Patient Gender Preferences In Healthcare

Modern medicine is assumed to be gender neutral, that is providers, nurses and assistants are equally able to offer their services to all comers no matter the genders involved. It is a tenet of our training. This had little relevance in the past when nearly all physicians were men and nearly all nurses were women. Times have changed. Nowadays medical students are nearly 50% women. Although the percentage of male nurses is also increasing, it is still low, likely over 10%. However the increase in male nurses may be due mostly to the recession and the loss of traditional male jobs rather than to any perceived need for more male nurses.

Changing practices in medicine can be exemplified by male urinary catheterization. Thirty plus years ago this was always done by physicians or male orderlies; nowadays it is usually done by female nurses. The reason for these changes is mostly financial as hospitals got rid of orderlies in favor of less expensive ‘transport aides.’ As all physicians were male, they of course treated all patients. Women providers of today have the same expectations of being able to treat everyone.

Yet no one has ever asked patients how they feel about this. Are patients gender neutral in their preferences? The answer is clearly no. The factors are complex and need analysis. The clearest division is with intimate care. Women have strongly gravitated to female Ob-Gyns. Ninety percent of Ob-Gyns in training are women and men are discouraged from entering the field. The younger the woman, the clearer is the preference for female providers. The results vary somewhat from study to study likely based on how the study was conducted. Older women are used to using male gynecologists and some are reluctant to admit they prefer women because those concerns were made light of in prior years. Yet in nearly all studies, at least 50% of women prefer female OB-Gyn care with no more than 10-15% preferring male care. References include: Obstetrics Gynecology Apr 2005, Vol 105, #4, p 747-750, Obstet Gynecol 99: #6, 2002, 1031-1035, and Plunkett, Beth et al. Amer J Obstet Gynecol, 186: #3, 2002, 926-928. An Australian study put the number at 70%.  I haven’t seen a study which looked just at adolescents, but clearly the percentage is even higher, approaching 90%. Women are not gender neutral in their preferences for intimate care.

Not surprisingly the preferences that men have are not as striking, but still present. A similar study asking men their gender preferences for a urologist has not been done to my knowledge. Yet 90% or urologists are men and many of the few practicing female urologists specialize in women’s problems. The percentage of female urologists is increasing, but nowhere near as dramatically as the number of female Ob-Gyns. Men are not demanding more female urologists to take care of them. In terms of routine male genital exams, men still show a preferences even though the exam is brief and generally done as part of a full physical. In one study 50% of men preferred a male physician whereas the rest had no preference. Other studies have said up to 70% of men have no preferences, but once again it is critical how these studies are performed. An anonymous questionnaire will give different results than a series of questions asked by a nurse. Most men are loathe to admit that they are embarrassed by receiving care from women. They are frequently made to feel humiliated if they do. Women can have this same problem but it is far more acceptable for a woman to be modest than it is for a man. A man is likely to accused of sexism or suspected of homoerotic tendencies if he refuses opposite gender care whereas a woman will just be considered modest. It is much easier for a man just to avoid receiving any medical care which men do in far higher numbers than women who are forced into entering the healthcare system early in their lives for contraception and obstetrical care.

There are other factors besides gender in determining how likely it is that a patient will prefer same gender care. As noted, age is the most important of these. Adolescents are far more likely to be embarrassed by intimate care. A choice should be offered them. This often happens nowadays for girls but rarely for boys. This may become less of a problem for boys in the future as many are used to care by female pediatricians. But as they move into adolescence, this should never be assumed. Conversely elderly patients routinely have less concern. Religion also plays a role especially with Muslims and other orthodox sects. A history of sexual assaults or homophobia may also account for preferences.

