctors and nurses have developed a variety of strategies that work different patients with a focus on making the patient more comfortable, too. But some medical professionals, depending up the personal baggage they bring with them, and their communication skills, are more focused on their own comfort, or perhaps on just getting the task done.

This study deals with physician and nurse comfort. But the theory seems to be that if they feel comfortable and go about the exam demonstrating that comfort, then the patient will be comfortable. And that theory as much merit to it. No one wants medical professionals working on them who seem uncomfortable and uncertain of what they are doing.

But this is a tricky and sensitive subject. And, as far as I can determine, it’s rare to find any studies that look at this from the patient perspective. How do patients see this? What strategies work for what patients? What role does the gender of the doctor or nurse play when matched with male or female patients? How do patients react to strategies used by same gender care or opposite gender care?

This study focuses on gender and the caregiver as it tries to answer questions like “How does the gender of the doctor or nurse, and the gender of their patients, figure into their choices of which strategies to use? The authors aren’t so much interested in how successful or effective these strategies are, but rather the logic behind the strategies used and how they may differ for male and female patients.

These strategies, the authors contend, are mostly “unreflective habits bolstered by an organizational context that frames their workplace interactions.” We can call this the hospital or clinic “culture,” the underground values and mores that are mostly hidden, not discussed, rarely challenged, considered “just the way we do things around here.” The authors write: “…it is likely that most health care professionals follow hospital rules and conventions without considering their disparate impact on men and women. Many may not even be aware that they use different strategies for men and women.”

The researchers conducted lengthy interviews with doctors and nurse, asking questions like: “How do you make yourself and your patients comfortable when you are physically examining them when they are unclothed? (Note here that the interviewers don't appear to ask how the doctor or nurse really knows if the patient is comfortable. Do they ask?) Do you think you treat your male and female patients differently? Are you concerned about allegations of sexual impropriety? If so, how do you protect yourself from false allegations?

I believe this study is extremely important. I’m not claiming it is definitive. The authors didn’t interview thousands of medical professionals -- but they did conduct in depth discussions with the ones they did contact. This study does represent, I believe, important indicators regarding patient and caregiver modesty and how this subject intersects between and among them. I would like to see a team of sociologists and doctors continue studies in this area, perhaps using this study to help them get started.

In a series of articles, I will cover these various strategies from the patient perspective, how to recognized and analyze, and more importantly, how to communicate your feelings to caregivers based upon how comfortable you feel.

These strategies discussed in this study are:

-- Using a Chaperone

-- Objectifying the Patient

-- Empathizing with the Patient and Protecting Privacy

-- Joking about Sex (I would broaden this to read -- Using humor, perhaps body humor.)

-- Threatening the Patient (I would rather put this as -- Using power to control and/or intimidate patients to do what they’re told.)

-- Looking Professional

These are the strategies we’ll explore in upcoming articles --

but more specifically, how patients can recognize these at work and learn to express their personal comfort level. If a strategy makes you feel uncomfortable, more embarrassed, or humiliated -- don’t hesitate to speak up and let the doctor or nurse know. They may or may not even be aware of how what they are doing affects you as the patient. And if you find a caregiver who is particularly good at making you feel respected, valued, dignified and comfortable in any intimate situation -- be sure to compliment them. They don't often get feedback in this area and, like all of us, I'm sure they would appreciate knowing they did an excellent job.

Male Modesty

Male modesty is a subject that’s generally ignored in our society.  Very little documentation is available to even discuss it intelligently.  I know physicians who believe that their male patients are more modest than the ladies, yet almost nothing is written about this.  To be clear, let me clarify that I am talking about modesty concerning ones own body.  A  recent study has touted that male modesty is looked down upon by society, but they were referring to the trait of humility or a perceived absence of aggressiveness, especially in the business world.  But medical modesty isn’t respected either.  What percentage of men are modest in a medical situation?  It would perhaps be clearer to ask a similar question, what percentage of men are embarrassed by being exposed in a medical situation?  I would guess that over half are, but it is rarely a subject for discussion.

Is this any different from the situation that women face?  There is no doubt that exposure in medical settings is common for both male and female patients.  On the whole though, the medical establishment is far more sensitive to female modesty than to male modesty.  Examples can be found on the other blog.  One poster related that he had a testicular ultrasound done by a female technician.  As he was leaving, the tech told a waiting woman that her ultrasound was to be done by a male technician, but she could wait until the women tech was again free.  No such courtesy was offered to the male patient.  Obviously men are at a disadvantage in that medical personnel outside of physicians are overwhelmingly female.  But little attempt is made to offer gender choice to men when available.  Even in most Urology offices, men are given no choice of personnel for intimate procedures.  I once questioned my urologist about this.  He freely admitted that many men are clearly embarrassed when a woman assists on a urologic procedure.  He even observed that the embarrassment was more pronounced when the assistant was a young woman.  When I asked why they didn’t hire men, he explained only that they couldn’t find any to hire.  Clearly though the practice had made no concerted effort to hire men.

