Sunday, December 7, 2014

Eric Garner: a Comedy of Errors...

I have not weighed in on any of the "black men killed by white officers," such as Trayvon Martin, Michael Brown, Tamir Rice,and John Crawford. That is because I see this as people (human beings) killed by police.  White people are killed by police too. I am going to take race out of this equation as I analyze this case.

What caused me to comment on this is police are saying Eric Garner was "complicit in his own death."[Source: The Huffington Post]

In each of the above mentioned cases, the victim is painted as a “thug,” Every time, it seems the bar gets lower to justify the use of deadly force. In Garner’s case, they call it “resisting,” when all he was doing was asking the police to treat him with basic dignity:

Garner was approached by NYPD officers on July 17 because he was allegedly selling “untaxed cigarettes.” Video shows Garner pleading with police to leave him alone and stop harassing him. Garner had previously been arrested and charged with misdemeanor offenses for selling loose cigarettes. He insisted he was not selling anything and was minding his own business. 
As he urges police to let him be, Garner, who was 6-foot-4 and weighed around 400 pounds, is wrestled to the ground by officers including Pantaleo who puts him in an illegal chokehold. Garner is crying out, “I can’t breathe. I can’t breathe,” as Pantaleo pushes his leg into Garner’s head, which is now on the sidewalk. “I can’t breathe,” he cries again. [Source: The Dissenter

The medical examiner ruled Garner’s death a homicide and found he had been killed by a chokehold.
The Medical Examiner issued its report on the death of Eric Garner this afternoon and found the "manner of death" to be homicide. It ruled the cause of death to be from "compression of neck (choke hold), compression of chest, and prone positioning during physical restraint by police." In addition, the ME cited contributing conditions as Garner's pre-existing "acute and chronic bronchial asthma, obesity, and hypertensive cardiovascular disease." [Source:]

NYPD Chief Bill Bratton, the architect of the “broken windows” policing that likely led officers to aggressively interrogate Garner about whether he was selling loose cigarettes, declared after Garner’s death, “Chokeholds are, in fact, prohibited by the New York City Police Department, as they are, in fact, by most police departments in the United States.” [Source:]
Even the EMS workers who responded have been suspended.
The EMS workers, who have not been identified, included two EMTs and two paramedics. The workers are not city employees but work for Richmond University Medical Center, according to the FDNY. They were first placed on modified duty, and then hospital officials announced Monday the workers were being suspended and would not be allowed to work at the hospital or throughout the 911 system...
...A friend of the victim showed NBC 4 New York new cellphone video Monday that showed the response moments later as Garner lay on the ground, not moving: the paramedics, EMTs and police peer over Garner, and none administer CPR[Source: NBC 4 New York]

Police: Chokehold Victim Eric Garner Complicit In Own Death

"Police officers feel like they are being thrown under the bus," said Patrick Lynch, president of the police union. 
Pantaleo's defenders have included Rep. Peter King, R-N.Y., who argued that the grand jury outcome would have been the same if Garner had been white, and that police were right to ignore his pleas that he couldn't breathe. 
"The fact that he was able to say it meant he could breathe," said King, the son of a police officer. [Source: The Huffington Post]

Rank-and-file New York City police officers and their supporters have been making such arguments even before a grand jury decided against charges in Garner's death, saying the possibility that he contributed to his own demise has been drowned out in the furor over race and law enforcement.

As the video sparked accusations of excessive force, the police unions mounted a counter-narrative: that Garner would still be alive if he had obeyed orders, that his poor health was the main cause of his death and that Pantaleo had used an authorized takedown move - more like a headlock than a chokehold - to subdue him.

Pat Lynch is the president of the Patrolmen’s Benevolent Association, the largest NYPD police union.  At a press conference last night, Lynch made sure to tell everyone that the NYPD doesn’t feel the kind of support they need from De Blasio, Eric Garner is to blame for his own death, and Officer Pantaleo is “literally an Eagle Scout.” [Source: slta_]

A second video shows CPR was not performed by the EMS workers. It does, however, show nearly four minutes of the cops gently shaking Garner as he lies unmoving on the ground. They search his pockets, but do not seem particularly concerned that their suspect hasn’t moved in minutes.  Cops know CPR, and are expected to perform it if necessary.

One officer asks the woman filming to back away and give Garner air, another checks his pulse and a third offers a supportive pat on the back while saying, "C'mon guy, breathe in, breathe out, all right," to the seemingly lifeless Garner. None of the eight cops seen in the video provide him medical help.

An emergency responder, who arrives about four minutes in, takes his pulse and tries to rouse Garner, saying, "Sir, it's EMS. C'mon, we're here to help, all right. We're here to help you. We're getting the stretcher, all right." Afterward, an officer can be heard saying, "He's breathing, he's got a pulse."

Around the 6-minute mark, officers roll Garner onto his back and lift his body onto a stretcher.
"Why nobody do the CPR?" one onlooker asks, as Garner is wheeled away. "Cause he's breathing," an officer responds.

Forearm across trachea = DEATH!!!

How is this NOT manslaughter at the very least?

