Friday, August 22, 2014

KevinMD: Defending the physician, even when they are wrong

Recently I read a post on KevinMD titled: The blonde minority: Sexism is alive in medicine. on August 18, 2014, by Elizabeth Horn, a resident physician.

I look at the world very differently, I see patterns and connections that others don't see. Think Sherlock Holmes or House M.D. (Here is a little known fact: David Shore, the creator of House, based the character of House M.D. on Sherlock Holmes.)

As i read this article, I saw the proof of the theory (sexism is alive in medicine) presented supporting the opposite conclusion. What put me over the edge was Dr. Horn admonishing someone who was acting in a very respectful manner, in dealing with a confusing situation that healthcare created and refuses to address: the position of a person wearing scrubs.

I commented on how her story did not support the title and how she disrespected patients and their families. My comment was deleted. That pissed me off. So now I am going to hit back harder.

Here is my original comment that was deleted on Kevin MD:
There is a glaringly simple answer to the problem that you present and it is not sexism. (I hope you don't diagnose patients like you diagnose social issues).  
First I will address the "marry a plastic surgeon" thing. Plastic surgery is MOSTLY elective. They are usually not covered by insurances so they don't have to jump through hoops to get paid. They are happier with their profession, patients, etc.  
I don't know what your speciality is (you conveniently left that out) , but unless you are going into something where the pay scale is comparable with that of a plastic surgeon, then that person spoke the truth. I will acknowledge that it may have been inappropriate, but still the truth.  
Just as a physician says "we are professional and have seen it all" when a patient expresses apprehension about exposure of their body, thus making it about the physician's feelings and totally ignoring the patient's feelings: you are doing the same with this issue.
Perhaps the real issue is how you present yourself: 
"A natural blonde... my diminutive blonde mane...rather than a skirt suit... heels to a respectable 1.5” or less. I avoid using the word “like” too often...become disproportionately focused on the thoughts and opinions of male physicians and residents... Not that I mind a youthful complexion...a young, reasonably attractive blonde doctor... trust-fund boyfriend I had... the tortoise shell glasses, changed into my skinny jeans, a favorite sweater, suede heeled boots, put down my hair and applied a little mascara and blush." (Your words.) 
LIKE, oh my God, it's Elle-izabeth Woods of "Medically Blonde."   
Don't take not being called "doctor personally." In the 1970's you saw 3 people in hospitals: doctors, nurses, and orderlies. Each wore a specific uniform and were easily identifiable.  
As you stated, today there are "physician... ...nurse, physical or occupational therapist, student or housekeeper" and everybody wears scrubs. Let's not forget visiting surgical company reps (demonstrating equipment in the OR), janitors (sometimes), phlebotomists, lab techs, quality control specialists, EMT, and a host of others subject to the facility's infection control plan.  
Is it NOT just as disrespectful to you for someone to call a CNA doctor???? 
Calling you "miss" was sign of respect, respect that you are obviously LACKING for the person who called you that! Obviously they did not know your title, and used a respectful address for any unknown woman. 
Obviously with that paternalistic, arrogant, everything-about-you attitude, you are fitting quite well in the medical profession quite well.

While my comment may have been slightly inflammatory, the way she disrespected patients  and their families was more inflammatory. Everybody wears scrubs, there is no color coding to tell what position a person holds. People have been complaining of this for years. Calling her "miss" was polite and respectful!

Here is how she describes herself:
A natural blonde... my diminutive blonde mane...rather than a skirt suit... heels to a respectable 1.5” or less. I avoid using the word “like” too often...become disproportionately focused on the thoughts and opinions of male physicians and residents... Not that I mind a youthful complexion...a young, reasonably attractive blonde doctor... trust-fund boyfriend I had... the tortoise shell glasses, changed into my skinny jeans, a favorite sweater, suede heeled boots, put down my hair and applied a little mascara and blush.
If she is using sarcasm here, then I apologize for not catching that. I don't think that is the case though. I think that she presents herself (perhaps unconsciously) in such a manner then call it sexist when people don't take her seriously. I am not saying that this is right, and there may be some sexism involved.

There is nothing here about paying for college and med school, the burden of student loans, the years at a resident's salary trying to survive. If indeed she did have a trust-fund boyfriend then the only way you meet someone like that is if you are in those circles. Mentioning "residency at an ivy-league institution" is another giveaway, usually implying influence of the family she comes from. I suspect that she comes from a very wealthy family.

LIKE, OMG, it's Elle-izabeth Woods of "Medically Blonde." 

The frightening thing is how she deals with this issue and (more importantly) it would affect her interactions with patients  and their families:

 I have learned to speak up, to maintain eye contact and to assert myself if needed when rounds become disproportionately focused on the thoughts and opinions of male physicians and residents.

This is PATERNALISM! What if a patient doesn't agree with her decision of treatment?