The concept of medical modesty also needs to be amplified to include respect as they go hand in hand.  As an example, I would be angry about being given a gown open in the back and paraded in the hall.  I personally would not be that embarrassed, but I would be angry about being treated with so little respect that no one thought to close the gown in back.  When exposure is necessary, respectful care with thorough explanations can frequently make a patient comfortable with embarrassing situations.  It is vital that the patients’ feelings be taken into account whenever possible.  For many patients, both men and women, the loss of independence is the most embarrassing part of the situation.  That is a much bigger factor for men though.

We need to be clear that not all men prefer male assistants for medical procedures.  At least 10-20% prefer women and many more will accept either gender.  The reasons why some men prefer female nurses or techs vary.    Some believe that a woman’s touch is gentler, others are homophobic, and still others have a sexual fetish about being treated by women.  Some are childhood victims of sexual assault, usually committed by a man.  This is a very significant segment which is poorly acknowledged.   Best estimates are that boys are assaulted at 25-50% of the rate that girls are  (Finkelhor, Current Information on the Scope and Nature of Child Sexual Abuse, The Future of Children, Summer Fall 1994).  No matter the reason for a preference, patients should be given a choice whenever possible.

Another very important variable is age.  Adolescents are far more subject to embarrassment than mature adults.  I’ve seen it estimated that 90% of adolescent girls prefer a female gynecologist.  The analogous figure is less for boys as many are used to female pediatricians.  Still it is a major factor.  It should be assumed that an adolescent is embarrassed by exposure.  Any necessary exposure should be done as discreetly as possible.  Chaperones should be only used when necessary and desired by the patient, and priority should be given to same sex chaperones, which almost never happens for boys.

Why do we hear so little about male modesty?  It’s hard to say.  First of all, men are much less likely to protest than women are.  It’s just not macho to be complaining about the presence of women, whereas the reverse situation is much more acceptable.  Nurses are taught in training to respect a patient’s modesty.  In this regard, they are better trained than doctors.  I think any female nurse would tell you that many of her male patients are embarrassed when they have to give intimate care.   Yet it is rare indeed that they would offer to find a male nurse.  The reverse situation is not rare by the way.  Many male nurses will offer to find a female nurse to provide intimate care for their female patients.  Numbers are against men here, but there may be other factors.  Some nurses just get jaded and want to do their job and get on with it.  Others will tell you that the men prefer female nurses.  But most men either don’t care or would prefer a male for intimate care.  The nurses don’t ask, so they can’t know how any individual would feel about this.   Some nurses may be reluctant to admit that there is a need for more male nurses.

These issues are important.  Men seek far less medical care than women and die younger.  The reasons for this are poorly studied, but clearly a very significant part of this is that men are too embarrassed to seek care.  It’s common to see occasional advertisements offering screening exams for prostate cancer which are totally run by female nurses.  One can’t even imagine the analogous situation, a breast screening program totally run by men.  Is it any wonder that many men are turned off by this?  The majority of hospitals and cities have clinics and practices that specialize in women’s health.  They are nearly always run solely by women.  It is rare to find a men’s clinic anywhere.  Even Urology clinics don’t make men feel comfortable.  You might have to explain your potency difficulties to the young woman at the front desk.

More information is urgently needed to know how to deal with these problems.  Please add your comments.  Further discussion on this topic can be found at the discussion blog.

15 Secrets Your Patients Won't Tell You

DEAR DOCTOR AND NURSE:

15 SECRETS YOUR PATIENTS WON’T TELL YOU

by Doug Capra © 2010

Earlier this year, Reader's Digest published an article titled "41 Secrets Your Doctor Would Never Share." The article had some interesting insights. All patients should read it. Certainly, it's good to know what's on doctors' and nurses" minds, thoughts they won't say out loud to us. But from my perception, some of these thoughts, or perhaps it's the way they phrase them, seem presumptuous, even paternalistic. How about the chiropractor from Atlanta who writes: "I was told in school to put a patient in a gown when he isn't listening or cooperating. It casts him in a position of subservience." That's a good piece of information for a patient to possess.

Perhaps it’s time for patients to speak up and reveal some “secrets” they don’t often tell their caregivers, and the reasons why. Perhaps it's about time doctors, nurses and patients start really talking with each other -- talking about those "elephant in the room" subjects that tip toe with heavy thuds through hospitals and clinics.