New York’s statutes on manslaughter are pretty unequivocal. Just going on the plain language of the law, the police officer who killed Garner certainly appears to be guilty of second-degree manslaughter at the very least:
§ 125.15 Manslaughter in the second degree.
A person is guilty of manslaughter in the second degree when:
1. He recklessly causes the death of another person; or
2. He commits upon a female an abortional act which causes her death,
unless such abortional act is justifiable pursuant to subdivision three
of section 125.05; or
3. He intentionally causes or aids another person to commit suicide.
Manslaughter in the second degree is a class C felony.
Source: State of NY 

The second-degree manslaughter charge requires only two factors: 1) the person charged must have caused the death of the victim, and 2) the perpetrator must have caused the death of the victim via reckless means.

As the video shows, the officer clearly caused the death of Eric Garner, who was alive until the officer put him in a chokehold, a move which is banned by the NYPD for good reason. And why did the police department ban chokeholds? Here’s an article on the subject from 1993, when a previous police chief banned the practice:
The New York City Police Department has issued an order banning the use of choke holds, the restraining maneuvers that cut off the flow of blood and oxygen to the brain and have been blamed in the deaths of suspects here and around the nation.

So an officer used a banned practice that is known to lead to the deaths of people who are subjected to it? That certainly seems to satisfy the second condition of a second-degree manslaughter charge?

Monday, December 1, 2014

We can make a change now!

Please send comments about this draft. 
It can pave the way for ensuring gender choice by patients for  ALL their providers in healthcare.

A friend alerted me to this:

The National Association of Insurance Commissioners has released draft regulations expected to impact the makeup of health plan provider networks on a state and federal level, including on the marketplace exchanges set up under the Affordable Care Act.
NAIC in November released draft updates to its Managed Care Network Adequacy Model Act, [link:] a model law routinely used by state and federal lawmakers when creating insurance laws and regulations, particularly in regards to the creation of health carrier networks and the adequacy and accessibility of services offered under a network plan.
The model Act, which hadn’t been updated since 1996, has been highly anticipated due to the changing insurance landscape under the implementation of the ACA. A controversy over the use of narrow networks on the marketplace exchanges has led the Centers for Medicare and Medicaid Services to investigate the adequacy of provider networks more closely; and the agency said it was waiting for NAIC’s revamped model law before proposing changes to its network adequacy policy for products offered on the 2016 exchanges...

These were my comments:

The reason that gender is a criteria, is because many people exercise their Constitutional rights under Title VII of the Civil Rights Act of 1964 and The Federal Nursing Home Reform Act (“OBRA 87”).

There is a reason that gender is included in directory listings. The problem is that once you get there, nurses, PAs, technicians, etc. who may be necessary for treatment are of the opposite gender of the physician.

There needs to be the additional criteria for the "gender of other personnel" AND "can accommodate request for same gender care."  

What caught my attention was that this paper is being discussed in "narrow networks." By adding the additional criteria of "requiring networks to be broad enough to accommodate request for same gender care," can further the original intent of including the gender criteria originally. 

My friend made the following recommendations:

Include 2 additional criteria for the following in section 8:

Section 8.B(1)(f) Gender of support staff;
Section 8.B(1)(g) Provide same gender care for;

Section 8.B(2)(d) Gender of support staff;
Section 8.B(2)(e) Provide same gender care for;

Section 8.B(3)(e) Gender of support staff;
Section 8.B(3)(f) Provide same gender care for;

Section 8.C(1)(f) Gender of support staff;
Section 8.C(1)(g) Provide same gender care for;

Section 8.C(2)(c) Gender of support staff;
Section 8.C(2)(d) Provide same gender care for;

Section 8.C(3)(e) Gender of support staff;
Section 8.C(3)(f) Provide same gender care for;

Here is an example of the new criteria:

Section 8.B(1)(f) Gender of support staff;
This can be answered: "All Female," "All Male," OR "Both Female and Male."

Section 8.B(1)(g) Provide same gender care for;This can be answered: "Female," "Male," OR "Both Female and Male." This is important due to the situation I mentioned above where the urologist is male, but the rest of the staff is female. The following is possible:

Section 8.B(1) For health care professionals:
(a) Name; Dr. So-and-so
(b) Gender; male
(c) Contact information; (555) 555-1212
(d) Specialty;  urology
(e) Whether accepting new patients. Y
(f)  Gender of support staff: Female
(g)  Provide same gender care for: Male

In this situation, the practice can bring in a male nurse from the affiliated hospital to provide for all male care with advanced notice. This is another trend in today's healthcare. 

I also included references to gender choice in healthcare and modesty issues. 

Here is where to direct comments:

Comments are being requested on this draft by Jan. 12, 2015. The revisions to this draft reflect changes made from the existing model. Comments should be sent only by email to Jolie Matthews at

I am encouraging everyone to comment on this. We can make a difference...

Live like there is no tomorrow....

Tuesday, November 11, 2014

Patient Dignity 20: "It's called sticking your finger in my ass! "

Warning: This post is brutally honest and NSFW (not safe for work).

Physicians and other providers like to correct patients on the terms that we use. It is not a cock, a dick, a willie, mini me, or even Fred, it is a penis.

Does anyone know the reason human beings don’t like to use the words like penis and vagina, but prefer “pussy,” “cock,” “privates,” “wee-wee,” etc.?
Context. Those scientific terms are sterile and devoid of emotion. Those parts of our bodies are very emotional to us all.