Up to now we have only considered gender preferences for providers, but of course this can also be extended to nurses, technicians and assistants. Patients do not look at these healthcare workers like they do physicians. Clearly women are far more likely to accept male physicians than male nurses or technicians. Men who wouldn’t see a female physician routinely accept female nurses. Of course they usually have no choice. But beyond that there is still a common prejudice against male nurses in that they may be considered not as nurturing as women or they may be considered gay. I don’t think that either of these prejudices have much basis in fact, but they keep many men from going into nursing. This is changing, but slowly. Men are clearly at a disadvantage here. Many men who need urinary catheterization would request a male to do it, but they are rarely offered a choice. It is difficult to insist on it as the man may be embarrassed by asking and the need may be urgent. Female nurses almost never offer a man a choice; the only common exception is when the nurse feels the patient will harass her and asks a male nurse to do it instead. In short when men are offered male nurses for procedures, it’s usually done for the nurse’s comfort, not the patient’s. Although there are male nurses who catheterize women, it is far less common and many male nurses will routinely ask a female nurse to do it. Intimate care in hospitals nowadays is usually done by CNAs, who are 98% women. This includes giving baths and showers. The only option a man has is to refuse the care; no male CNA will likely be found.

In summary, American medicine claims to be gender neutral but patients are not. This is essentially a fact we’re not supposed to know. Hospitals routinely publish a patient’s bill of rights, but I’ve never seen one which included gender choice. At best it may be implied by statements that the hospital will respect the patient’s values. Of course gender is a protected class under federal laws so hospitals are in a bind. Federal law does make exceptions (BFOQ) where matters of bodily privacy are involved so it is legal to request a specific gender for care. However hospitals cannot base employment on that in general with rare exceptions. Still and all, hospital employment policies are never based on giving patients a choice of gender; their major consideration is cost and availability.

Will this ever change? It’s not likely to change in the foreseeable future unless a lot more patients speak up about their preferences. Hospitals are only likely to make the change if they see it as in their financial interest. For example, if men routinely asked for a male technician for testicular ultrasound, hospitals would soon provide them just as they provide an all female staff for mammography. Ultimately you as a patient must make your preferences known.

Please add your comments.  Further discussion can be found on my companion blog. This slightly modified article has also been picked for publication on Kevin.MD, a widely read medical blog.

PATIENT MODESTY AND HOW WE COMMUNICATE

PATIENT MODESTY AND HOW WE COMMUNICATE

Assumptions, Stereotypes & Efficiency

The story plots form patterns. They narratives involve patient modesty violations. The main characters are patients, doctors, nurses, medical and nurses assistants, and patient techs . The stories are set in medical clinics and hospitals. The elephant in the room is the entire issue of how the gender of the patient and the caregiver affect patient care. Although the patients in these stories are both male and female, I’ll be using male examples for several reasons.

First, men don’t go to the doctor as often as women. Unless they’ve had chronic health problems from youth, they don’t end up facing the health care system regularly until their 50’s when they begin to have problems with, for example, their prostate. Women have contact with health care at much younger ages for obvious reasons. Second, men often won’t speak up in medical situations, and when doctors and nurses are busy, that’s sometimes regarded as a good thing -- for the caregivers. The job gets done faster -- it's more efficient. Women often fail to communicate, too, but in recent years our culture has empowered women more regarding their health care. Third, with the gender imbalance in bedside care, men often have little choice of gender anyway. Fourth, men are sometimes stereotyped as not caring about the gender of caregivers for intimate exams and procedures. It’s sometimes assumed that it either doesn’t matter, or that, for homophobic reasons, they prefer female caregivers.

As I’ve stated many times, a significant part of what we consider to be modesty violations come down to communication issues. Medical culture today is not known for it’s outstanding communication skills. Like customer service throughout the country, when a patient experiences great communication in medicine, it stands out as exceptional. Poor communication experiences are often the norm, and shrugged off as just the way it is.

Many of us communicate well with our primary care physicians. We should. If we don’t, we should find another. But, as we move away from local care into the hands of a specialist -- the communication sometimes breaks down. When we move from the specialist into a hospital, and face a team of caregivers we don’t know, we often have problems and need to be extremely proactive.

Let's look at a scenario, examine what may be happening and consider how patients might respond.

