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Monday, November 26, 2007

“We’re all professionals here”

A sufficient safeguard for your privacy???

108 comments:

Joel Sherman said...

Being ‘professional’ seems to be the standard reason given to patients to ease their privacy concerns. Is it valid? What protection do patients have?
Well they are significant. Physicians, nurses and all assistants are bound by privacy rules. These are formalized under HIPAA, but have always been understood by the health industry and promulgated by the AMA and others. It means that all covered employees cannot talk or gossip about patients except to communicate with other personnel on a need to know basis. I believe that these guidelines are usually followed. I’m sure that there are violations but physicians and employees can and have been disciplined or fired for these. Physicians and nurses undergo 4-10 years of training at their own expense and are not likely to jeopardize their careers for the sake of a little gossip. Aides, technicians and other assistants have put in similar preparation and are taught the rules. They have less at stake but would also be subject to discipline or dismissal for violations. So patients with concerns about opposite gender care should have little to worry about apart from their own modesty and comfort level. There is nothing wrong with these concerns; it is just a matter of upbringing and experience. I do believe that providers should practice what they preach themselves. Here is a post from a female urologist who calls a male patient sexist for refusing to see her, but freely admits that she has only female gynecologic care. I believe this is hypocritical, but I’m sure she still protects her own patients’ privacy.

Are these privacy protections available in other areas? I don’t think so. Women reporters are freely allowed to invade the privacy of athletes. Are they really professional? Well they claim to be, but what does it mean? Is there a code of conduct that they pledge to adhere to? Are there any penalties for violations? Not that I know of. I think that professional reporters have significant reasons to maintain their professionalism and gross violations are uncommon. But this same scenario also happen on a college level with student reporters who have little at stake. Do they maintain professionalism at the weekend party? Doubtful.

In prisons the situation is worse. Although prisoners have legally limited privacy rights, they do not forego all protection. Yet at many prisons they may be strip searched with opposite gender guards doing the search or observing it. These guards or even incidental personnel who may be present do not have to uphold any guidelines for privacy. They can and do talk freely amongst themselves and outside and suffer no penalty.

In summary I believe that the vast majority of medical personnel act professionally and are responsible. I believe though that privacy rights are routinely violated in other areas that deserve more protection. On a legal level under equal employment laws, I believe that no bona fide occupational qualifications (BFOQ) are needed in medicine, but they should be granted in the other situations above. In lay language, individual athletes or prisoners should have the right to refuse cross gender interviews or searches. The law as it stands today does not agree with me.

Please post your own comments and opinions.

Anonymous said...

Dr. Sherman

I think "we're all professionals here" really hits a bump in the road when we consider how many "professionals" take special steps to protect their modesty when they are the patient, which is inconsistant of what they tell patients. The all nurse blog has numerous threads similar to the female urologist who says one thing to thier patients and practices another when they are the patient. A similar scenerio exists with the other cases you presented. While female reporters are allowed in male locker rooms, the reverse is not allowed. Are we saying female reporters are more "professional" than males or are we really recognizing the issue but as in the medical community "political correctness" or tradition over rides a persons rights? The same with prisons, a judge ruled males can not pat search females, but females can not only pat down a male, they can strip search them. While this is also a sexism issue, it exposes inconsistancies in the "we are all professionals" argument. It appears those incharge practice "some of us are professionals"...meaning I am. JD

Joel Sherman said...

JD,
I agree that many providers are hypocritical, and I think it's wrong. But beyond that even the hypocritical providers protect their own patient's privacy.
That's a big improvement over reporters e.g. who claim professionalism but have absolutely no boundaries as to what they discuss and make jokes of when they get together. Prison guards make no pretense of professionalism.
It's hard for me to suggest anything further that could be done to protect medical privacy that is practical. In hospitals, reviewing the rules regularly to keep people reminded of them might have some effect.

Anonymous said...

I agree with you to a great extent, reporters, and to a larger degree prisions place a me agenda with little concern at all for the atheletes or prisioners. In the case of prisioners I would even suggest in many cases it is punitive in nature with intent to degrade and control.

I would however suggest that providers also are prone to the me syndrome, placing their paticular needs or schedules infront of patient needs. While this is a bit different from the disregard for the other parties shown by reporters/prisions, acting in a professional manner while not taking every step to minimize discomfort for patients does not maximize professional behavior. Or perhaps we have different definitions of professionalism. The issues I have had with the medical system has had little to do with the manner in which providers conducted themselves. On the contrary, almost to a person they have been very professional and done a great job of conducting themselves in a professional manner, the issue, and perhaps I bring this up in the wrong place,,,,the medical community tends to use the "we are all professionals" to excuse their failure to take other steps that could provide even more benefit to patients. For example, I had to have an scrotal ultrasound, the 1st time I was assigned a female, she was very professional, couldn't think of anything she could have done different, it was still embaressing and uncomfortable, a follow up a different female, not so professional, that spurred me to request a male for the next time and it was much less stressful than either of the other visits. My point is the medical community seems to feel if they have people who are "professional" they don't have to take other steps i.e. ask the patient, try to address the gender embalance of providers, or try to provide same gender providers. So maybe I am off point here, but "we are all professionals" does not address, and perhaps masks or excuses larger issues in patient modesty concerns can we really say "we are all professionals" is a solution?. Now perhaps this is more a institution rather than an individual provider issue, but the net result is the same. Also consider the fact that I have never had a provider even ask if it mattered, though they have to know it is an issue, I would question whether providers do "everything" they can. And I firmly believe the medical institution make only nominal efforts in this area. Consider an issue debated with Dr. Bernstien, why should a patient have to be naked for wrist or shoulder surgery, Dr. Bernistien defended the practice as being a safety issue in case of emergency. OK I understand that...but, how can you defend the fact that there are "surgery shorts" on the market, one use, disposable, sterile, slit on the sides from waist band to cuff, velcro fastened at the waist and cuff on both sides..would provide a degree of comfort to the patient and not compromise safety...minimal cost, why in the world would we not be offered....becasue thats the way it is done and....we are all professionals........that said, can't compare medical providers and reporters/correction offiers. Providers care about thier patients, reporters care about themselves and thier stories, the correction officers care about thier own rights and the correction system uses it as punitive measures to assert authority. Providers are on a lot higher plane. JD

Joel Sherman said...

JD, "We're all professionals here" can and is used in several different contexts. If it is your privacy at stake, that is your medical history, the vast majority of medical personnel are indeed professional, that is they will not broadcast that you're HIV positive for example. But if they're telling you that to 'help' you overcome your modesty, it is of course pointless. They're saying it does nothing. Being caring and considerate in how they treat you does, as you yourself state above. That means keeping exposure to a minimum and explaining everything as they go. I personally don't care if I'm exposed as long as I'm treated with respect, but I draw the line at unnecessary exposure.
Of course reporters and correction officers fail on all counts.

Anonymous said...

Just a interesting (maybe just to me) side note. I was watching House a medical drama on TV. They just had a scene in a recent episode where two doctors (male I think) stepped in a room to have a private conversation, the room was occupied by a Dr and female patient in the middle of a GYN exam. When the patient protested both intruders said its ok we are doctors or we are professionals...just thought it was interesting, the issue is well known, and presented in that context on TV. Granted it is TV...but sometimes it mimic's life. I do agree with you that it is most commonly used by providers with the best intent, to make a patient feel more comfortable.

Anonymous said...

Why would any healthcare provider with a modicum of empathy believe that redirecting attention away from patients' concern for their self-respect and dignity to the status of a healthcare provider make the patient feel more at ease? I'm a bit familiar with a number of nursing models including the "Roy Model" and "Caring Model." Both discourage such a response to patients' modesty precisely because it dismisses the concern of the patient as unimportant. -- Ray

Anonymous said...

Ray,

Could you give us a brief summary of what these models suggest in that area? I like you find the "we're all professionals" to be a bit off the mark. As stated in other threads, the respinse from a paitent "this isn't about you". JD

Joel Sherman said...

The reason I started this thread was of course because the phrase 'we're professionals' is indeed often used to belittle the patient's concerns. It really doesn't convey much meaning. It would be better to stress that any exposure indeed stays private and is not discussed elsewhere. Much modesty is caused by the person being ashamed of their bodies, and not wanting it to be discussed with others. In medicine some exposure is generally unavoidable, but it can be minimized. That wouldn't help everyone, but some would find it reassuring. We're not all Paris Hilton and proud to display our bodies.

Among my wife's talents is included a degree in art. She told me that nude models are often told that the student artists are all professionals to help reassure them. How laughable is that, 18 year old students taking a few art courses are 'all professionals'? Of course these models are paid for their exposure so the situation is not fully comparable. But even so the protection provided for privacy in medicine far exceeds other areas.

Anonymous said...

JD -- I'm no expert on any nursing model, but my wife is, or was when she was teaching B.S. nursing students. I read some of the publications she had and we spoke a lot about the propositions behind the models. Pertinent to the "we're all professionals here" subject, both the "Caring" and "Roy" models seem to defend the use of "active listening" skills when communicating with others (not only patients). This requires, among other things, not judging patients' feelings but, instead, accepting the validity of patients' feelings. To dismiss a patients' modesty concern by asserting, "I'm a professional," fails in this endeavor; it is paternalistic and inconsistent with the dictates of the models. In short, the nurse who uses the "I'm a professional" defense to a patient is not behaving like a professional nurse.

The readings and research I've done suggests that the "I'm a professional" claim is just one of many a priori justifications learned by people in healthcare. Other claims include, "It means nothing to me," "I've seen it all," "There's nothing sexual about it," "It doesn't bother other people," "It doesn't bother me," "I'm a nurse (doctor, med tech, etc.), "This is my job," "I am trained to do this," etc. These justifications are learned directly and indirectly from others in healthcare organizations before and during the process of exposing patients to humiliating procedures. They neutralize internal constraints (e.g., conscience, feelings of embarrassment) and external constraints (fear of negative reactions by others). Healthcare participants are resocialized in a subculture of entitlement and part of this resocialization involves learning these justifications or neutralizations.

The theory I'm applying here is called neutralization theory. It is unique in that it explains the double standard or hypocrisy that contributors to this and the "modesty" blog have recognized.

Ray

MJ_KC said...

I am a patient who isn't bothered when multiple people are in the room when I am nude, but I would still not like it if I raised a concern and it was dismissed as if I didn't matter.

The key should be to listen when the patient raises a concern and to not make a flippant comment as if they were being silly for being concerned.

Some people are extremely shy and others are more like myself. Caregivers should listen and adapt to the individual.

JD said...

I was at a Christmas party my Company hosted this weekend. The comments you made regarding art students came to mind as I listened to a coversation between my daughter and three of her friends. The three were nursing students in their senior year. After several drinks the conversation was pretty free about what they had done and seen. It struck me that many people are part or hear these conversations and the "we are all professionals" gets less and less credible. I had never been able to put to words the other thing that bothered me, the discription of dismissing patient feelings with comments about themselves...good explaination, and thanks for the discription Ray. JD

Anonymous said...