This is part of the problem. There is a disconnect between providers and the rest of society. I would attribute it to the way providers are trained. 

What providers may find acceptable, the rest of society does not. Healthcare has granted itself privileges to our bodies that nobody else has. Not even law enforcement. 

Warning: the following example is to illustrate the control over our own bodies. It compares sexual actions to medical actions to illustrate the disconnect. . Although the actions are the same, the intent and purpose are different. 

There are married couples (partners, significant others, etc,) who are adventurous sexually and those who are vanilla. One area that is taboo for many is anal sex. There are many ways to stimulate the anus, but I will use digital stimulation for my example. 

There are people who will not allow this, even for the most important person in their life; their partner. Our partners are more important than healthcare. The species can continue without healthcare. It did for millions of years.

Yet, depending on our age, healthcare imposes an annual DRE on both partners. Imagine the psychological effect this has on people; healthcare imposing something a person would not even grant their spouse.

If a partner were to allow the other to try this stimulation out of love and trust, they have the right to say NO, otherwise it is considered assault (even within a marriage). 

Yet in certain situations (the ED), a healthcare provider can ignore our wishes and it may not legally be assault, but I am sure the patient feel assaulted. 

I am sure we have heard the adage of the American College of Surgeons in their Advanced Trauma Life Support (ATLS) is a training program: Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum. 

There are some spouses who do not like their partners to see them undressed. In certain Jewish sects, intercourse involves a sheet with a hole in it. Again, healthcare expects us to annually undress and place our genitals in the hands of strangers (literally) for a physical exam. 

Going back to my example of "digital rectal penetration," from the point of view of the patient, whether it is a sexual tryst with a partner, or an exam (with appropriate draping and conducted in a professional manner) to make a diagnosis... still feels like a finger up my ass!!!


I found this on

Do you see my point????

Thank you for reading.

Monday, October 6, 2014

Living with ADHD

ADHD is really a super power. If you gave me a pill that would instantly take away the ADHD and make me like everyone else, I would NOT take it. Some days, this is what my train of thought is like...

BTW: I am the guy on the pumpcar ahead of my thoughts....

Thursday, September 25, 2014

Patient Dignity 19: Doctor Are Examining Your Genitals for No Reason


When a girl becomes a woman, she is initiated into a bizarre and mysterious annual ritual. She takes off her clothes, sticks her arms through a backless medical gown, reclines on an examination table, and spreads her legs. A doctor fits her feet into a pair of stirrups, looks at her genitals, sticks a cold metal speculum into her vagina, cranks it open, and peers in. When the speculum is removed, the doctor inserts a finger or two, and pokes around to feel the woman’s internal organs. Sometimes, the fingers examine her rectum, too.

In 2010, doctors performed 62.8 million of these routine pelvic examinations on women across America. In total, gynecological screenings cost the U.S. $2.6 billion every year.

And yet, a new study published in the Annals of Internal Medicine reports that there is no established medical justification for the annual procedure. After scouring nearly 70 years of pelvic exam studies, conducted from 1946 to 2014, the researchers found no evidence that they lead to any reduction in “morbidity or mortality of any condition” among women. In light of the study, the American College of Physicians, a national organization of internists, has crafted a new set of guidelines warning doctors that exams conducted on otherwise symptomless women can “subject patients to unnecessary worry and follow-up” and can “cause anxiety, discomfort, pain, and embarrassment, especially in women who have a history of sexual abuse.”

In an editorial also published in Annals, internists George Sawaya and Vanessa Jacoby of the University of California–San Francisco, conclude that the pelvic examination has “become more of a ritual than an evidence-based practice.” Sawaya told me that the routine pelvic exam is such "a foundational cornerstone" of gynecology, it's hard to even trace its origins. The new report urging doctors to reverse course will be "very controversial," Sawaya says. "I expect a lot of physicians to raise their eyebrows."

Just two years ago, the American College of Obstetricians and Gynecologists admitted that “no evidence supports or refutes the annual pelvic examination … for the asymptomatic, low-risk patient.” Nevertheless, ACOG reupped its endorsement of the exam, writing that it “seems logical.” The procedure—which is routinely initiated early in a woman’s teen years and conducted annually—can aid in “establishing the clinician–patient relationship” and provide “an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks,” ACOG reported. In other words, according to ACOG, while the annual pelvic exam might not be worthwhile in and of itself, it can be a useful device for bringing a woman to her doctor every year to get some necessary information about her reproductive health.

These conflicting recommendations—one by internists, the other by gynecologists—speak to the effects of cultural shaming on women’s health. Some women—particularly women who have been abused—can experience enough anxiety and pain from the intimate exams that they become less likely return for future exams. That could deter women from heading to the doctor when they do have problematic symptoms or heightened cancer risks. Furthermore, women taking birth control pills typically have to undergo an annual pelvic exam before a doctor will refill a prescription, which could prevent some women from using this safe and effective contraceptive method. (The ACP insists that refilling an oral birth-control prescription should not require a pelvic exam.)