Mr. Smith, 55 years old, makes an appointment with his long-time male primary care physician, Dr. Anderson, and feels comfortable with him. Anderson has moved and now works with a new team of doctors at a new clinic. At the clinic, Smith goes through the regular routine -- fills out some paperwork, sits and waits, gets escorted into the examining room by the female medical assistant. He’s handed a gown and told to undress. He does so.

After ten minutes, to his shock, a female doctor, a complete stranger, enters the room with the medical assistant and says: “Hello. I’m Dr. Jones. Sorry, Dr. Anderson is on vacation. I’ll be doing the exam today. Kathy will be assisting me.”

Smith doesn’t know what to say. He’s speechless. He’s led a relative healthy life with no hospitalizations since he had his tonsils out at age seven. It’s only been the last few years, since he developed prostate problems, that he’s seen a doctor regularly. He’s greatly embarrassed at this situation, but even more embarrassed to complain. He lets the exam go on as planned, only nodding yes or no to any questions. Jones had planned to ask Dr. Anderson several embarrassing questions about some personal health problems, but on this visit, he asks no questions at all.

I’ve heard this experience referred to as an “ambush” by some patients. Not only have I read this story pattern on many blogs, but it actually happened to a friend of mine. And, although my friend and I had talked about these kinds of problems and he was aware of male modesty issues -- he responded just as Smith did. Later, he was angry and frustrated as much about his response as he was about the whole incident.

So -- how does one confront or respond to a situation like this?

1. The best response isn’t a response. It’s proactive action. Make it clear from the beginning that your appoint is with a specific doctor. Let the receptionist know that if that doctor’s not available, you want to be notified in order to reschedule. A few days before the appointment, phone and confirm your appointment with your doctor. When you get to the office, confirm the appointment with your doctor. In other words, take control of the situation. Make your personal needs and values clear. Don’t allow yourself to be ambushed.

Savvy medical experts recognize that gender matters in medical encounters. Male and female patients have different ways of communicating, and male and female doctors communicate differently, too, depending upon the gender of their patients.

2. If you haven’t been proactive, and you find yourself in Smith’s position, learn by heart that important four letter word -- STOP. You don’t have to actually say that word -- but your response should make it clear that the direction of the appointment has now changed and you’re leading it. Take charge. For the present, the issue is no longer the exam.

In the scenario described above, there are two issues to deal with, both involving lack of communication and unwarranted assumptions. First, nobody told you about the switch in doctors. It may have been assumed that it didn’t matter to you. The prime responsibility actually should fall upon Dr. Anderson to have seen you were notified. But unless you had made your preferences clear, he may have assumed it didn’t matter to you. Second, it’s just assumed that you have no objection to (or will not object to) a female medical assistant observing your exam.

Let’s go back and look at the initial encounter and imagine a response:

“Hello. I’m Dr. Jones. Sorry, Dr. Anderson is on vacation. I’ll be doing the exam today. Kathy will be assisting me.”

YOUR RESPONSE:

“Oh, I’m sorry to hear that, too. Why wasn’t I informed?”

OR

“I don’t feel comfortable with this situation Let’s talk.”

You may get a sincere apology. You may get indifference. You may get frustration, sarcasm, or even anger. Regardless of the doctor’s response, you should make your disappointment with their communication clear. Right now, the issues is lack of communication, not the exam itself. Indicate that you plan to notify your regular doctor about this incident. At some point, the female doctor may say to you:

“Well, you’re free to cancel and reschedule or we can go ahead with the exam today.” What’s your comfort level? If you received an immediate and sincere apology and you trust this doctor, you may decide to proceed with the exam. Or, you may reschedule

If you allow the exam to continue, there’s a second issue to face -- a female medical assistant chaperone. If you’ve read the two articles about chaperones on this blog, you know that some female doctors feel more comfortable with chaperones, especially with male patients. Make a conscious decision at this point, keeping this in mind. You’re paying for this exam. Your comfort is at the very least as important as the doctors comfort.