MJ_KC -- You are, of course, correct. I know this is what BS nursing students are taught by at least some faculty, but not only is there a hidden curriculum that challenges what they are taught (especially during their clinicals), but once they are out in the field, they are resocialized. I'm not sure what 2-year RN students and LPN students are taught. I'm skeptical that they are taught anything more than to be tecnicians.

JD -- About what were the nursing students conversing and how did those to whom they were speaking or who overheard them respond, if at all? -- Ray

Joel Sherman said...

JD, having been a young 'professional' myself, I am perhaps too tolerant of youthful chatter. It is certainly not professional however for students to be trading stories out of school for amusement. Most get over it as they start their careers. If they were talking about identified patients then they have crossed an ethical and legal line, and if I were present, I would have objected immediately.

Anonymous said...

The topics varied, what I overheard varied from "gross" tales of an enema & cleaning patients bottom to one story of a male cath. in more of terms of how difficult it was for her "the nurse" vs what the patient was feeling. It was as much the manner it was told as the topics. While the demeanor was typical of what you might expect from a 20ish kid drinking, it was not what you would expect from a "professional", it was more for entertainment of everyone. Personally I find little humorous about colon cancer patients problems with a coloscopy bag as I could only imagine the humiliation of the patient.
Those involved were all laughing hysterically, and I am not sure how many others heard it. The one person I was talking to at the time just rolled her eyes and didn't comment. DJ

MJ_KC said...

I can understand the need to talk about things and relieve the stress of dealing with difficult medical problems. It would be one thing to talk about it at home with one or two friends, but to be talking it up real loud and laughing about it at a party seems to be a bad idea.

Keeping the names of the patients out of these conversations is a must regardless of the setting.

Anonymous said...

mj_kc, I think what this really illistrates is a little more complex than what appears on the surface. The "we are all professionals" is often used to minimize or justify providers lack of effort to do everything they COULD do to minimize patients issues. They justify not asking if the patient would prefer same gender providers for intimate exams with its ok, we are professionals. The phrase is used to give the illusion that somehow because of their position they are somehow on a different plain than the average person, they don't see these events for feel the same as average people and therefore exposure to the opposite gender and the procedures should be more acceptable, or not a big of issue. When we witness this type of behavior, it erodes the ablity of people to convince themselves that it is indeed the case. They can't claim the higher ground during the event then justify thier behavior later with "we need to release stress just like everyone else". If the conversation was respectful and how these situations were stressful on the provider etc. I could understand. But to make light of and joke about it, that isn't professional or acceptable. They are either on a higher plain or they aren't. They did not name anyone and they go to school several hours from where we were so there was little chance of knowing who they were talking about...that much was good JD

Anonymous said...

DJ -- What you described is an integral part of the culture in which these nurses were resocialized. I've written about it elsewhere on this blog, I think. Conrad articulates it best when he writes, "Crude jokes and gallows humor about patients become part of the everyday scene of medicine. Although making fun of patients may release stress, it also sets doctors farther apart from their patients. . . The situation of the medical students, and later [the physician], does not lend itself to caring for and about patients. Quite the opposite is the case; the situation often encourages the definition of the patient as an adversary or even as an 'enemy.'"

Conrad's message is that part of becoming a professional is to learn to behave unprofessionally.

The same may be said about nurses in a general sense. Were one to read some of the contributions to allnurses.com, it would confirm Conrad's observations vis-a-vis nurses. A disproportionate number of the humor is, unquestionably, directed at the elderly. For some reason, they are more frequently than any other age group the object of the "crude jokes and gallows humor" about which Conrad writes. An example that recenty circulated among a group of nursing faculty members I know goes like this.

An elderly male nursing home resident was sitting with an elderly female resident by a pond near the nursing home. They got to talking and she asked him if there was anything she could do for him. He asked if she would hold his penis for him to which she complied. Each day from that day on they met at the pond to participate in this ritual. One day she walked to the pond to meet him but he was not at their usual spot. She looked across the pond and saw him sitting with another elderly female patient. This upset her so much that she confronted him later in the day. "What does she have that I don't," the distresseed woman asked? He replied, "Parkinson's Disease."

Offensive humor may take the form of making light of patients' misery. One example comes from "Nursing 2000" (2000: 80)in a list of "Bone ticklers" found in its column entitled "Grin & ShareIt."

"As an orthopedic nurse, I heard many stories about how patients broke their bones. Here are a few of my favorites.
1. One woman fractured her hip while stomping down a cereal box that 'got away' from her.
2. Another woman fractured her hip when she somersaulted over the rail of her balcony while shaking out throw rugs.
3. While dancing, a young woman's boyfriend tripped and fell on her, fracturing her hip. (He wasn't injured)
4. While mowing his yard, a man slipped on the dewy grass, slid down a hill, and hit a fence, breaking both ankles.
5. During a demonstration at a department store on how to lay floor tile, a shopper tripped into the exhibition -- tile, glue, and all. She arrived at the hospital stuck to a long board. The health care team used solvents to remove her from the board. When she arrived in the orthopedic unit, she was still tacky."

I don't think one would find this type of humor in popular magazines such as "Reader's Digest." If it is unprofessional, as you suggest DJ, then that lack of professionalism is built into at least one professional nursing journal.

Humor of this nature is a precursor to and sanitizes the dehumanization of patients. Although I know this to be the case, when I am exposed to it, I tend to stay mum because I am also aware that were I or anyone to take umbrage, the jokester is likely to respoond in kind by, for example, questioning the listener's "lack of a sense of humor." This has happend to me more than once. A documented example comes from a medical columnist's effort to defend himself against attacks for using the term "crazies" when referring to those unfortunate people who are tortured by mental and emotional diseases. He raked his accusers over the proverbial coals for taking offense at a term not meant to be offensive and for having "no sense of homor."

Some healthcare providers and students are likely to see humor in events that shame or show disrespect for patients. For example, in my naivete, I was taken aback when I spoke to a nursing ethics class in which the students responded with peals of laughter at two actual cases presented for discussion, the first by me and the second by the instructor of the class. The instructor's case was of a nurse who stretched out an anethetized patient's penis and commented on its length and size as other nurses laughed about it. My example was of a nursing student invited to watch her anesthetized college professor being catheterized and commenting to her roommate while laughing, "There he was, just hanging there."

Each year, several nursing students go overseas to work in hospitals that cater to the poor. Cultural beliefs of the people dictate that boys be circumcised between the ages of 12 and 18. Some of the nursing students are allowed to perform the circumcisions. When they return to the states, they give presentations.

As one nursing student spoke, a picture of gowned adult participants incuding the surgeon and a little boy, discreetly covered and with an arm over his eyes, was projected on the wall. Her description, which follows, elicited peals of laughter from the mostly-nurse and nursing student audience.

"Most people would say that their most exciting experience . . . was in delivering babies. For me, I enjoyed circumcision the most (laughter from audience). I might sound cruel, but it was a lot of fun (laughter from audience). . . I really enjoyed suturing. That's what I like about it. . . I've got to find something where I can do some suturing (laughter from audience). There's a funny story that goes along with this. It's not exactly the caring process we've been taught (laughter from audience). But, the little boys are awake while this is going on but can't feel anything. Our little boy . . . he keeps moaning at everything we do. Even if he can't feel it, he's seeing it, so he's making all these moaning noises. So, when [the other nursing student] goes to make the cut, our surgeon friend just screams out so loud -- AH, like that -- and we just all start laughing so hard because he's kind of mocking this little boy. But after that, the little boy was quiet; he was fine (laughter from the audiene). And [the other nursing student] was afraid that she was going to ruin that part of his life (laughter from the audience). . . And all the doctors and nurses were, like, telling the little boys they were lucky because they were circumcised by an American female [laughter from audience)."

On and on and so forth and so forth, ad infinitum. -- Ray

how husbands feel said...

Here is a link to the latest updated file that contains over 1100 news articles and supporting docts. that show professionals who are unprofessional.

http://www.megaupload.com/?d=86UUBQY1

Joel ask me a question in another section of this blog, what do I intend to do with these articles? My answer would be to just share them with anyone who always gives you the "pat" answer he is a professional.

I would encourage and invite anyone here to come over to the how husbands feel group not to take away from this blog but to just read the stories posted by our members to gain insite into why others do not favor cross gender examinations.

Mike

Joel Sherman said...

This is somewhat off topic, but has come up here, Bernstein, and on Mike's comments re how husbands feel.

The following is an unofficial summary of how the California board deals with physicians who commit sexual offenses:

Over the past six years, 78 doctors lost or surrendered their licenses for sexual misconduct, with the board likely to terminate a doctor's practice for any violation that includes a forced act or more than one victim. The other 45 doctors disciplined kept their right to practice, most of them placed on long probations. Seven were given only public reprimands.

The full article can be read here and is also interesting.

Anonymous said...

Prostitutes call themselves
professionals as well!

Anonymous said...

Some additional items, google reporters in locker rooms, many of the female sports writers say they are just professionals as well and as such the male atheletes should not complain or protest, yet some of them are college students from the college paper entering male locker rooms at their college, one who complained about the treatment started her post with, I saw more ass in....than my past 19 years. So we have college students, 19 year olds, and "professionals" who comment on seeing ass......professional is an easy term to toss out there when it benefits you......would it suffice to allow a professional sanitation engineer come into the locker room when they are showering.......they seem to want to use the we are professionals when it fits and we are only human as an excuse...

Joel Sherman said...

I have seen several posts by women reporters trying to justify their presence in locker rooms by saying that they're professionals, just like women physicians. But I agree, women reporters can be 19 year old kids and unlike physicians, they are not legally bound to protect anyone’s privacy. Reporters talking about what they’ve seen are rare, but it happens and as far as I can tell they are never disciplined for it. They are not professionals in the sense that physicians are.
But it's the leagues that fail to protect player’s privacy. The women can't be held fully to blame for it. Most are trying to do their job.

Anonymous said...

A BERNSTEIN Modesty Blog poster recently added the URL to this story from 2004.

"A few weeks ago I had nursing assistant students in one of the level one hospitals in the city. Two of the students were assigned with an older female CNA. The student’s reported to me the inappropriate way the CNA was treating the patients. They told me all three of them went into a room where a 24-year-old male quadriplegic was resting. He had a trach in place and was unable to talk. They were there to give him a bed bath. After getting all of the supplies for the bed bath, the CNA proceeded to strip all of the covers away from the patient’s body. She also took off his hospital gown. There lay the patient fully awake and completely naked. The CNA then proceeded to take the patient’s genitalia into her hands and tells the students it may get hard because they were such young good looking females. As she is saying this she is inappropriately touching and moving his genitals. The students did not know what to say. They helped the CNA give him a bed bath. They wanted to cover him up so he would not get cold. This was the way they were taught to prevent embarrassment and hypothermia. The CNA did not allow them to do this and proceeded to give him a bed bath her way."