Meanwhile, other women experience enough generalized anxiety about their genitals and reproductive systems that the fear pushes them to see their doctors every year and undergo examinations that, it turns out, won’t actually tell them much of anything about their health. While the 70 years of studies parsed in Annals paint an incomplete picture of the full effects a pelvic exam can have on a woman’s well-being, they do suggest that the exams can produce both “false-positive results” and “false reassurance” among women.

The pelvic exam is just the latest women’s health ritual to be reexamined in light of new research. In 2012, the United States Preventive Services Task Force and the American Cancer Society released new recommendations suggesting that women should undergo routine pap smear tests every three years, not once a year. In March, an Food and Drug Administration panel voted to replace the pap smear—in which a doctor scrapes cells from the cervix that are analyzed under a microscope for visual abnormalities—with an HPV test targeted at identifying the strains of the virus most likely to lead to cervical cancer. And in 2009, the USPSTF changed its stance on routine mammograms, recommending that women begin undergoing mammograms at age 50, not 40, and that they do them every two years, not every year.

Proponents of yearly pelvic exams may say that they compel women to seek counsel from their doctors and receive vital information about their own health. (They also, of course, bolster gynecologists' job security.) But it's becoming clear that this line of thinking is self-defeating: There’s no reason for women to report to their doctors every year if they can’t even trust what they’re being told.

What happened to, "First do no harm?"

...and physicians wonder why their patients do not trust them.

There is no reason that a genital exam ever needs to be performed on anyone older than 2 years as part of an annual physical or as part of any other exam in asymptomatic patients. You can not distinguish between the physician who is being "thorough" and a serial sexual predator in the medical setting. In order to protect the patient, it is necessary to err on the side of caution. The patient should be given the option AND allowed to decline this exam without penalty. 

The physician's "fiduciary duty" requires the physician to sacrifice his own well being for that of the patient. This justifies the "without penalty to the patient" requirement. 


Thursday, September 18, 2014

Patient Dignity 18: Doctor-Patient Relationships and Domestic Violence

I have heard physicians and other providers respond to the fact some patients have been harmed by the healthcare system that they were not aware of ever harming their own patients. They say things like "No patient ever told me," and it seems that they assume that everything is fine since other patients return.

The first question to ask is what about patients that never return? The answer is "I don't know." That is because very few providers track patients that leave. In today's environment very few practices are taking on new patients let alone track down patients who have not been in for a regular visit. It is commonly assumed that these patients found another provider, moved out of the area, passed away, etc.

The ugly truth is that although those reasons may be true for some, there are others who have just decided to "opt out" of healthcare rather than suffer repeated indignities. I have also heard from people, I can't take any more after XX years." What? Why stay if you are being abused?

That prompted me to look at the bad doctor-patient relationship in terms of domestic violence and abusive relationships. All too often whether it be an abusive relationship between lovers/partners or doctor-patient, people say, "Just leave." If it seems like common sense to leave a lover/partner /spouse who is abusive, the lines may me a little more murky for the doctor-patient relationship.

By examining the more obvious abusive lover/partner/spouse relationship, we can gain insight why a patient may not speak up to a physician, and then we can understand why physicians may believe things are fine.

Let's start off with "Understanding domestic violence and abuse."  Then next we will look at the basic questions, "Why people abuse," "Why do people stay in abusive relationships," the "Characteristics of an abusive relationships," the "Characteristics of those who batter," and "What does an emotional abuser get out of the abuse," Finally  we will examine "Consent."

Note: I will highlight the aspects of abusive lover/partner /spouse relationships that apply to abusive doctor-patient relationships.  I will place my comments in purple italics. 

Understanding Domestic Violence and Abuse

Domestic abuse, also known as spousal abuse, or an abusive relationship, occurs when one person in an intimate relationship or marriage tries to dominate and control the other person. Domestic abuse that includes physical violence is called domestic violence. The very nature of the doctor-patient relationship makes it one of intimacy. 

Domestic violence and abuse are used for one purpose and one purpose only: to gain and maintain total control over you. An abuser doesn’t “play fair.” Abusers use fear, guilt, shame, and intimidation to wear you down and keep you under his or her thumb. Your abuser may also threaten you, hurt you, or hurt those around you.

Domestic violence and abuse does not discriminate. It happens among heterosexual couples and in same-sex partnerships. It occurs within all age ranges, ethnic backgrounds, and economic levels. And while women are more commonly victimized, men are also abused—especially verbally and emotionally, although sometimes even physically as well. The bottom line is that abusive behavior is never acceptable, whether it’s coming from a man, a woman, a teenager, or an older adult. You deserve to feel valued, respected, and safe. The same is true of the doctor-patient relationship.

Why People Abuse

People abuse their partners because they believe they have the right to control the person they’re dating. Maybe the abusive partner thinks they know best. Maybe they believe that as the more knowledgable person, more popular person, etc. in the relationship they should "wear the pants." Maybe they think unequal relationships are ideal.

Abuse is a learned behavior. Med school? Sometimes people see it growing up. Other times they learn it from friends or popular culture. But, no matter where it's learned, it's not ok and it's never justified. Many people experience or witness abuse growing up and decide not to use those negative and hurtful ways of behaving. It's most important to know that abuse is a choice -- and it’s not one that anyone has to make.