Sometimes, a deep chasm seems to separate patients from their caregivers in our suffering health care system. Both caregivers and patients have a role in bridging this gap. But, as Dr. David H. Newman writes in his book, Hippocrates’ Shadow, “…there is a phenomenon within the culture of modern medicine that guarantees the widening of this patient-doctor chasm."

What is this phenomenon? “Secrecy,” Newman claims. “Doctors have secrets, and we have lots of them.” The culture of hospitals and clinics is quite mysterious to many patients.

Newman hopes, and I agree with him, that acknowledging these elephants in the room is essential for more healthy and open relationships between doctors, nurses and patients. He has great respect of his profession; for, the essence of medicine, he writes, is a “profoundly human, beautifully flawed, and occasionally triumphant endeavor.”

But then there’s the other side: “The truth is,” he writes, “the real secrets of modern medicine are protected by tradition, group-think, and system constructs that punish inquiry and self-examination. They are embedded in the presumptions and thought patterns that we are taught to embrace during our indoctrination and on which we come to rely. They originate at the highest levels and trickle down; physicians are often merely bit players in a systemic – and systematic – dishonesty stemming from these secrets. These are the secrets and lies that shape the practice of modern medicine.”

I embrace his primary solution to this problem. Better communication. Getting these “secrets” out in the open. So…doctors, nurses, various assistants and tech’s – Let’s communicate.

If you’re a doctor or nurse reading this article, it may anger you. You may not agree with some of what’s here. But I can assure you that the thoughts I’ve listed below are on the minds of a significant number of your patients. And most won’t tell you what’s written here, unless you gain their trust, give them your time, and open your hearts to their feelings and what’s really on their minds.

Talk with us.

1. If we made an appointment with you, we trust you. We may not feel comfortable telling the most intimate details of our private lives or revealing our naked bodies to your unlicensed medical assistants or even your licensed nurses or their assistant. On the other hand, if we’ve developed a relationship with them as well as with you, we may be just fine. Talk with us.

2. Get rid of your paper and flimsy cloth gowns. Get some that really cover your patients. Better than that – find alternatives to gowns when possible and let patients know about those alternatives. If you do tell us to put on a gown, be specific about whether we can keep any underclothing on. Unless it’s obvious, don’t assume we know exactly what you want. Talk with us.

3. We’re scared. Actually, hospitals and clinics intimidate some of us. It’s like a different world. Some of us don’t even understand the language. When you ask us questions, we won’t consciously lie to you, but we may not be thinking straight. Look us in the eye and try to read our emotional state. Talk with us.

4. If you’re a male and we’re a female, we may neither feel comfortable talking with you about intimate matters nor with you examining us in an intimate way. Unless we specifically chose you as a caregiver, ask if we’d prefer a female to do the procedure or exam. The same goes for male patients who prefer same gender care. People have different values. We know. To some of you, there are no male or female doctors or nurses, only doctors and nurses. You’ve been taught that your world is gender neutral, that it doesn’t or shouldn’t matter. Maybe that’s true in a perfect world. But the world we both really live in is not gender neutral when it comes to the most intimate parts of our bodies. You see naked patients every day. To you it may not matter anymore. To some patients it does matters – and it’s not up to you to judge their personal values. Don’t take this personally. It doesn’t mean we never want a male or a female to take care of us. It doesn’t mean we hate men or women. Our choice may depend upon how intimate the exam may be. Respect that choice. Walk in our shoes. Consider what your personal gender preferences might be for intimate procedures. Consider how you would want your mother or father, brother or sister, son our daughter treated. Talk with us.

5. Let’s talk about men. Some men have problems with their perception of how their modesty is treated by some in the medical community. Many of these men will not speak up and tell you what they prefer – which would be for same gender intimate care. They may appear arrogant, angry, sarcastic, silent or compliant. Speaking up and asking for same gender care is as or more embarrassing or humiliating to them than as is having a female nurse or technician conduct an intimate procedure. You can say, “Oh, they’ll get over it.” But many won’t. They take these unresolved negative feelings home from the hospital with them, and it influences their attitude toward medical care and the system in general. They may feel their dignity hasn’t been respected. “How dare they!” you may be thinking. “I treated them with dignity.” Were they asked about their preferences? Did they get a chance to define their dignity, or did you define it for them? Talk with us.

6. If you need a chaperone, don’t pretend it’s only for your patient’s comfort. Acknowledge that it’s for your own protection. In our culture, there’s no denying that this may be necessary. But be upfront about it. Many man are unexpectedly faced with a female doctor who then brings in a female nurse or assistant as a chaperone. How often does a male doctor bring in a male nurse or assistant as a chaperone when conducting an intimate exam with a female patient? This is a double standard that needs to be changed. Does your hospital or clinic have a written chaperone policy? Does it insure that patients will be asked if they want a chaperone? Does it insure that same gender chaperones will always be offered? Many studies show that most men don’t want chaperones regardless of the caregiver’s gender. They don’t want an audience. The same is true for some women. Always ask and respect those choices. Talk with us.