TOTALLY DISGUSTING!

I hope this blog's readers will not only protect themselves against such moments but also reach out to those patients they might encounter who are unable to protect themselves against abusive medical personnel.

WJB

Joel Sherman said...

Here's the link for the above story.
Quadriplegics need extensive urinary care and are used to being handled and exposed. They don't have any sensation from being handled but can get stimulated nonetheless through spinal reflexes. But I agree that this story as written is abusive. Hard to say anymore without full details.

Anonymous said...

When it comes to addressing modesty the medical community tends to accomdate females and tries to comfort, assure, or convince males. One of the biggies is of course we are all professionals here. One of my female inlaws recently started working at the local hospital. Her training to become a "professional" included a couple of hours oreientation and training once or twice a week for a month or two and issuing her a set of scrubs. She now "cares" for patients in the medsurg section including changing thier gowns, checking incisions and caths....a couple hours training and scrubs do not make a professional. She happens to be a great person....but how many are there just becasue of the job openings and aren't....the we are all professionals just doesn't cut it. It's another way of saying, it's easier for us if you just accept it

Joel Sherman said...

I'm not a medical historian, but it is well documented that traditionally people who cared for others were low down the social scale. There are historically a large number of Jewish physicians because in Europe centuries ago it was one of the jobs they were allowed to do. Of course it was dangerous as well exposing people to all kinds of health risks and plagues.
So the lower tier of health care providers is never very well trained or professional. If you work in a hospital you inevitably will occasionally come across exposed patients, whether you're a physician, cleaning lady or janitor.

Anonymous said...

I have long considered the issue of "professionalism" in medicine. While I certainly desire that medicine be considered a profession, and it should be, I am having difficulty accepting that it currently is.

When we consider double standards regarding male versus female modesty, draping and privacy concerns, the issue of opposite sex chaperones, female staff only at many facilities, female providers who won't themselves accept opposite gender care, how can I as a patient regard the medical community as professional? Added to this are the dismissive comments discussed here, and the imposing of sex based limits on male medical personnel in the treatment of female patients that are not reciprocated by the female staff when caring for male patients.

It all adds up to a huge amount of discrimination. Nobody benefits from this, certainly not the patients, the medical staff, and very importantly, the medical community as a whole.

Why is it so widespread when it is clearly wrong?

The essence of discrimination is the belief that a particular group is not worthy of the respect and value that the others take for granted. If male healthcare providers are held to limits and standards that their female counterparts are exempt from, and male patients are not allowed the comforts and protections that female patients have come to expect, how can the community that practices this be considered professional?

As I posted on the nurse forum, professionalism and discrimination cannot coexist.

Mike

Anonymous said...

Wow

That you Mike. As a male health care worker I see this
double standard issue everyday!It
makes me sick!
Why is this? Because of this
I HATE my job. At least it's one
of the reasons I hate my job. The
article you wrote needs to be sent everywhere. As a healthcare worker
I don't consider healthcare as a
profession when these double
standards exist.

PT

Prefer FM Care said...

I have a concern that my wife feels is ridiculous. She steadfastly adheres to the "we're professionals here" mantra without question. Prepareing for an upcoming testicular ultrasound I posed a question to her: "do you think techs, nurses and doctors talk among themselves about individual patients' endowment or lack thereof?" She of course said they don't because they are professionals and become numb to genitalia. I disagree, as I feel I understand human nature better than most as a police officer. My feeling is there are conversations after private exams that may go like "Janet, you should have seen the equipment on the guy I just examined, I've seen bigger on 12 year olds." followed by a good laugh. Or maybe "Bob, that girl had a huge set; she should pose for Playboy."

I would be interested to know if anyone from the medical profession would be brave enough to offer comment on this, and if conversations such as this occur, admit it to all of us patients.

Joel Sherman said...

FM care, if you read through all the threads here, especially Privacy Violations, you'll find plenty of concern about that. Some derives directly from allnurses blog forums. I personally think it is uncommon, and when it happens it tends to be with young nurses or students. Anyone who has been a nurse for years is not likely to pay much attention unless it is part of your medical condition.

prefer FM care said...

Joel,

I really can't say if "talking out of school" happens much or just occassionally. I do know that as a police officer, I have a lot of contact with EMTs and medics at accident scenes and the like and I know that they almost all "talk out of school." Most of the responders are female and I have heard comments about a male patient's "size" or lack thereof as well as "he's really good looking." They do not identify patients by name, but at gatherings, they will remenisce about memerabe calls and patients. Usually alcohol is involved at these gatherings. Unfortunately, many of these women have really bad home lives and seem to be sex starved. Many engage in extracurricular activities with the few male EMTs and medics there are. Many marriages have been destroyed by activities at the ambulance station in the wee hours of the night.

I just wonder how prevelant this practice is in hospital and doctor office settings.

I had a testicular ultrasound today and I certainly wouldn't want the tech (not that I think she would, she was very professional) talking to her girlfriends and comparing my equipment to others. But as hypocritical as it sounds, and I admit it is, I guess I wouldn't mind so much if the talk was complimentary. But just the same, I would rather they keep my "private" details private.

Anonymous said...

FM care,

As a police officer I worked for many years doing security at a level 1 trauma center. The female nurses it seemed were constantly making comments about the sexual parts of male patients. They even made comments about me, and I was dressed! The inappropriate behaviors lessed when I called them on it in various ways, but it still happened.

Answer this: Why was it that male medical personnel never, and I mean NEVER, made inappropriate comments about female patients at that hospital?

Could it be that men are more professional than women?

Mike

Joel Sherman said...

Well, ' we're all professional' but some are more professional than others. As you go from physicians to nurses to aides and EMT's the amount of training and presumably professionalism decreases. That's not meant to be an excuse; it's just the way it is.
I must point out that there is nothing illegal about anyone discussing their jobs, patients, and problems in general. What is against regulations and against the law in many states is identifying patients to others. This would normally be actionable in a court of law and a cause for dismissal.
Disrespectful chatter about even unidentified patients however is still very unprofessional. If you hear it, a complaint to the hospital or institution is still in order. I personally have never in my long career heard nurses speak disrespectfully about identified patients, but they probably wouldn't talk in front of me.

prefer FM care said...

Joel,

Your last sentence says it all, "they would probably not say things in front of me." Obviously, you are a doc and they are not stupid. I think I said in my post that I never heard anyone identify a patient by name, but it's pretty obvious when there is only one patient on a scene and I just got done interviewing him, I know who they are talking about.

I really haven't had much experience directly with nurses "behind the scenes" as Mike has, only as a caregiver for my Dad who has been hospitalized more times than I can count. I do know a couple of EMTs who also work at the local hospital as nurses aides and I would have to assume that they talk.

I agree with Mike though, I never hear males make the same kind of comments the females do, with one exception: there was a woman who would call 9-1-1 about once a week and have various medical complaints. When the ambulance would arrive, they would find her in bed with the covers pulled up and when asked what her chief complaint was, she would rip off the covers being totally naked underneath and point to her privates and say "It hurts here." The male EMTs would sometimes relate this story, but it was not in a sexual way, more like she has real problems. She was eventually dealt with by her family who moved her out f town and I assume obtained mental healh assistance for her.

Joel Sherman said...

FM prefer,
Talking about a patient in a setting that makes it clear whom you're talking about is equivalent to using a name. The violation is the same and reportable. It may be their talk was looser in front of you than others if they consider you a professional as a policeman. Don't know if you are bound by the same privacy rules as providers.
The comments about men are interesting. As I don't hear the women talk I wouldn't know if your observation is true, but I believe it. Men are much more likely to be charged with sexual misconduct or vulgar speech than women and may well be more guarded about what they say.

prefer FM care said...

Joel,

Amen about men being more likely to be charged with sexual misconduct. But if we get into all the topic areas where there is a double standard between the way women are treated as opposed to men in the workplace and society in general, we could go on forever. :-)

Anonymous said...

there is an intersting thread on allnurses go there and search rules for the ER
So real professionalism there, seems we should go to the ER and not inconvenience thems

Joel Sherman said...

The ER is a trying place to work. They're oriented to life threatening emergencies but spend much of their time being basically a walk-in clinic for the uninsured or indigent depending on the location of the hospital.
But the thread is not attractive to read as an outsider. That's for sure. I only got through a small part.

Anonymous said...

Here is a link to a Canadian site with a paper regarding care of female patients by male nurses. It's quite lengthy and I haven't read all of it, but it does address concerns of patient care by providers of the opposite sex that nurses in this country would do well to consider.
http://www.collectionscanada.gc.ca/obj/s4/f2/dsk3/ftp04/MQ56129.pdf

Mike

Anonymous said...

Joel, The link won't work in this form, it's cut off.
Copy and patse this into your browser..

http://www.collectionscanada.gc.ca/obj/s4/f2/dsk3/ftp04/MQ56129.pdf

Thanks,
Mike

Joel Sherman said...

Thanks Mike. The link works fine. This is a long paper which is the nurses master's thesis.
I will read it through. Academic works are great for this blog. I'm sure I'll have comments when I'm done.

Joel Sherman said...

I've posted a comment about Mike's article on the Equal Employment and Gender thread.

Anonymous said...

This post shows the attitudes of typical nurses at allnurses.com

http://allnurses.com/emergency-nursing/rules-er-long-170440.html

Unbelievable isn't it?

MER said...

Joel:

I'm not sure precisely where this post goes. But I'm posting it here because the expression "We're all professionals here" and others like it, seem to me an example of how power is used in medical situations.

I want to call attention to a book that covers much of what I’ve talked about in past entries regarding the sociological aspects of medicine, especially nursing.

The book is: "Sociology as Applied to Nursing and Health Care" by Mary Birchenall. It’s a British publication. As I’ve noted before, this topic along with that of patient modesty, seem to be covered more in Brittain, Canada and Austraila. Is just a coincidence that all these countries have a national health system? Perhaps. That’s a whole other topic.

The link I’m providing should take you to the section that discusses the use and abuse of power in medicine in general and nursing in particular. When you get to the link, go to Chapter 8 -- page 152, “Nurses, Clients and Power by Martin Johnson.” Later, I’ll give you another article by Johnson that is quite insightful regarding nursing and power.

I’m not suggesting that most nurses (or medical professionals, in general) abuse power. I’m pointing out that this issue is well known, discussed, debated, incorporated into training programs, etc. within the profession. It’s just not a subject that gets out into the general public. Most patients, although they feel this power dynamic, sense it intuitively, when they enter hospitals, have probably never really read much about it. It’s embedded within the hospital culture. It’s part of the “under the radar” rules of the road. After a while, either patients “get it” or don’t “get it.” If they “get it,” they either comply with the rules, negotiate, challenge them, and/or become “difficult” or "compliant" patients. If they never “get it,” life can become quite confusing and possibly miserable for them, unless they go along with what they don’t understand. Rarely, if ever, are patients every instructed in this dramaturgy. At best, they’re “guided” along by the doctors and nurses. They’ve got to figure it out for themselves. As the chapter I’ve given you points out, some nurses use their power to empower their patients. Others do not.