Why Do People Stay in Abusive Relationships?

People who have never been abused often wonder why a person wouldn’t just leave. They don't understand that breaking up can be more complicated than it seems.

There are many reasons why both men and women stay in abusive relationships. If you have a friend in an unhealthy relationship, support them by understanding why they may choose to not leave immediately.

Conflicting Emotions
  • Fear: A partner may be afraid of what will happen if they decide to leave the relationship. If a person has been threatened by their partner, family or friends, they may not feel safe leaving. Fear of being "blacklisted " and not finding another provider.
  • Believing Abuse is Normal: If a person doesn’t know what a healthy relationship looks like, perhaps from growing up in an environment where abuse was common, they may not recognize that their relationship is unhealthy. This may be more common for some one who has a chronic illness or disease from childhood. They may have grown up having their dignity and body violated without their consent and believe that it is normal. 
  • Fear of Being Outed: If a person is in same-sex relationship and has not yet come out to everyone, their partner may threaten to reveal this secret. Being outed may feel especially scary for young people who are just beginning to explore their sexuality. Fear of all the intimate aspects of our lives that we shared when asked about our "history."
  • Embarrassment: It’s probably hard for a person to admit that they’ve been abused. They may feel they’ve done something wrong by becoming involved with an abusive partner. They may also worry that their friends and family will judge them. Some people blame themselves for their illness. 
  • Low Self-esteem: If a person’s partner constantly puts them down and blames them for the abuse, it can be easy for a person to believe those statements and think that the abuse is their fault. Illness (especially chronic illness) and hospitalization causes depression.
  • Love: Your friend may stay in an abusive relationship hoping that their abuser will change. Think about it -- if a person you love tells you they’ll change, you want to believe them. Your friend may only want the violence to stop, not for the relationship to end entirely. Stockholm Syndrome? (Info link here:)


  • Social/Peer Pressure: If the abuser is popular, it can be hard for a person to tell their friends for fear that no one will believe them or that everyone will take the abuser's side. Physicians are highly respected individuals in a community, and by the nature of a "physician's fiduciary duty," they are assumed trustworthy.
  • Cultural/Religious Reasons: Traditional gender roles can make it difficult for young women to admit to being sexually active and for young men to admit to being abused. Also, a person’s culture or religion may influence them to stay rather than end the relationship for fear of bringing shame upon their family. Physicians are highly respected individuals in a community, and by the nature of a "physician's fiduciary duty," they are assumed trustworthy. Families may not believe their "own blood," especially if that person is the "black sheep."
  • Distrust of Police: Many people do not feel that the police can or will help them, so they don’t report the abuse. Physicians are highly respected individuals in a community, and by the nature of a "physician's fiduciary duty," they are assumed trustworthy.
Reliance on the Abusive Partner
  • Lack of Money: A person may have become financially dependent on their abusive partner. Without money, it can seem impossible for them to leave the relationship. Physicians are highly respected individuals in a community, and by the nature of a "physician's fiduciary duty," they are assumed trustworthy.
  • Nowhere to Go: Even if they could leave, a person may think that they have nowhere to go or no one to turn to once they’ve ended the relationship. Fear of being "blacklisted " and not finding another provider.
  • Disability: If a person is physically dependent on their abusive partner, they can feel that their well-being is connected to the relationship. This dependency could heavily influence his or her decision to stay in an abusive relationship. Dependency for tratments and/or medications.

What are the Characteristics of an Abusive Relationships?

What Is Abuse?

  • Abuse can be physical, emotional, or sexual. Physical abuse means any form of violence such as hitting, punching, pulling hair, and kicking. Abuse can occur in both dating relationships and friendships.
  • Emotional abuse (stuff like teasing, bullying, and humiliating you and others) can be difficult to recognize because it doesn't leave any visible scars. Threats, intimidation, putdowns, and betrayal are all harmful forms of emotional abuse that can really hurt — not just during the time it's happening, but long after too.
  • Sexual abuse can happen to anyone, guy or girl. It's never right to be forced into any type of sexual experience that you don't want.

Signs of Abusive Relationships

Important warning signs that you may be involved in an abusive relationship include when someone:
  • Harms you physically in any way, including slapping, pushing, grabbing, shaking, smacking, kicking, and punching. Abuse by physicians rarely sink to this level, but they can make procedures or exams uncomfortable and downright painful. They may order unneeded exams, procedures, and tests.   
  • Tries to control different aspects of your life, such as how you dress, who you hang out with, and what you say. Medication refills? No birth control without a pelvic exam (even though one is not required? 
  • Frequently humiliates you or makes you feel unworthy (for example, if a partner puts you down but tells you that he or she loves you) threatens to harm you, or self-harm. Physicians can make procedures or exams uncomfortable.  They may order unneeded exams, procedures, and tests, have additional people in the room during the exam, have you examined by students, have you photographed or exposed needlessly.   
  • Twists the truth to make you feel you are to blame for your partner's actions. A physician saying that your feelings and requests are irrational, excessive, contrary to the protocol for the procedure or saying that this is how things are always done. 
  • Objectifies a person, thus taking away aspects of their humanity. Physicians often do this to "desexualize" patient encounters.  
  • Unwanted sexual advances that make you uncomfortable are also red flags that the relationship needs to focus more on respect. In more blatant cases, the behaviors can range from sexual abuse to rape. Some people believe that forced sex with a partner, spouse or lover (someone you previously had sex with) is not rape. Any unwanted, forced sexual contact is sexual assault/abuse and unwanted, forced sexual intercourse is rape.  Physicians may easily commit sexual assault/abuse under the guise of healthcare. Trust your intuition. If something doesn't feel right, it probably isn't.   
  • When someone says stuff like "If you loved me, you would . . . " that's also a warning of possible abuse, and is a sign that your partner is trying to manipulate you. A statement like this is controlling and is used by people who are only concerned about getting what they want — not caring about what you want. Similar to saying "If you want me to keep treating you, then you will..." 