“Let’s go ahead with the exam,” you may say. “But I don’t feel comfortable with a chaperone.” See what happens. If a trust relationship has started to develop with you and this doctor, that may be all it will take. She’ll ask he chaperone to leave. If the doctor offers to have the chaperone turn away or stand behind a curtain -- consider how ridiculous that is. A chaperone is a witness, and a witness needs to see as well as hear. Can you imagine a chaperone in court on the witness stand:

“What did you see?”

“I didn’t see anything?

“Why?”

“I couldn’t. I was standing behind a curtain."

If you were on the jury, how much credibility would you give to that witness? I’m not sure why some doctors use this strategy. It doesn’t make sense, unless the chaperone is also supposed to take notes, but that’s another issue. That’s where the concept of efficiency comes in -- how do we balance efficiency issues with your modesty? Even in this situation, you can still state that you don't feel comfortable with anyone else in the room but you and the doctor.

Be prepared for some objections. After all, this is a new doctor. You don’t know each other. There’s no basis for any trust. And you have challenged the status quo. You need to accept the fact that this doctor may now not feel comfortable examining you in private. Of course, that would be as good a reason as any to cancel the exam and reschedule.

With some adaptations, this scenario can be fit may similar situations. Regardless of the specific event, follow a few important principles:

1. Don’t be paranoid. Don’t think everyone’s out to get you. Don’t go looking for a fight. Doctors and nurses are human beings and get busy and have bad days like everyone else. Assume the best about people -- that they have good intentions and want to help you. Having said that…

2. Go into medical situations with your eyes wide open. Have high expectations of your providers -- but be prepared for situations like the one described in this article. Think and plan ahead. How will you react? What are your bottom lines? Don’t expect an “ambush,” but have various plans to deal with them.

3. Learn to read body language, facial expressions and vocal tones. Focus more on those than on the specific behavior. Does your doctor or nurse mean well? Are their intentions in your best interest? Is there real caring behind their actions? You can still state your objections and preferences, but focus on intention.

This becomes especially important when confronted with common expressions caregivers may use in this situation:

“There’s nothing you’ve got that we haven’t seen.”

“We’re all professionals here.”

What’s the tone? The intent? Are the caregivers really trying to put you at ease, trying to make you feel more comfortable? Their strategy may not be working, but that doesn’t mean they don’t care about your modesty. Or, are these statements used to shut down communication and get on with the job? That happens sometimes, too. When you infer that, you need to take control and reframe the entire discussion.

4. Learn to accept an apology, forgive and move on. This doesn’t mean you have to give up your values. Communicate them clearly and civilly. But nobody’s perfect. You’re not, either. If you get an apology, that’s a good sign that you’ve found a good provider. You can count on the fact that, after this encounter, they’ll probably remember your preferences.

5. Even if -- especially if -- the communications gets heated -- maintain control. Be calm and polite. If it turns into a battle, occupy the moral high ground. That’s the most powerful weapon if weapons are needed. If this attitude continues, this is a strong indication that you may need to find new provider. Don’t be bullied.

6. Be reflective and reasonable. Ask yourself if you have contributed to the communication problem. If so, admit it and change your behavior. Be honest. If you have specific modesty preferences and you haven’t communicated them to your provider, they’ll assume whatever may be most convenient them. You and your caregiver may owe each other an apology.

Many of these encounters we refer to as modesty violations are at heart communication issues. As a patient, it's your life, your body. The relationship between you and your providers are partnerships. Take the responsibility for your role in that relationship.

(c) Doug Capra 2010

Privacy ComplaintsWhat to do about them

This article has been chosen for reposting on KevinMD. blog


Few patients enter our health care system prepared for the unexpected and embarrassing circumstances that can routinely happen.  Most can accept it when we’re treated with modesty and respect.  But not many are prepared for those times when you might be unnecessarily exposed or treated rudely.  The possibilities for embarrassment are endless and it is usually unexpected.   When avoidable incidents do happen, most patients are not prepared to speak up.  Many regret their inability to speak at the time of the incident.