And, make no mistake – power is necessary for doctors and nurses in the healthcare system. But, power itself is neutral. It can be used positively or negatively. And medical professionals need to exert a certain amount of power over their clients to do what they have to do. It’s how they communicate that power, exert it, distribute it, delegate it, that makes the difference.

Here’s the link:

http://books.google.com/books?id=KwGzXROJP3wC&pg=PA168&lpg=PA168&dq=naked+intimate+exam+nurse&source=web&ots=_oqaHEPrXR&sig=J1Z-B_84ayy5Mc96fFpzmKy5FKQ&hl=en&ei=McmMSbbiOZmMsQPbj6mSCQ&sa=X&oi=book_result&resnum=10&ct=result

Joel Sherman said...

Thanks for the link, MER. Do you know if it is amplified further in the book or article?
I have trouble knowing where to go with the article though. Just as doctors have been accused of having a god complex, some nurses have a power complex. It's probably a part of human nature that some people react that way. The important part to know is that patients are not bound to accept it. You are always free to question and ask for explanation from the providers and nurses involved. They won't always be happy with that, because of ego and time considerations, but it is always proper to ask.

MER said...

Joel:

The book is quite comprehensive in dealing with the sociological aspects of medicine in general and nursing in particular. Yes, it does amplify more on the topic in other chapters.

I just posted a note on Dr. Bernstein's blog going into the historical/cultural aspects of how we have dealt with the body. You're welcome to put that post on here if you want.

My point in bringing this up is that power is just part of the dynamic in medicine. As the philosopher Foucault points out, knowledge is power, and patients can never really "know" what doctors and nurses "know" from a technical point of view. Of course, the reverse can be true, too. Medical professionals need to trust more what the patients "know" about their own condition and their own body.

But what makes medicine and the penal system different from other systems where "knowledge" represents power -- is that hospitals and prisons deal with the human body and spirit and a person's atonomy over that body and spirit. It's not just who "knows" what. It's a question of control and power over of the body.

This is the epistemological problem. How do we know what we know? What's the source? How can we be sure? In the past, the "doctor" as the possessor of the knowledge has been the rule. Foucault talks about the almost supernatural attitude toward the "medical gaze." (In his book The Birth of the Clinic). The doctor as the surveyer of the body and the mind. The doctor's "gaze" and his ability to come up with a medical solutions was almost considered magic.

Anyway, I talk more about this on my recent post on Dr. Bernstein's blog. But this is where I we need to go, I think, with this article. Power is part of the process. Patients need to willingly grant necessary body access to get the care that may be necessary. But how doctors/nurses get patients to do that is essential. They can use subtle force and intimidation and bullying -- justifying that by saying it was in the best interest of the patient.(Read William Carlos Williams wonderful short story, "The Use of Force." Williams was a doctor as well as a talented writer.) Fortunately, most medical professionals don't use those techniques.

We've all known people who have had power over us but made us feel empowered by the use of their power. We didn't feel smothered by their power, but freed by it. How did they do that? Good communication? Respect? Delegating that power? This is the direction, I believe, medicine is trying to move these days, ethically and philosophically. But like any system, medical systems are running into the power of inertia -- let's just keep things the same, do the same as usual. Let's look out for what's best for the system. Those two forces are clashing today.

Joel Sherman said...

MER, I have trouble summarizing thoughts on this topic. Many many situations include having power over people you deal with. -Not only providers and correction officers, but teachers and police. I'm sure there are many others. Obviously the dynamic for all these situations is different, but medicine is the only one where the relationship is completely voluntary and can be broken at any time. Providers can only act with the consent of the patients except perhaps in emergencies. Unlike prisoners no rights have been taken away or abridged. Even students have lost some significant rights and are subject to school regulations and restrictions. The major difference between the relationship between providers and students vis-a-vis prisoners is that the former is based on their specialized knowledge and ability to help. So yes, it's understandable that most patients feel at a disadvantage in health care situations. But the disadvantage is a lot less than it used to be for intelligent well prepared patients. The disadvantage becomes much greater when there is an emergency or the patient is very ill and there are not family or patient advocates to intervene.

MER said...

Joel:

This is not an easy subject to summarize. It’s complex. But – if you read those two articles I provided by Martin Johnson regarding power in medical situations, and you also look at his references, you can see that this is a recognized topic in healthcare -- and there is a sense that the medical power dynamic is quite different than others .

Power isn’t unique to medicine. But, as I mentioned in another entry, I believe it’s no accident that modern hospitals/clinics and prisons evolved at about the same time and with similar architectures and, frankly, similar philosophies regarding surveillance (observation). Prisons are what sociologists call “total institutions,” that is, they have total control over the person. In some hospital scenarios, that’s also the case – and a necessary situation. Consider ER’s and ICU’s, and being under the knife on the operating table. One turns oneself completely over to the institution. That’s about as “total” as any “total institution” can be. Nursing homes and LTC units can be that way, too. We don’t see that totality in education or business or other institutions. Totalitarian governments can be like that (1984), but democracies are not.

It’s been a few years since I read Michel Foucault. I got the books out again and skimmed through them. He’s not the easiest read. I do recommend his “The Birth of the Clinic: An Archaeology of Medical Perception” and his “Discipline and Punish: The Birth of the Prison.” He also wrote a multivolume series about “The History of Sexuality.” You see Foucault referenced often in articles about medicine and power. Jocelyn Lawler, in her “Behind the Screens” and her discussion of Western attitudes toward the body and what she calls somology references Foucault.

I think there’s a disconnect regarding what the healthcare system means when they say “The patient is in control” and the culture of the clinic and hospital. Medical professionals really believe that statement, I’m sure, but it’s not as clear and cut a statement as is assumed. I can say patients are in control, and then unconsciously create contexts and cultures and atmospheres where sick, vulnerable, naked patients don’t feel or sense that they are in control. And sometimes they can’t be in control. That’s just the reality of it. But there’s a line that can be crossed. Sometimes it’s just easier to operate the institution on one side of the line than on the other side – that is, it makes life easier for the staff if they are in control even when it may not be necessary to be in control from the patient’s point of view.

You write: “but medicine is the only one where the relationship is completely voluntary and can be broken and any time.” Although theoretically true, it’s a doctor’s (a system’s) point of view, not a patient’s. If a patient “needs” an operation or procedure or exam, that’s not voluntary. It’s a necessity. Theoretically the doctor/patient relationship can be broken any time, but it’s not so simple from a patient’s point of view. There’s trust relationships, insurance requirements, non insured patient expenses, travel, and the general lack of knowledge about medicine etc.

Also, I think we overlook that, although a patient may have a trust relationship with his personal doctor, once that patient is referred to a specialist and then gets into the hospital, the personal relationships are usually gone.

I think people who work in healthcare, in hospitals, day after day, week after week, year after year – don’t realize how intimidating hospitals can be to the uninitiated – unless they’ve been there themselves. Large hospitals can be intimidating institutions for psychological and spiritual reasons that are different than other large institutions like universities or even government buildings. It wasn’t more than a few generations ago when going to a hospital for many people meant going somewhere to die. Some people still feel that way. Frankly, for some people that’s the case, even though we don’t like to talk about it. Hospitals, more than any other institutions (except perhaps prisons), I think, are associated with loss of body autonomy and control, pain, suffering, death, etc. Existential questions come to the front when one’s in the hospital for serious reasons – Have I lived a good life? Is there life after death? If so, which way am I going? If not, what’s to become of me?

There's the other side, of course, especially with today's advances in medicine. Hospitals are also a place to go to get fixed, or even saved.

Another factor that’s related to this power dynamic that I don’t think gets enough discussion -- is the role/game playing dynamic. Now, social role and game playing applies to all aspects of society. We do it all the time not even realizing it. Most often we’re at least somewhat familiar with the script.

But this role playing has special significance in hospitals. Erving Goffman, in books like "The Presentation of Self in Everyday Life" (1959), writes about this. Since Goffman, other sociologists have written more specifically about this dramaturgy in medical situations.

What makes hospitals different is that frequently patients don’t know the rules of the game/role playing that happens. I’ve written about this in past volumes on Dr. Bernstein’s blog. Patients unfamiliar with hospitalization are thrown into this alien culture and then expected to play their part in a script that they’ve never even read. Quite often their role is a powerless one, at least from their perspective. Sometimes it’s just expected that they remain silent and passive. Frankly, sometimes that may be necessary. But not all the time.

Studies of embarrassment show that role playing disruption can have a significant influence in creating awkward situations, thus, embarrassment. For example, if the role playing scenario is known and expected, and one person breaks away from his or her expected role – depending upon the situation – the other member (or both) can become embarrassed. Let me give you an example that I think applies to what we’re talking about on this blog

A young female nurses, who is still dealing with comfort levels herself as far as caring for patients intimately, approaches a male patient just expecting to perform an intimate procedure. Her experience and training tells her than it’s okay because males don’t really care one way or another. They rarely refuse or even ask for a male nurse. The script that she’s following runes like this: I’ll introduce myself, explain what I’m going to do, I’ll be careful of privacy, and I’ll try to make the patient feel at ease, we probably won’t talk to each other much, He may be embarrassed but that’s okay, I'll pretend this is no big deal, that I do it everyday and I’m used to it, that should make him feel at ease, and I’ll work as quickly as I safely can to get this over with, and things will be okay.

She introduces herself, explains what she’s going to do – and the man does one of several things:

He says he wants a male nurse. That’s not part of the script. The nurse gets flustered and embarrassed and doesn’t really know how to respond, or she responds in ways like “We’re all professionals here,” “I’ve done this many times before,” This doesn’t seem to work as the man still wants a male nurses. The script is being disrupted.

The man wants to talk, asking questions like how old are you, how long have you been in nursing, where are you from – personal kinds of questions -- and the nurse doesn’t feel comfortable answering those kinds of questions within that context. The script is not being followed.

The man seems to enjoy the fact that a female nurses will be working on him. He makes some lewd remarks. Experienced nurses know how to deal with that, but it’s not part of the main script – it’s an alternative script. Inexperienced nurses may become embarrassed. This is often when a male nurse, if available, is brought in to deal with a sexual harassing male patient.

Now – if the patient picks up on the scenario, and begins to understand that his role is to just be quite, accept his embarrassment, follow the nurses conversational cues, don’t talk too much, etc. – things will probably go just fine – at least for the nurse, and may even for the man -- because that's what the script calls for.

So – I think this “The patient is in charge” mantra is often a myth in medicine. It’s the ideal. It happens in some places and in some situations. But most hospitals and medical situations are not designed to make patients feel they are in change. As I’ve said before, I think modern medicine has that as an ideal and is trying to move in that direction. But, overall, we have a long way to go.