Signs That a Person Is Being Abused

In addition to the signs listed above, here are some signs a friend might be being abused by a partner:
  • unexplained bruises, broken bones, sprains, or marks Perhaps the results of unnecessary or extremely "rough" procedures/exams.
  • excessive guilt or shame for no apparent reason Especially in people having chronic or life long illnesses.
  • secrecy or withdrawal from friends and family This is to avoid talking about their illness or medical subjects (such as an annual physical exam).
  • Fear, anxiety, or phobias around certain subjects, depression, PTSD (or the symptoms of any of these).  

Characteristics of Those Who Batter

  • Emotional Isolation: These people do not see their friends as a source of emotional support, or do not have friends outside the primary relationship. If they do, they're generally superficial, social not emotional. This is one of the causes of the high rate of suicide among physicians. (Link to my post on physician suicide here:)
  • Dependency on the Victim: These people see their partner as being responsible for recognizing and meeting their emotional needs; in short, the partner has the power and responsibility to make them feel good, to nurture and to comfort them. This dependency closely resembles, what children attribute to their mothers, "Mom can make it "all better." This dependency can be material as well, including money, housing, clothing, transportation, etc. Physicians depend on their patients for their livelihood.
  • Externalizing the Responsibility for Behavior: Violent people tend to attach responsibility for their actions to persons and external situations and not to themselves. They rationalize their violence by attributing it entirely to the victim. Paternalism? I need to do this to make the patient compliant.
  • Minimization and Denying the Violence: The people generally minimize or denied the severity and frequency of the violence. For example, "I just pushed her," "I've got some problems, but I'm certainly not one of those wife-beaters" are common ways of minimizing the violence that has occurred. This was the way I was taught. The "Hidden Curriculum." 
  • Extremes of Behavior: These people are often described as being nice guys by friends, co-workers and even the partner. But the partner also sees the irritable, nasty, belligerent and hostile other side. These extremes in behavior make it difficult for many people to identify these people as batters. There have been many issues with the way physicians treat nurses.
  • Not in Touch with Own Stress: Most people who batter, tend to be very disconnected from their own feelings of stress. So, it is a potentially dangerous situation because they don't see the need to deal with that stress until it becomes extreme in size and is expressed through violence. This is one of the causes of the high rate of suicide among physicians. (Link to my post on physician suicide here:)
  • Drug and Alcohol Use: Drugs and alcohol are involved in more than 60 percent of violent episodes. Alcohol lowers inhibitions against violence, while heavy use of drugs like cocaine increases paranoia, which increases the likelihood of violence. Some people attribute their violence to the drugs or alcohol, claiming to feel out of control when under their influence. However, most of the people have been abusive with or without a substance problem. This is one of the warning signs of suicide among physicians. (Link to my post on physician suicide here:) The State of California feels that this is such a pervasive problem, that there is pending legislation to require random testing of physicians.
  • Internal Feelings of Depression and Despair: Often under the hostility and aggression are the feelings of depression and despair. These feelings tend to emerge in people at two points. First, when the person is actively working at and succeeding in controlling his aggression. Secondly, after his female partner has left him as a result of the violence. The second point is critical in that it is very common for the person at this point to think about suicide and homicide. This is one of the causes of the high rate of suicide among physicians. (Link to my post on physician suicide here:)
  • Instrumental Aggression: One of the most frightening and dangerous batter is a person whose violence becomes "instrumental" in getting what he want. It's no longer simply an out-of-control rage response, but a calculated way of gaining a desired reward. This person seems to show no emotion during the violence and remorse afterwards. Physicians depend on their patients for their livelihood. This was the way I was taught. The "Hidden Curriculum." 
  • Military Experience: It's estimated that over 58 percent of batters have had prior military experience. These people are given training in the use violence to deal with conflict. Most military people tend to hold the notion that they are in charge. These factors may increase the possible violence in the home. The abuses of medical school have been compared to that of "boot camp."

What Does an Abuser Get Out of the Abuse?

Abuse is almost entirely about control. It is often a primitive and immature reaction to life circumstances in which the abuser (usually in his childhood  [ Medical school maybe?] ) was rendered helpless. It is about re-exerting one's identity, re-establishing predictability, mastering the environment - human and physical.