7. We like you and trust you, but some of your staff may be distant, rude and/or unfriendly. We may not feel comfortable telling you this, but you’re responsible for their behavior. If we suddenly stop using you as a provider, or request another caregiver, you may never know why. So why not find a way to make us feel comfortable giving you this valuable feedback. Talk with us.

8. “Privacy” doesn’t just refer to paperwork and speech. It also refers to patient respect and dignity – and that involves how we feel about our bodies. Drape patients properly, keep doors and curtains closed, don’t “pop in” when another caregiver is working intimately with a patient. Always ask permission (when patients are fully dressed) to bring in a student or observer, especially when intimate exams or procedures are involved. We know – you’ve done this a million times, and “seen it all.” But it’s the first time for some of your patients. Talk with us.

9. Don’t tell us how many other patients you have or how busy you are. That may certainly be true. And if you’re in a rush, don’t be obvious about it or tell us. When we’re naked, perhaps frightened, vulnerable and sick, we don’t want to hear that. At that moment, the moment we’re in your hands, as far as we’re concerned, we’re your only patient. And we expect you to treat us that way. Talk with us.

10. Even if we have a valid request or complaint, we may be afraid to state it. Why? Because we may be afraid that you may take it the wrong way, label us as a “bad” patient – and that may negatively affect our care. We realize you may find this absurd or even insulting, and we’re not saying this feeling is necessarily rational. But just because feelings aren’t always rational doesn’t mean we don’t feel that way. So, don’t tell us we don’t feel that way. Respect our feelings and prove to us wrong. Talk with us.

11. Most of us want to be good patients. We understand about being polite, respectful and not overly demanding. But hospitals operate under all kinds of “under the radar rules” that are unknown to inexperienced patients. There are many “elephants” stomping around in hospital rooms. You live with those unspoken rules day after day, month after month, year after year. You know them by heart. We don’t, and we’re not given a list of them upon admission. Most of the time, you don’t tell us. You expect us to figure them out. Talk with us.

12. Be careful about using the following expressions in response to patient requests: “Don’t be silly.” -- “I do this all the time. You don’t have anything I haven’t seen before.” -- “We’re all professionals here.” You may have good intentions, but these may seem insulting and disrespectful to some of us. These kinds of expressions are not meant to open up discussion. They’re designed to shut down communication. If you use one of these expressions, and your patient shuts down, don’t assume everything is just fine. We know. You’re busy. But we don’t see ourselves as just another “job” to get done so you can move on to the next one. Talk with us.

13. We know. You sometimes need to vent. But be very careful. Venting used to be mostly done behind closed doors, whispered in break rooms and over lunch among professionals. Now it’s become more public – blogs, Facebook, at parties, in corridors – sometimes even within patients’ hearing. Don’t underestimate how this public venting can damage the credibility of your profession and destroy patient trust. And remember, patients sometimes need to vent, too. Talk with us.

14. We know. You know what it’s like to be a patient. Some of you have been hospitalized before. But you’re missing an important point. You don’t know what it’s like to be a patient who doesn’t know what you know about medicine –a patient who doesn’t understand the culture of a hospital, who doesn’t speak the language, a patient without any medical training at all who has rarely or never been hospitalized. You may have known that point of view before you became a doctor or nurse. But you can’t unlearn what you know now. You’ll never see being a patient the same way again. Try to recall how you felt way back then. Talk with us.

15. Don’t forget -- You have the primary responsibility to open up communication with us. Sometimes we’re tired, frightened, vulnerable, naked, intimidated. Often we won’t say anything, even if we feel uncomfortable, embarrassed or humiliated. Sometimes we’re just too tired and exhausted to fight with you. Don’t assume that everything’s okay just because we don’t speak up. I realize that this may be risky business for you. Asking a question might get you an answer that you don’t like or want. You may know the answer but not want to really hear it. But do ask. Communicate. Talk with us.

Realize that at heart most of us do trust and respect you. We put our lives in your hands everyday. We make incredible leaps of faith. We know we don’t know more than you do about the science of medicine. But we do know our own bodies and our own values – and many of us want to have a critical role in the details of our care. We can bridge this chasm between patients and our health care system.

Talk with us.

NOTE -- I've tried to summarize my ideas within 15 items. What are some other thoughts you as patients would like to tell doctors and nurses (and CNA's and medical techs) that you hesitate to mention? Let's hear from the patient perspective.