Another example – I’ve often wondered about patients complaining about healthcare workers coming and going in and out of rooms, doors left open, drapes not pulled, knock on patient doors but then just walking in (or not even knocking). We all, hospitalized patients included, try to create some special boundary around us, a little piece of earth that is ours and can’t be trespassed without our permission. Our body is not only on the small piece of ground, but the body itself is our private domain. It's where we live. When a patient is in a hospital room (especially a private room), that patient assumes it’s his or her room. To the doctor or nurses or CNA or housekeeper, that room is just part of their work place. They work there 40-50-60 hours a week. They don’t associate that specific place with a specific patient. Patients come and go. Unless they look at things from the other side, they just assume that the patient understands this situation. Some patients eventually get it, Some accept it. Others don’t. It’s part of the hospital culture. “Private” space is often not recognized within hospitals. I’m not saying that doctors and nurses always disregard privacy. But the definition of “privacy” changes in the hospital culture. And it’s just expected that patients pick up on this, right away. Some do, some don't.

One other point – I think it essential that healthcare workers recognize this power imbalance, recognize that it’s different in hospitals than it is in most other institutions, and remind themselves every day that it is an important part of the patients viewpoint. There’s a real danger if doctors and nurses get so used to what they do that they just don’t recognized the existence of this important psychological element. They may not feel that they are holding all the cards, but the patients often do. The more I interview healthcare workers, the more I see that routinization is prevalent. They're so used to what they do that the sometimes don't even think about it anymore. "It's no big deal," makes sense to them, because it is no big deal to them any more.

There. Sorry for going on so long response. You’re right, Joel. This is not an easy topic to summarize or articulate.

Joel Sherman said...

MER, I still think that any similarities between a hospital and a prison are superficial. Really the comparison is somewhat offensive. I've seen a fair number of prisoners in hospitals, many of whom wanted to go there to get some relief from prison. You'll never find any patients preferring a prison.
Yes many patients feel intimidated in a hospital setting. But do you really think that there is a practical alternative? Many patients in hospitals have never been seriously ill before and have never even been hospitalized before. They are scared and upset. The unaccustomed indignities they may undergo that are often necessary don't help. They may feel comfortable with their own physician but not with strangers caring for them in a hospital. Most caregivers are understanding but TLC cannot be their priority. Seeing that patients get the proper care is always foremost.
The only real parallel between hospitals and prisons is that almost no one would choose either.

MER said...

Granted -- the differences between prisons and hospitals are significant, too. But I must say, you too use the analogy in paragraphs 3 and 4 of this thread.

Offensive? I can see why medical professionals might see the comparison that way. I'm not suggesting hospitals "are" like prisons and that medical personal treat patients like prisoners. If my words imply that, I regret it. I'm probably not doing a good job explaining this analogy. But I'm not make this stuff up. I've given some sources.

I'm just trying to get behind the title of this thread -- "We're all professionals here." What does that mean? What's behind a sentence like that? Or others like "If I've seen one I've seen it all" or "You've got nothing I haven't seen before."

Too often, I think, these are used as a way to end, not encourage communication or ease the patient's concerns. A job needs to be done, the schedule needs to be kept, a patient complains or challenges or is embarrasased, and these kinds of statements are used to shut down conversation and get on with the job.

These type of expressions are also used in other occupations. Off hand, I think of how teachers use these techniques -- and sometimes must when they have a class of 30 or 35 students. I can't read the voice tone from here as we discuss theory. That can make all the difference.

Perhaps this is why this topic is so sensitive. I'm having as much trouble articulating it as perhaps you are.

MER said...

Joel:

I was going to drop this topic, but your response suggested to me that perhaps American doctors and nurses haven't been exposed enough to these theories. I say "exposed enough" because I'm sure they're introduced to some of them as part of their academic curriculum, but whether and/or how it carries over into their practice is something else. Are these theories important?

I've been reading that book, "Sociology as Applied to Nursing & Healthcare." Here's a quote regarding Ervin Goffman's work. In writing about Goffman's theories, especially in "Asylums: essays on the social situation of mental patients and other inmates," and "Stigma: notes on the management of spoiled identity," the authors write:

"Goffman's original text should be essential reading for any nurse. It is not the most simple of books to read first time around but the introduction provides a sound overview of this thesis and the first chapter on the inmate world helps in developing an understanding of the impact of power in the caring services." (p. 148)

Granted, this quote is from a chapter called "The Social Interpretation of Deviance." That's the context. But the authors also go into role playing and Goffman's theory of "impression management" -- how we as humans are concerned with how others see us, thus we want to present ourselves in the best possible light. The author's write:

"...the person confronted in a hospital emergency admission bed will be playing the role of 'patient'. I doing so that person may be radically different in terms of her (or his) personality and behavior compared to what she was a few hours ago." p. 145.

Now, Goffman's theories can be pushed to the extreme -- experts like Erving Zeitlin and Anthony Giddens argue against some of Goffman's ideas.

But my point is that comparing what healthcare workers do to what happens in what sociologists call "total institutions" is a very valid analogy that is not only covered in books like the one I mention -- but also considered an important part of a medical education -- at least in Great Britain, where this book was published.

Joel Sherman said...

MER, I went back and looked at my first introductory post. Yes I did mention prisons, but only so as to contrast the professionalism of medical workers to correction officers. My point was that medical workers are sworn to protect the privacy of patients whereas correction officers (and reporters) are under no such legal obligation. I wasn't commenting at all on the power dynamics.
But I will try to get Sociology as Applied to Nursing & Healthcare if for no other reason than my daughter who is a professor of sociology would be impressed.

Joel Sherman said...

I have no real category for this topic, but I list it here as manufacturers representatives and vendors are clearly NOT professionals in a medical sense. Here's an interesting article which summarizes the poorly defined issues of vendors in the OR. It doesn't highlight privacy issues, referring to them in passing.

Anonymous said...

It is interesting to not that there is a very common thread through most of medicine. Privacy is most often linked to personal information i.e. identity, medical history, etc rather than personal bodily privacy...alan

MER said...

Alan:

You're right. I see very little effort in American medicine to delve into the meanings of "privacy" and "dignity" and "modesty," etc. There's a movement that could be called "transcultural" medicine, where different values of different cultures are taken into consideration. I have found a few good articles out of Britain that have grappled with the philosophical and sociological definitions of these words. I'll post the source of these articles in another later, if anyone's interested. Problem is, few people really seem interested in these foundational issues. Too many people just assume that everyone just undersrtands and agrees upon what these terms mean. I don't think they do agree. In fact, I think there's an abyss between how some in professional medicine defines some of these terms and how some patients define them.

Anonymous said...

Interesting article regarding vendor reps. Here is a better
example regarding non-hospital
employees entering the hospital.
Suppose an ambulance brings to
the ER a code patient. These 4 or
5 emts accompanying this patient
and additionally 4 or 5 fireman
who had nothing to do with this
patient at the scene but they just
have to show up at the er as well.
These fireman now know the name
of this patient and only add to the
lack of privacy to many er patients. Long after the code ends
I've seen these fireman still lingering in the er making cat calls at young 15 year old patients
being wheeled by on gourneys.
This is a gross hipaa violation
and only a matter of time before
this practice changes.

PT

Joel Sherman said...

There have been multiple comments about being a medical assistant. Perhaps the training is more than I thought. Here's a quote from a school that gives out certificates in 'medical assisting' and qualifies the students to take some tests in the field. I don't know if anything about this 'degree' is standardized from state to state. This quote is available online, but I won't identify the source as I don't have any permission.

This program will prepare and assist students in acquiring the basic knowledge and skills necessary to be hired into an entry-level position as a Medical Assistant. This program develops the student’s knowledge base and skills by providing a theoretical foundation and by developing the student’s ability to perform clinical as well as office and administrative procedures. Training is provided by a balance of lecture, lab, and clinical components.

The clinical area first introduces the student to the functioning of the body as a whole, then proceeds to the study of the anatomy, physiology, and pathology of each body system, and finally to the integration of the psychological, physiological, and nutritional needs of the patient. Clinical office skills and laboratory procedures are taught through a series of competency-based, hands-on courses.

The administrative area provides the student with the basic clerical knowledge and skills necessary to function in the medical office, using both manual and automated methods. In addition to providing a foundation in medical office procedures, students receive courses in medical billing and insurance, legal and ethical concepts as well as varied computer skills.

Hands-on practice and work experience is gained during an externship component. Graduates of this program are eligible to acquire entry-level positions as Medical Assistants working in physician’s offices, walk-in clinics, outpatient clinics, and hospitals as phlebotomists and as medical office workers.


Of interest to me is that many of their ads that I've seen in papers includes pictures of male medical assistants whom they are apparently trying to encourage to apply. Sounds like this is at least a two semester course for which they charge tuition. None of this may be applicable in other states.

Anonymous said...

There is an interesting thread running on allnurse right now. Seems a female nurse was doing her OB rotation and recieved permission to witness and film the birth of someone she worked with child. She then went on to her my space or face book and wrote a really graphic, unflatering, and unprofessional account. She was terminated by the school for doing so. There is arguments mainly supporting her termination from the program, however, there are also those who feel she was within her right under free speech, AND here is the kicker, some justified it with the we are human....now the problem here is you can't claim the high ground when expecting a patient to shed their modesty because the providers claim to be professional, then claim exemption from scrutiny for their actions under the claim of being just like everyone else. Obviously there is the issue of a HIPPA violation...but then even more grevious is the loss of trust in providers when something like this happens. Trust is earned not given, when one does this, and others defend them, the us vs them mentality comes out and the trust goes down...unfortunate for the 99% who are professionals...alan

Joel Sherman said...

Can you give a link to the thread, Alan, or at least the title? Was this nurse a student? Most regular nurses don't do rotations but have regular assignments. If she was a student and the patient wasn't identifiable, I don't think she should have been necessarily fired. But it is certainly a betrayal of trust. A mature nurse should certainly know better than to vent in public. If the patient was in any way identifiable, it is a gross violation and could merit a HIPAA complaint.
I got even more info on medical assistants from the school above. The students take a year's full time program of study or equivalent and cover some anatomy and physiology plus procedures and record keeping. The tuition is substantial, over $15000. So these are not casual career choices. They qualify to take a test in my state to become 'registered medical assistants' though there is no legal requirement to do so. I asked and found that very few men are in this program, but they have some more technically oriented medical career programs that do attract substantial guys. So these medical assistants are really trained and have significant professional standing (despite their low pay) but still anyone can be introduced as an assistant so you never know unless you specifically ask.

Anonymous said...

Where is the hypocracy regarding the female urologist? She does not complain about him refusing to let her treat him, (in fact by mentioning that she uses a female gynecologist, she is empathizing), she only complains about his rudeness about it. I did not see the word sexist being used anywhere either.

MER said...

Joel:

Let's not forget, that description you provided is written by a private for profit institution. That, of course, doesn't necessarily mean they're not doing a good job. But, unless there is some kind of accreditation in place, we don't really know whether they're actually doing or accomplishing what they say they are. Is there an accreditation for schools like that? I doubt it.