The bulk of abusive behaviors can be traced to this panicky reaction to the remote potential for loss of control. Many abusers are hypochondriacs (and difficult patients) because they are afraid to lose control over their body, its looks and its proper functioning. This may explain why physicians (and medical students) refuse to be the subjects for medical school training and insist patients have that obligation. It may also explain why physicians (themselves) avoid the healthcare system, self treat, and are usually "fitness nuts."

They are obsessive-compulsive in an effort to subdue their physical habitat and render it foreseeable. Typical physician personality. They stalk people and harass them as a means of "being in touch" - another form of control. To the abuser, nothing exists outside himself. Meaningful others are extensions, internal, assimilated, objects - not external ones. Objectifying the patient.

Thus, losing control over a significant other (patient) - is equivalent to losing control of a limb, or of one's brain. It is terrifying. Independent or disobedient (noncompliant) people evoke in the abuser the realization that something is wrong with his worldview, that he is not the centre of the world or its cause and that he cannot control what, to him, are internal representations.

To the abuser, losing control means going insane. Because other people are mere elements in the abuser's mind - being unable to manipulate them literally means losing it (his mind). Imagine, if you suddenly were to find out that you cannot manipulate your memories or control your thoughts ... Nightmarish! In his frantic efforts to maintain control or re-assert it, the abuser resorts to a myriad of fiendishly inventive stratagems and mechanisms.

What is Consent?

(Informed) consent is an important component to the doctor-patient relationship, just as it is to lover/partner/spouse relationship. Legally there instances when consent in not required, even though it is not criminal, it is just as emotionally/mentally damaging to the patient to ignore their wishes.

As important as consent is, we don’t talk about it enough. So it’s understandable if you’re a little unsure as to what consent is – and what it isn’t. You may have heard the idea that “no means no,” but this doesn’t really provide a complete picture of what consent is because it puts the responsibility on one person to resist or accept. Implied consent and the issues that accompany it. It also makes consent about what a partner doesn’t want, instead of being able to openly express what they do want. Again, implied consent and the issues that accompany it.

Well, How Does It Work?

Some people are worried that talking about consent will be awkward or that it will ruin the mood, which is far from true. That is why consent is usually hidden in the form you sign when being admitted. If anything, the mood is much more positive when both partners are happy and can freely communicate what they want. Is this not true of healthcare too? First off, talk about what terms like “hooking up” or “going all the way” (or exam, exposure, treatment) mean to each partner. Consider having these conversations during a time when you’re not being physically intimate (or naked in the exam room).

If you are in the heat if the moment (in the Emergency Department, during a procedure or exam), here are some suggestions of things to say:

  • Are you comfortable?
  • Is this okay?
  • Do you want to slow down?
  • Do you want to go any further?
What Consent Looks Like:
  • Communicating every step of the way. For example, during a hookup (in the Emergency Department, during a procedure or exam), ask if it’s okay to take your partner’s shirt off and don’t just assume that they are comfortable with it. 
  • Respecting that when they don’t say “no,” it doesn’t mean “yes.” implied consent
  • Breaking away from gender “rules.” Girls are not the only ones who might want to take it slow. Also, it’s not a guy’s job to initiate the action (or anything else, really). Gender choice in healthcare, the disparity between the way men and women are treated and the choices each is given.

What Consent Does NOT Look Like:

  • Assuming that dressing sexy, flirting, accepting a ride, accepting a drink etc. is in any way consenting to anything more. Assuming that being put in a gown gives everyone and anyone in healthcare complete and unfettered access to the patient's body.
  • Saying yes (or saying nothing) while under the influence of drugs or alcohol. An instances when consent in not required.
  • Saying yes or giving into something because you feel too pressured or too afraid to say no. Paternalism!
Here are some red flags that indicate your partner doesn’t respect consent:
  • They pressure or guilt you into doing things you may not want to do. Paternalism!
  • They make you feel like you “owe” them — because you’re dating, or they gave you a gift, etc. Paternalism!
  • They react negatively (with sadness, anger or resentment) if you say “no” to something, or don’t immediately consent. Paternalism!
  • They ignore your wishes, and don’t pay attention to nonverbal cues that could show you’re not consenting (ex: pulling/pushing away). Paternalism!

Get Consent Every Time

In a healthy relationship, it’s important to discuss and respect each other’s boundaries consistently. It’s not ok to assume that once someone consents to an activity, it means they are consenting to it anytime in the future as well. Whether it’s the first time or the hundredth time, a hookup, a committed relationship or even marriage, nobody is ever obligated to give consent just because they have done so in the past. A person can decide to stop an activity at any time, even if they agreed to it earlier. Above all, everyone has a right to their own body and to feel comfortable with how they use it -- no matter what has happened in the past.

It is important to know that just because the victim “didn’t say no,” doesn’t mean that they meant “yes.” When someone does not resist an unwanted sexual advance, it doesn’t mean that they consented. Sometimes physically resisting can put a victim at a bigger risk for further physical or sexual abuse

...But Physicians, Nurses, and Other Providers are not Abusers...