In fact it is important to speak up at the time of occurrence if at all possible, or if not, as soon as possible thereafter.  It can often be difficult or impossible to identify the offenders days or weeks after the occurrence.  Situations are most likely to be rectified if they are brought to the immediate attention of the offenders and their superiors.   A common example would be being exposed in an examining room when someone leaves the door open or comes in without warning.  Few patients appreciate that but most don’t say anything.  But if you wait several days to complain, it is likely that the office will not remember who was involved.  Despite your embarrassment, the office personnel may recall nothing unusual; it was just in a day’s work for them and consideration of patient’s privacy doesn’t cross their radar.  In a hospital a common occurrence would be for the patient to be exposed during a bath or procedure with the curtain or door being left open.  The potential is even greater for embarrassment if you’re in a semiprivate room and your roommate has visitors.   Even without exposure, having your history taken in a semiprivate room with or without visitors present may cause you to reveal embarrassing and confidential information.  Once again, if you don’t speak up immediately, it will be difficult to identify the perpetrators later.

It helps to have a clear idea what you want from your protest.  A simple apology is the easiest to obtain and may be all that’s needed.   If you want a clear indication that policies will be changed to prevent re-occurrences of the problem, you will need to go beyond a simple apology and communicate the problem with the physicians or managers in charge.  They may indicate that policy directives will be updated and sent out on their own, but if not you may have to request that they take specific action to correct the problem.

The best course of action to take depends on where the incident occurred.  Usually make the complaint immediately to the person who caused it.  In an office, this could be the physician, nurse or assistant.  If you’re not immediately satisfied with the response, also bring your complaint to the physician in charge.  If the infraction was incidental, a simple apology should be enough.  If the infraction was part of a pattern of behavior, you should notify the physician in charge.  If you don’t complain at once, the next best course is to call or write a letter as soon as possible afterwords.   If the complaint is serious and you remain unsatisfied by the response, the usual next course of action is to lodge a complaint against the physician with the state medical board.  All 50 states have them.  Here is a link to them.  If they don’t handle the complaint themselves, they will tell you where to take it.  All states have a board which investigates complaints against physicians.  In all cases, when a written or electronic complaint is filed, you should keep copies and note that you will send copies to their superiors , or to the state and federal institutions which may have jurisdiction.

In a hospital, again make your displeasure immediately known to the person responsible.   If not satisfied, take your complaint to the head nurse or physician in charge.   Try to get the names of the people involved so that you can pursue the complaint more profitably.  If the complaint is against a specific nurse, you can also complain to the state nursing board.  Again all 50 states have them and will investigate complaints.   State boards are listed here. Most hospitals will deal with complaints against specific personnel internally.  If this doesn’t work, continue up the hospital hierarchy.  Most hospitals have a patient advocate whose job it is to handle complaints.  Start with her, but remember that she still works for the hospital no matter her title.  If still no satisfaction, I would send a letter to the CEO of the hospital.  When formulating complaints against a hospital, it is well to remember that nearly all publish a patient bill of rights which might give you considerable help in outlining your complaint.  If still unsatisfied, you should consider sending a complaint to the state board that regulates and licenses hospitals (I haven’t found one website that lists them for all states.)  Another possibility is sending a complaint to JCAHO, the Joint Commission on Accreditation of Healthcare Organizations, usually now shortened to the Joint Commission.   They are more likely to respond to systemic complaints against a hospital rather than one incident unless there were life threatening implications to the occurrence.

Of other venues to be considered, probably nursing homes are the most common source of complaints.  All states have regulations for nursing homes.  Many also have further laws concerning elder abuse.  Once again, see if the problem can be solved internally in the facility, but if the nursing staff and management won’t help, complaints to the state are appropriate.

Probably the last place to complain is with HIPAA.  They do take patient complaints but they are not oriented towards individual complaints unless it clearly has to do with information transfer.  If say a hospital posted photos of your operation on an instructional site without your permission, it could fall under their purview.  There is no right of private action under federal law though there may be under individual state laws.  Finally you can contact a lawyer at any time but beware that most privacy violations won’t bring large monetary damages.  So do so only if you are really motivated to obtain redress as the attorney bills will be significant.

If you have violations to share or questions to ask, please comment below.

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.