Also, these jobs are so task oriented, that I question how much time they really spend on psychology and ethics. Again, it depends upon the qualaity of the school. But remember, with issues like modesty, so much depends upon where the instructors are coming from, whether they perceive it as an important issue or not. And then how much value they attach to it. The topic should really be incorporated into everything they learn because it ultimately rests on patient dignity.

Two semesters is not really a long time for all that material. It sound good, although very idealistic. And let's remember, as far as I know, there are no real professional standards, national, or even statewide, for this title. I also wonder what educational level you have to posses before being accepted into the program. I've read that some of these med tech schools in Calif. don't even required a high school diploma.

I guess my point is, how do we tell the really good, ethical schools from the cheap, education mills? We sure can't tell just from how they describe their programs as part of a sales pitch.

Joel Sherman said...

Not sure what your point is anonymous. The title of Keagirl's thread is 'Sexism at its best'. That certainly means she thinks he's sexist. She does complain about his rudeness, though really abruptness is a better term. She asks have you ever heard of a woman doing that, but perhaps a better question is 'have you ever heard of a male physician complaining of it' as it has certainly happened. I think she is indeed sexist, but the subject has been covered already.
I have brought up the double standard to a few women physicians who have expressed their discomfort online at being seen by male physicians. Most have at least rethought about their stance. Keagirl has never replied to the objections on her thread.

Joel Sherman said...

MER, I didn't mean to imply that these women are well trained or sensitive to patients' needs. I wouldn't know.
My only point is that it was not a casual commitment on their part and almost certainly they're inclined to take their job seriously. They didn't spend the time and money to get a quick cheap thrill. Part of what keeps us 'professional' is the personal stake we have in the matter.

Anonymous said...

Sorry I am not very good with posting links etc. Google allnurses.forum, or allnurses.com and go to forums. in the search box at the top next to the allnurse search type in nurse blog lawsuit. you can then click on the topic and go to the start there are around 15 pages of comments...its interesting reading. The female urologist was definately calling the guy out as sexist but she failed to see the hypocracy in her actions and attitude

Anonymous said...

OK I saw the sexist in the heading later. But I think she is probably referring to the second incident where the male patient refuses to let her treat him because she is a woman and he thinks that women cannot be competent doctors. That is pure sexism. There is no mention that he has modesty issues. Don't you agree? As for your comment that female physicians are uncomfortable with male physicians, I also know that there are male gynecologists uncomfortable with seeing female urologists. So what is your point?

Joel Sherman said...

Anonymous, Keagirl doesn't differentiate between the two guys putting them under the same sexist heading. If the second guy said that he doesn't think women doctors are competent, that certainly qualifies as sexist. My main point however is that we all have some gender preferences in healthcare to a greater or lesser degree, and that there is nothing per se sexist about it. Some women readily accuse men of being sexist, but don't see it in themselves. Keagirl says she always sees female gynecologists, that is her right, but it is the same attitude that the first guy had whom she accused of being sexist for the same attitude.

Anonymous said...

Responding to Dr Sherman's post about medical assistants of 4/13/09. This largely mirrors the info I got when I looked into the medical assistant program after my run-in with a medical assistant in a urologist's clinic in 1995. At that time a local career institute offered a MA program and I went there to inquire about the program pretending to be a potential student looking for a medical career after my retirement from law enforcement. The program was 6 months long with 4 months spent doing the clinical and admin studies. Then it was another 2 months as an intern, basically volunteering for free at a local doctors office in the role of an MA. The program cost about $9000 and then a new grad could expect a salary of $8 to $10 an hour. Remember this was 1995. Seemed to me to be awfully expensive training to only make that salary.

In poking around online it appears that MA programs vary widely in cost and volume of study. I know there are associate degree programs in medical assisting and I am left to wonder why anyone would invest that amount of time and expense when for the same effort they could get an RN or at least an LPN license. But then one has to remember that a school is in the business of selling a product like any other enterprise. In my state (Florida) an MA is not licensed and the MA statute, as of the last time I read it, still does not specify what amount or type of training that an MA has to have. They are not regarded as healthcare professionals and are lumped into the same category as UAPs- unlicensed assistive personnel. In my personal experience with MAs, I have met some who were top notch and some who were absolute idiots. I am sure most doctor's offices would prefer to hire an MA who had some formal training but there are many MAs working who have had no training at all. Scary to think they are allowed to do intimate care on patients of the opposite sex, well at least the women are, and unchaperoned at that. Then they want to call themselves nurses.

Mike (58flyer)

Joel Sherman said...

I have refused a comment by PT in which he doubted that Keagirl is really a urologist. He said the same thing about Dr Alex above, which I also deleted but not in time. Despite his doubts, both women are very real and active physicians. Keagirl has in fact been interviewed by an independent reporter who published the story, keeping her anonymity. I'm sure you can find it online if you search.
Comments like these are detrimental to getting active involvement by professionals on boards and are counterproductive.

MER said...

Someone pointed out this ad to me, from a newspaper not far from where I live for a Medical Assistant. The job is for "patient screening and support services," which include taking vitals and "basic" tasks like assisting with patient exams (pretty broad description), minor surgery procedures (again, broad description), EKG's, etc.

Qualifications -- High School Diploma OR a GED. The ad said they would prefer an experienced Medical Assistant and/or one those who had completed training programs. But the ad ended with this: "Willing to consider a trainee."

A "trainee?" What does that mean? Someone off the street? That's the implication.

It seems that this clinic wants an experienced, trained Medical Assistant, but if they can't find one, they're willing to pretty much hire anyone who can pass a criminal background check. With the shortage of healthcare workers today, this is what's happening.

Thus, in this case you could be faced with a 17-year-old girl (the odds are great that the hire will be female) fresh out of high school with no training who is assisting with your physical exam or with your minor surgery.

This ad does not give me any confidence in the position of Medical Assistant. So -- when you go to a clinic and faced with a Medical Assistant who is only taking your vitals, how do you even know what kind of training that person has had?

Anonymous said...

MER
I don't mind them doing the vitals part, but boy I sure get riled when they want to do apre-doc exam to tell the doctor what????? I am not going to show where I hurt when it is in my privates..hurt finger ok...but with no real training I don't know what her inspecting anything is of any value.
I did not choose a male PCP so a female with any kind of training canbe my provider( I don;t care if she were to be a PA-C RN)
leemac

Anonymous said...

I would have to agree that the term "proffesional" is a bit watered down. In my state CNA's are eligible to work at both nursing homes and hospitals, giving basic, yet very intimate care. The standard for these "proffesionals" is fairly low, a three week certification course. One does not need a high school diploma or an GED, I know many 16 year olds who work as CNA's. So my question is how much weight does the term "proffesional" carry when the "proffessiona;" is a 16 year old high school kid who two months ago worked at the local burger king. Did that three week course make them "proffesional"? I think not.

Ajak

Joel Sherman said...

There is no doubt that medical assistants can be anything. In some states CNA's have had some significant training; in other states not.
Few of us would want 16 year old kids (though usually they are at least 18) doing anything significant for us including intimate care.
Unfortunately it is hard to get really trained medical assistants. Some hospitals may be able to meet higher standards by training their employees but many doctors offices will hire anyone they can get. The pay is low.

Anonymous said...

"The pay is low."

So is my trust, patience and respect for them.

I couldn't agree more Ajak.

(Thanks again for this blog Dr. Sherman.)

MER said...

Do any of you read the comics regularly? You may have noticed the Blonde strip from around June 15 or 16. Dagwood is in a doctor's office sitting on the exam table in his boxers and t-shirt. A nurse comes in. "When is the doctor going to come? I'm freezing," he says. The nurse replies: "Well, put some clothes on." Dagwood says: "But you told me to strip down to my shorts." The nurse replies: "For heaven's sake. When are you going to stop letting women boss you around?"

Though probably quite innocently written and fitting quite well into Dagwood's character -- I thought the comic quite telling.

Joel Sherman said...

Very cute strip MER. It can be found here.
Blondie has been around for 75 years. I read it as a kid. He was always a henpecked husband, though apparently not as much now.
But that strip does catch the spirit of many male encounters with medicine very well.

MER said...

Joel:

A recent cartoon by Harry Bliss shows a man sitting in a doctor's waiting room. A female receptionist says to him: "The doctor's nurse's nurse practitioner will see you now."
Although it isn't stated, it's pretty clear what gender the man will be seeing.

Another cartoon, I think, that highlights medicine today -- Males confronted with females in charge.

You may want to start a humor thread -- not that modesty violations are funny. But cartoons demonstrate cultural attitudes and stereotypes quite well.

Joel Sherman said...

That would be fun MER. If we can come up with a few more examples I'd do it. Don't really know how much medical humor focuses on modesty or privacy issues.
I'm not familiar with Harry Bliss, but I don't think gender was the point of it. I believe the cartoon was trying to highlight the fact that the provider was several steps away from being a physician. They got it wrong though. The physician could have a nurse practitioner who could have a nurse of her own. But a nurse wouldn't have a NP under her supervision.

Luke said...

I was reading JD's comments about the group of young nurses talking and laughing about their patients.
It raises the question...when do they step over the line? Certainly, if they identified the patient by name or made him identifiable to others.
I have a twist on that...
As a young Uni student we frequently dined at a friend's home.
My friend's father was a gynecologist and he never failed to have a few rude jokes for us...most quite blue and he'd make crude comments about any attractive young woman who appeared on the television.

Of course, once you clock off, surely, you're free to do as you please...go to a strip club or sex shop.
BUT...Every one of us felt very uncomfortable listening to this man.
I suppose it was an indication to us that he viewed women as objects or disrespectfully.
It was also the constancy of this conduct that made us squirm.
Perhaps, it's just that we like to disassociate maleness with male gynecologists because of the intimate access they have to women.
Was he suppressing lasciviousness all day? Or, using his work as an outlet?
It certainly stirred up lots of emotions in us and we all warned the women in our families to avoid him at all costs.
Is it unprofessional for a male gynecologist to make dirty jobs at the expense of women? Clearly, yes...at work.
What about elsewhere?

Joel Sherman said...

Luke,
You would certainly think a gynecologist would avoid crude sexist jokes. At least I gather he told no jokes about patients.
Was this a long time ago as that sort of talk was more common then? When I was in training that kind of talk among surgeons was particularly common. Many may have picked it up during war time service. I think it occurs much less now though data is impossible to come by.

Luke said...

This was about 15 years ago.
He didn't actually refer to patients but did say some fairly ordinary things.
One night we were all watching the television and he commented on the young female actress, "I'd love to get her in the stirrups"...every man (and there were only men in the room) froze at that comment.
I don't believe male doctors are any less male than the rest of us.
I've always assumed their training means they don't act on any impulses and never let the patient know what they're thinking.
To be professional and clinical at all times.
I've never believed that male doctors "don't notice" or are "asexual" during working hours.
As a male, I know that is impossible.
I assume if a man went into that area for lascivious reasons, (along with other reasons) as long as it remained in his head, there would be no problem.
I know my exposure to that man has colored my view of male doctors.
Perhaps, quite unfairly.