One physician hurled a surgical instrument at his co- workers in a fit of anger. Another tried to stuff a nurse head- first into a trash can. A group of nurses banded together to blackball a doctor and get his privileges revoked. 
Bad behavior among doctors and nurses has always been health care’s dirty little secret. Almost everyone in the indus- try has a story to tell about harassment, insults traded back and forth or a screaming match in the operating room. 
But a new survey conducted by the American College of Physician Executives illustrates just how pervasive the prob- lem has become. And ACPE is working to find ways to curb the bad behaviors. 
According to the survey results, outrageous behavior is still common in this country’s health care organizations. More than 2,100 physicians and nurses participated in the survey, and some of the tales they related were surprising:
  • Physicians groping nurses and technicians as they tried to perform their jobs.
  • Tools and other objects being flung across the OR.
  • Personal grudges interfering with patient care.
  • Accusations of incompetence or negligence in front of patients and their families.
Source: American College of Healthcare Executives (2009 Doctor-Nurse Behavior Survey)

Patient Abuse. Gerald Hickson, MD, and colleagues analyzed patient complaints to his hospital, Vanderbilt University, and linked the results with malpractice suits. Researchers estimated that about 6% of physicians are abusive. Abusive doctors were defined as those receiving more than two complaint letters a year. They found that most physicians at Vanderbilt (80%) receive no complaints from patients (Hickson et al. JAMA. 2002;287:2951). However, physicians who regularly receive complaints have a much greater chance of being sued for mal- practice. 
Source: Society of Critical Care Medicine (Problem Doctors: Is There a System-Level Solution? 2007)

Physicians are prone to abuse. The system creates abusers then isolates them.

"After at least seven years of post-college graduate medical education on the emotional, mental, and physical condition of the human being, you would expect a physician to be a powerhouse of goodwill for his or her patients. Unfortunately, too many doctors fail to keep the welfare of their customers at the forefront, as their main concern. The needs to boost their own egos, self-preservation, and the quest for more money often result in inappropriate care and harm the patient" 
Source: John A. McDougall, MD (How to Protect Yourself from Abusive Doctors 2011)

"During residency, doctors trained in authoritarian systems are likely to internalize as normative a model of interaction with underlings and patients that desensitizes them to problem behaviors if not converts them into outright abusers themselves." Source: National Institute of Health (Cruelty in Maternity Wards: Fifty Years Later 2010)

"...use of harmful medical interventions to outright verbal, physical, and even sexual assault. Furthermore, the more extreme examples are not aberrations but merely the far end of the spectrum. Abuse, moreover, results from factors inherent to the system, which increases the difficulties of implementing reforms." Source: National Institute of Health (Cruelty in Maternity Wards: Fifty Years Later 2010)

You Can't Compare Healthcare to Domestic Abuse.... Can You?

According to (an online resource devoted to helping individuals recognize, address, and prevent domestic violence), domestic violence and emotional abuse encompass “name-calling or putdowns,” “keeping a partner from contacting their family or friends,” “actual or threatened physical harm,” “intimidation,” and “sexual assault” (“Domestic Violence Definition,” 2009, para. 2). In all cases, the intent is to gain power over and control the victim. One could add that perpetrators, obstetric staff or otherwise, feel entitled to exert this control on grounds of the victim's inferior position vis-à-vis the perpetrator... Source: National Institute of Health (Cruelty in Maternity Wards: Fifty Years Later 2010)

Why a Physician Might be Unaware of Patient Abuse

Whether caused by the the current physician or a past physician, if the abuse was intentional or unintentional, and if the abuse was real or perceived, the current physician may be unaware that the patient is a victim of medical abuse. The current physician may conclude, that if they were the cause of the abuse, the patient would certainly discontinue the doctor-patient relationship with them.

By examining abusive relationships between spouses/partners, where the abuse is overt and obvious, we can see that patients may remain in an abusive relationship with a physician. Just because a patient returns,  a physician should NEVER assume that they are treating the patient in an acceptable manner.

Many procedures and examinations may appear to be tolerated well by the patient while the doctor is present, yet the patient may collapse into tears or let the suppressed terror and panic show the moment the physician leaves the room or the patient leaves the office. Many persons who were badly abused as children were taught to suppress any expression of apprehension or displeasure, lest they be punished more. Not only may a previously abused patient be mustering their courage to tolerate what must be done, but also the same patient may consciously or unconsciously be anticipating being treated poorly should any discomfort or displeasure be shown.

It should be noted that because of the authority generally afforded to physicians by society, some patients will acquiesce to exposure, intimate examinations, even abuse under the guise of healthcare, despite internal fears and concerns about the procedure. The physician should be sensitive to this possibility and ensure that the patient has truly given "informed consent" and not simply tacit acceptance.

Update: October is Domestic Violence Awareness Month

September 22, 2014

Domestic Violence Awareness Month evolved from the first Day of Unity observed in October, 1981 by the National Coalition Against Domestic Violence. In October 1987, the first Domestic Violence Awareness Month was observed. That same year the first national toll-free hotline was begun. In 1989 the first Domestic Violence Awareness Month Commemorative Legislation was passed by the U.S. Congress. Such legislation has passed every year. (Source: National Coalition Against Domestic Violence)

By just as  violence and abuse occur in domestic relationships, violence and abuse can occur in the doctor-patient relationships. The National Institute of Health article;Cruelty in Maternity Wards: Fifty Years Later, details how domestic abuse parallels abuse in healthcare. By studying domestic abuse we can better understand and prevent abuse under the guise of healthcare.