Joel Sherman said...

Luke, all physicians, both men AND women, have to learn how to deal with their own feelings during intimate exams. The large majority do it successfully.
As I've said, I've heard other male docs make inappropriate comments, though most were years ago. Haven't heard it done in front of lay people.
I'm sure if I was 'one of the girls,' I'd have heard some women doing it too.

Anonymous said...

It's very common with women too, especially nurses. I will never believe that ANY medical person, male or female is completely gender neutral.

Sophie said...

"When I was in training that kind of talk among surgeons was particularly common. Many may have picked it up during war time service."

I wonder whether things have changed...
Perhaps, these men realize women now have a choice of doctor so that sort of talk might have economic consequences.
Or, doctors are no longer considered Gods, so someone might just report that sort of conduct.
What other explanations might there be?

Joel Sherman said...

All kinds of explanations, Sophie.
Society has changed since then and everyone's consciousness has been raised.
Sexist comments were common then but are universally frowned on now, at least in a business or professional setting. Forty years ago, it was common to for example give a passing nurse a poke in the ribs. Few thought anything of it. But it could be considered harassment today.

MER said...

Part 1

On Dr. Bernstein's blog, someone reprinted an analogy about a custodian cleaning a woman's bathroom and shower, as an example of professional access to naked people. The focus was on the double standard. Dr. Bernstein responded: "Custodians are not given license, permission by society, to routinely intrude upon a person when they are undressed as part of their "professional" work. ..Maurice."
I responded: Although I agree with your basic premise, I think you've oversimplified this.
1. It was another world when that "license" and "permission" was granted doctors by society. Permissions like that need to be rediscussed and renewed. Note that I say "doctors." In the last 30-40 years, many other medical jobs have been created -- all kinds of nurse assistants and technicians that require what might be considered non professional training people complete access to he most intimate exams and procedures. And frankly, these positions are now doing many of the intimate procedures (or assisting with them) that doctors and nurses did and assisted with in the past. Are these nurse assistants and techs professionals? Do they have the same "professional" status that you do, Doctor? I say, no. Have they been granted the same license and permissions that doctors and nurses have been granted by society? HAve these questions even been discussed and debated with patients at the table? Obviously, not.
2. The entire definition of "professional" has changed in the last several decades. Everyone is a "professional." Plumbers, electricians, carpenters consider themselves "Professionals" by one aspect of the definition. And, frankly, some of these so-called "professions" go through mnore rigorous training that do some nurse assistants (cna's). Granted, there is still the concept of a "profession" and those characteristics that attach themselves to such a calling. But more and more these other "professions" are adopting some of those same characteristics.
3. I'll give you an example. A significant number of female OB-GYN will accept a male doctor but not a male nurse. Why? Does it have something to do with the concept of "profession" in the patient's minds? Is it that they have been socialized to accept male doctors but not male nurses? Many male nurses, though accepting this attitude, don't understand why a male is accepted in on sense but not in another. I suggest it's connected to the idea of a "professional." Continued...

MER said...

Part 2

4. Professions face their shortcomings, discuss,debate and try to improve. We see that kind of professional attitude on this and Dr. Sherman's blog. To some extent we see this on allnurses.com, though they find some topics more uncomfortable than others because nursing is so female dominated. Someone, show me a medical tech or cna site where these issues are discussed as they are here. You won't find one. Why? These occupations are not professions. They are jobs.
5. The custom in many hospitals now is for almost everyone to wear scrubs. What do scrubs represent? Among other things, they stand for access. If you're wearing scrubs (and in some hospitals custodians and housekeepers wear scrubs), a patient can't tell you from a doctor or nurse. Who's who? It's not uncommon at all for these same people wearing scrubs not to wear name tags. I've heard doctors and nurses tell me sometimes they don't know who's who in these large hospitals. And, if you're wearing scrubs, you can go almost anywhere.
6. This "license" and "permission" oiginally extended to doctors and nurses. Now it seems to be extended to the hospital itself, anyone in the hospital, anytime, anywhere -- depending, of course, on how savvy and considerate any individual hospital is regarding patient dignity. It will vary. But the true "medical profession," which I consider to include doctors and nurse, cannot just assume that this license extends to everyone associated with what they do for patients, especially these intimate, embarrassing procedures.
That's why I've pushed for written polices regarding patient requests for specific gender care. The medical profession had better start discussing this question seriously or polices will be forced upon them through legislation.
So, although the custodian analogy has many problems -- it's trying to tell the medical profession some important attitudes held by many patients about what they consider professional and nonprofessional access to their bodies. The profession had better start listening.

Joel Sherman said...

I agree with your comments fully, MER. Physicians and nurses are professionals in the sense that they have trained for years, met standards of tests, and have an ethical code of conduct to uphold. They are also sworn to maintain patient privacy. Importantly they have an investment and a license which they can lose for unprofessional conduct.
Although some of that applies to techs and nursing assistants, it is much less true. CNA's in most states have to meet some standards but their training is highly variable and may be 6 months or less. Uncertified medical assistants can be anything. They could be just out of high school and have been working in a doctor's office for only a few weeks.
At one time, all the functions of assistants were done by nurses. That's not going to happen again with the present structure of health care in this country. So it's up to each patient to decide how much care they will accept from assistants, especially for intimate care. And you're right, most of the time a patient has to ask to find out what the title of any caregiver is in most hospitals. None of this should be interpreted as meaning that I don't trust all medical assistants. Most assistants in hospitals are quite good, but it varies. The most suspect assistants are found in physicians' offices.

MER said...

We agree, Joel. My sense is that patients under hospital care take in, mostly subconsciously, the whole picture, the entire ambiance of the medical culture around them. This sense either makes them feel at ease and safe and respected, or uncertain, or not safe and respected. This feeling then may determine how they react to care. Most, as we've said, will say nothing, won't complain. They're afraid complaints may affect their care. Those who do speak are often considered "bad" patients. Now, the whole issue of opposite gender care, by both men and women, has a lot to do with whether the patient feels safe, comfortable, respected. My sense is that those who do feel that way, and are approached positively and with empathy, will be more open to this.
Do hospitals hire people to give them feedback on the holistic experience? Everything from the receptionist to when you're wheeled out out the hospital after surgery. It would seem productive to have that kind of feedback because much depends upon how patients see the context of what's happening to them.

Joel Sherman said...

MER asked: Do hospitals hire people to give them feedback on the holistic experience? Everything from the receptionist to when you're wheeled out out the hospital after surgery. It would seem productive to have that kind of feedback because much depends upon how patients see the context of what's happening to them.

No rule MER, but I would think most hospitals nowadays do ask for feedback when patients leave. I think there is a mandate to show level of patient satisfaction, though I'm not sure if it's state, Federal, or JCAHO.

Anonymous said...

“We’re all professionals here”

That's the biggest joke. I will never consider a CNA or an MA professionals, and very few nurses deserve to be called that. Doctors are the only professionals in my eyes. Everyone else is just a "helper" that may or may not know what they're doing. I don't trust the opinion of anyone that's not a doctor.

Joel Sherman said...

It occurs to me that it would be a good idea to define just how professional the various classes of providers are. In descending order:
Physicians spend four years post their bachelor’s degree in medical school and then do another 1 to eight years of training depending on specialty. Nearly all take further training of 2 years or more. At every step there are usually national exams to be passed. Most have had extensive clinical experience when they start out on their own in practice.
Nurse practitioners spend 4 years in nursing school receiving a bachelor’s degree and then continue on in a post graduate program which may be either on a master’s or doctoral level. Their actual practice privileges vary from state to state but may include a fully independent practice or be under the supervision of a physician.
Physician’s assistants programs may vary from state to state. Locally it is a 2 year post graduate program leading to a master’s degree in health sciences. PA’s are not independent practitioners and practice under the aegis of a physician.
Registered nurses take a four year undergraduate program in nursing. There are national exams to be passed. RN’s have no independent practice.
CNAs or certified nurse assistants vary greatly from state to state. Some states may have no licensing requirements for them. They generally have a high school diploma and then take a course usually at a private institute whose curricula may vary greatly. The training can vary from one to 6-12 months, rarely more. They usually work under a nurse doing specified patient care.
Medical assistants can be anything. They need have no prior education or training and are unlicensed. Most work in private offices and do assigned tasks. Many hospitals won’t hire them, or if they do, they have a training protocol similar to what a CNA would take which they have to pass prior to starting work.
There are of course other jobs such as medical technicians who are usually trained in a specific field such as radiology and ultrasound and are licensed to do tests in their field. They vary too much to really categorize. Other jobs include orderlies and transport aides who are trained on the job.

Anonymous said...

Joel:

In your last post, you establish a hierarchy, but you don't address the question -- What constitutes a "professional?" At what point in this hierarchy do we draw the line? It seems to me that characteristics of a professional include years of education, significant autonomy, certification and/or license, status within the culture, etc. These fit quite clearly with doctors and mostly clearly with nurses. It is less clear if not untrue for CNA's and med techs.

On another post, maybe on Bernstein's blog, I wrote about the various uses of the word "professional." I contend that the word has essentially lost its meaning today -- it's too vague. Look in the newspaper or in magazines at "professional" advertising directories. They include everyone from doctors and lawyers to plumbers and carpet cleaners. Everyone considers him/herself to be a professional -- meaning I do this for money and I am honest and ethical.
If we all agree that doctors are professionals, does everyone who works for them deserve the same title? Same with nurses -- if we agree that nurses, especially those with 4-year degrees, are professionals -- do the CNA's and med techs who work for them deserve that designation?
I say, no. The problem, I think, is that many doctors and nurses just assume that people who work for them have attached to them an aegis of professionalism just because they are employed by a professional. Some patients make no distinction. Others do. Frankly, I don't see the logic or ethics in a medical professional's right to reassign the title "professional" to anyone who happens to be in their employ -- especially within the context of this discussion, that is, having access to the most personal aspects of a human being's body.
I believe it's quite valid to believe that a med tech and/or a CNA is not a medical professional and at the same time have respect for that individual as a person.
A little side note -- I've noticed that, when I ask most cna's what they do, rather than say they are a cna, they respond that they work in the "nursing" area or in that department. I've even found accounts of the nursing department suggesting to cna's that this is how they should describe themselves. CNA's will often/sometimes not identify themselves when they come to a patient to do a procedure -- or, if a nurse arrives with a CNA to work on a patient, the nurse will often/sometimes just introduce the CNA as the person who will be working with her/him. Sometimes/often they'll be no name tag and both will be in scrubs -- so the patient will not know who is who. In a doctor's office, an uninformed patient may think he or she is dealing with a nurse, it is most likely a medical assistant. Sometimes they're identified a such, sometimes they're not.

There seems to be a conscious or subconscious attempt to professionalize these nurse assistants, move them up the professional hierarchy, at least superficially -- to make it easier to work with patients.
I don't think most patients mind a cna or med tech taking my vitals and doing basic things like that. Some patients want to know the title of who's working with them. It's the more personal procedures that may cause problems with some patients.
MER

Joel Sherman said...

MER, I think I've reviewed the elements of professionalism in this thread before, but I agree with your criteria. Ultimately, what keeps people beholden to maintain certain standards? I believe it relates to the investment and stake they have in their position. A physician who has invested literally hundreds of thousands of dollars and a decade of life to achieve their present status, is not likely to do anything that jeopardizes it. That of course doesn't mean it doesn't happen; it just makes it uncommon. As you go down the line, less is required and the investment and stake are more easily forgotten or ignored. I don't know what the general public thinks of CNAs and MAs, but I have certainly never considered them professionals. Many are quite dedicated though.
I disagree with you only about medical technicians, many of whom really are professional in the sense that they have spent 6 months to 2 years taking courses and exams, and are fully licensed by their state or by their respective societies. But it's hard to generalize as all kinds of people can be called technicians. An ultrasound technician has probably had a year or two of training and passed exams. An ECG technician may have had a week of training on the job.

Anonymous said...

I believe only doctors are professionals. Everyone else is just an assistant. I don't care who takes my vitals as long as they know what they're doing, but I draw the line when the pants come off. I can accept a non-professional like a MALE nurse or tech seeing me in my boxers or less if it's really necessary, but I don't allow any females in the room, no matter how "professional" they claim to be. I don't care how many naked men they've seen or how many months they studied at the community college. I consider it a major insult if any woman feels ENTITLED to my body (except my wife) and I'm not afraid to tell them so.

Anonymous said...

As we have seen on this blog and other blogs the guidelines for the use of chaperones present for procedures and examination. They usually state try always to use chaperones the same sex as patient and we all know what the outcome of that is for a male. Also many guidelines suggest to use a nurse or a nurse assistant first. The guidelines also suggest it is OKAY to use a clerical employee to witness full nudity of same/opposite sex patients during exams if staffing is limited. This clerical employee could be from a temp service which many doctors do use such agencies. So my question is, IS THAT TEMP SERVICE EMPLOYYEE A MEDICAL PROFFENSIONAL? I would have to say no. Art Stump is a classic example of "WE ARE ALL PROFFESIONAL HERE" was that teenage high school senior a medical professional?

Daniel....

Joel Sherman said...

This is an ad for an online program to become a CNA. It does give some details about the job and responsibilities.
I further find the ad interesting for the many grammatical errors and unclear writing. I hope their 'graduates' are more professional than the writer of this ad.

Joel Sherman said...

Here's an interesting thread on Allnurses started by a nursing student who was upset that their school wanted the students to practice bed baths on each other. A large number of comments supported the practice saying that it's better that they use themselves for practice rather than patients and that they should know how patients feel.

Anonymous said...

A very interesting comment on an allnurse thread.

"This thread is a great reminder to think about how we deal with patients. It's so easy over time to get your standard phrases and responses that you use, that just roll off your tongue without even thinking about it. There are so many things I would do differently since having my mother go through terminal cancer. .. it's quite astonishing how rare it is to find a good nurse when you're on the patient/family side. The things that make someone a "good nurse" when you're sick aren't necessarily the same things you think when you're a nurse with no experience on the other side."

We've talked about these kinds of pat phrases used with modesty issues -- "We're all professionals, etc." Although there's nothing about modesty on this thread, you will see it demonstrated that nurses --
1. Do learn from personal experiences as a patient.
2. Are aware that some of the phrases they use may not be appropriate.
3. As a group are sensitive to how their patients feel.

Done correctly and civilly, it might work on occasion to remind them of this if they use one of those phrases on you. Of course, it depends upon the nurses tone and your tone as to how successful this interaction could be.

You can read this thread at:
http://allnurses.com/general-nursing-discussion/nursey-things-youll-456279.html
MER

Anonymous said...

Here's a fascinating article in the NYT called "When the Nurse is a Bully." Bullying is an issue in nursing and the profession is trying to address it. Most of you know my positive attitude toward nurses in general, so do realize I'm not suggesting most nurses are bullies. But those few cause many problems in the profession. What's interesting about this article are the comments following it. Several responders talk about bully nurses who also bully patients. That's a topic that isn't so much considered -- but bullies are bullies, in any profession. And to think that a nurse, who bullies other nurses, won't use that same strategy for power and control with patients, I think is to be naive.
Is nurse bullying connected to modesty issues, esp. male modesty issues? You bet.
Here's the link:

http://well.blogs.nytimes.com/2010/02/11/when-the-nurse-is-a-bully/#comment-496601
MER

Anonymous said...

I have been quite a fan of these blogs for some time, I check them daily. I must admit though, they make my blood boil. As a person who avoided medical care for 12 years after the way I was treated, this stuff does nothing to restore my confidence in "medical professionals.
My father in law works at a large hospital nearby. He said what few nurses they have are paper pushers and the aids/assistants do all the work. The hospital recently had to stop allowing the longer stay patients to bring in personal items to make their room more familiar. THE MEDICAL AIDS WERE STEALING THE PATIENT'S BELONGINGS! True professionals.

Anyway, I noticed a new school going in on my way to work, turns out it was a Medical Assistant School. I looked it up on the internet and I KID YOU NOT, the slogan under its name on the home page is "No High School, no G.E.D, no problem".
I was shocked, but not completely surprised. These are PROFESSIONALS indeed.
Mike B

Joel Sherman said...

It's not really a surprise Mike. Medical assisting is about the lowest rung on the medical ladder. CNA's are medical assistants who usually have completed a state certified course of instruction and passed an exam (though it varies by state). Medical assistants can be anyone, though I'm a little surprised that they don't even insist on a high school diploma. Many doctors' offices have so much trouble finding help that they will hire anyone, give them a week or two on the job training, and call them a medical assistant. They pay them very little and can't attract a better quality applicant.
I recently had a urology appointment. The girl took my blood pressure and used ultrasound to check for residual urine (no exposure required). She asked me if my BP was usually so low (she didn't know I was a doctor yet). I explained to her that it was low because she was taking my BP improperly, holding my arm at shoulder level. Before all this started I asked her if she was a nurse and she said she was an assistant. I recommend that patients always ask if it's not clear what the status of the personnel is. Then you can decide for yourself what level of care you're getting. In my case, the assistant was not a problem. After these preliminaries the doctor came in by himself.

Anonymous said...

I agree with you that the pay is commensurate with the training, (low) and in most cases this is OK. I would actually expect the more remidial jobs to be handled by an "aid" of sorts to free up the nurses to handle more important tasks. I am not at all surprised they get what they pay for, and fully agree assistants have their place in the system. This situation works well as long as the assistants are confined to the appropriate responsibilities. From what I hear, this is not the case. What really bothers me about it all is my father in law's observation that the assistants are being pushed into arenas way beyond their scope. They are being implemented in areas of patient care, which I believe they have no business. He said with all the new regulations and staff cutbacks nurses spend more time documentating and record keeping than care. I am not an expert in this field, but perhaps HIPPA or some other regulation forbids the assistants from performing this role. Surely the nurses talents could be better utilized. Recently he said they were starting to use the assistants to disperse certain meds. I see the role of the assistant only expanding out of necessity, but I really doubt the training and quality of applicant will grow as well. That worries me.

Thanks for all your work on these blogs, I believe the discussion of these issues is long overdue.
Mike B

Joel Sherman said...

I have been asked the following by email and will respond here:

I am curious about your stance on medical provider modesty?
I ask this question because sometimes nursing or midwifery students are required to perform intimate exams on their fellow students as a learning tool--and to submit to having these exams performed on them. Is this something that MD students do as well? I would think not.


I really cannot fully answer that as I haven't been a medical student for 40 years and I'm sure practice varies from school to school. When I was a student we did listen to each others chests but did no intimate exams on each other. Students were 90% men in those days and the few women weren't part of this. I once was 'volunteered' as a subject for an abdominal exam in front of the class. Again, there was no intimate exposure. It wasn't a big deal.
I doubt that schools have students do intimate exams on each other, but I can't tell you that it doesn't happen somewhere.

Knitted_in_the_Womb said...

Thank you for posting my question about medical providers in training doing intimate exams on each other.

I actually was attending a midwifery training where the participants were asked to perform pelvic exams on each other. I was in shock--that was NOT in the course description. I begged out of being examined with the (true) excuse that my cycle had just started. But I was still expected to examine my fellow classmates, which I was extremely uncomfortable with. I've been a birth assistant (doula) for nearly 10 years, so I can assure you it was not a discomfort with seeing a naked woman--I've seen that plenty of times, and gotten past being embarrassed by it. But I was acutely embarrassed as my fellow students--two at a time--lay down side by side naked from the waist down. I had expected that at the very least that there would be privacy where the woman being examined would only be exposed to the instructor and the student examining her--not that the whole class would stand around watching.

To me, listening to heart beat, taking BP, even doing blood draws on fellow students is no big deal. I actually did the heart beat and BP measurements as part of my undergrad during my labs for Human Physiology.

The pelvic exams is my question. I understand that when you were in school it was mostly a male student population, so that would not be a possibility. But I'm assuming based on your response that you did not do prostate exams on fellow students in order to "learn?" That would be the closest equivalent you would have had to pelvic exams.

If medical students are indeed not performing pelvic (or prostrate) exams on each other...I think that is instructive regarding the question of whether the "we're professionals" argument is a valid justification for denying modesty concerns in patients.

Anonymous said...

Knitted_in_the_Womb wrote:
"I had expected that at the very least that there would be privacy where the woman being examined would only be exposed to the instructor and the student examining her--not that the whole class would stand around watching."

For me, that's the key to your post. We can debate whether medical students should do intimate exams on each other. Valid points can be made on either side. But, if a medical school decides it will be done, the very least it should be done using procedures and polices that demonstrate the protection of patient modesty. Teach by example. What you describe shows how they teach disregard of patient modesty by example. That's the key.
MER/Doug

Doug Capra said...

More evidence for what I consider the "deprofessionalization" of some medical care in this country comes from this story from Minnesota.

Article: "Minnesota OKs Care Jobs for Former Criminals"
Dec 12, 2011 by Brad Schrade and Glenn Howatt.

It's all about money. As the baby boomer generation gets older and moves into nursing homes, there will be a great demand for aides and other minimally trained personnel. They're cheaper.

You'll find the article here:
http://www.hispanicbusiness.com/news/2011/12/12/minnesota_oks_care_jobs_for_former.htm

Joel Sherman MD said...

That is a startling article Doug. I hope it isn't routine in other states. I don't think that ex-cons should be barred from all jobs, but they certainly need to have intensive monitoring of them if they are put into positions dealing with vulnerable people.
The fact that they have been placed without followup and been responsible for abuses of the elderly and helpless is inexcusable.

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