It is troubling issue is that she aims this at ALL men. Has no man ever taken her seriously? This is stereotyping and REVERSE SEXISM. Then she makes the following comment where the man that she chose to marry is the only "good man" in the whole post, And the gender of the "trusted adviser" is conveniently undisclosed due to lack of pronouns:

During my internship, I went on a date with a good man and a couple of years later, he proposed. As I made plans for my career after residency, I met with a trusted adviser who after discussion of the several options I was considering, fellowship, research, physician positions, assured me not to worry too much. I was, after all, marrying a plastic surgeon.

I also comment on lack of disclosure of what her choice of speciality will be. All physicians are hurting financially, but general practitioners are hurting the most. The physicians that are thriving are the ones free of the bonds of medicare, medicaid, and insurance. Concierge physicians and plastic surgeons are two of these, and they are prospering. Dr. Horn fails mentioning her choice of speciality.

On July 28, 2014 KevinMD titled "Doctors today: Young, broke and human" by Aunna Pourang M.D. Indeed financial security is a major concern, even when both spouses are physicians. One being a plastic surgeon, alleviates much of the financial burden of that household.

Either I am missing sarcasm in this article, it is poorly written, or she is learning to be paternalistic. Looking at how the healthcare system operates, I go with the latter.

As a man I am offended by this post. As a patient, this post invokes fear in me of how Dr. Horn as a physician would respect my choices and my dignity.

I welcome a response from Dr. Elizabeth Horn or KevinMD.

--A. Banterings

Tuesday, August 19, 2014

A Physician that can Truly Empathize with the Patient

What if our providers had to do this? How different would they treat patients? You think it silly, but how would you really feel?

Thursday, August 14, 2014

A Bantering on Changing the World

"Give me a lever long enough and a place to stand and I will move the world"- Archimedes, 230 BC

Patient Dignity 15: The "Eye of the Beholder"

I was in a talking with someone today who made me thought of this analogy. Previously there was a discussion about our bad encounters with healthcare providers who were paternalistic, lacked empathy,  just didn't care about our dignity, or suffering stress from the healthcare system. It was suggested that we might be "the exception and not the norm."

Just because a physician is paternalistic, it does not mean he doesn't care about the patient. Think of paternalism as a pair of glasses that only let the physician see the physical body of the patient. The physician does not see the soul, spirit, or mind of the patient. He ignores the patient's wishes, especially for modesty.

He is running on the autopilot that was instilled in him over the many years of his training. This autopilot is good because he can react immediately to any situation. The downside is not seeing the patient's soul or wishes. He is the source of knowledge, of healing, and the treatment has to be his way.

Remember the Twilight Zone episode "The Private World Of Darkness" (originally titled and more commonly referred to as "Eye of the Beholder")? It originally aired on November 11, 1960 on CBS.
Fact: Many TZ fans mistakenly believe that the tile of this episode is "The Eye Of The Beholder," which would have been quite appropriate as the relative nature of beauty was discussed. Apparently, that was the original plan as creator Rod Serling referred to this episode with that title in a preview announcing it as the next week's episode, but somewhere along the line it was changed...

Janet Tyler has undergone her eleventh treatment (the maximum number legally allowed) in an attempt to look like everybody else. Tyler is first shown with her head completely bandaged so that her face cannot be seen. She is described as being "not normal" and her face a "pitiful twisted lump of flesh" by the nurses and doctor, whose own faces are always in shadows.

The twist in the tale is unveiled when the bandages are removed, and the reaction of the doctor and nurses is horror and disappointment. The procedure has failed, and her face has undergone "no change—no change at all". The camera pulls back to reveal a gorgeous blonde surrounded by grotesque doctors, nurses and hospital staffers.

Distraught by the failure of the procedure, Tyler runs through the hospital. Flat-screen television screens throughout the hospital project an image of the State's despotic leader giving a speech calling for greater conformity.

As she runs through the hospital until she encounters another "disfigured" human with the same "condition" as her. He arrives to take the crying, despondent Tyler into exile to a village of her "own kind", where her "ugliness" will not trouble the State. Before the two leave, the man comforts Tyler, saying that "beauty is in the eye of the beholder."

This made me think that the patient's dignity is mistreated by the healthcare system, and providers can't see it because of how the healthcare system enforces conformity...

Don't believe me? Read: "Death by a thousand cuts: how the machinery of academia enforces conformity." Academia is also involved in the teaching of the healing arts.


Tuesday, August 12, 2014

Suicide Is Painless, It Brings On Many Changes, And I can take or leave it if I please.

If you are in crisis, call 1-800-273-TALK (8255) 
National Suicide Prevention Lifeline

(CNN) -- Robin Williams -- who first made America laugh and eventually touched "every element of the human spirit" in a remarkable range of performances -- died at his Northern California home Monday. 
Williams apparently took his own life, law enforcement officials said. He was 63."He has been battling severe depression of late," his media representative Mara Buxbaum told CNN. "This is a tragic and sudden loss. The family respectfully asks for their privacy as they grieve during this very difficult time." 
Coroner investigators suspect "the death to be a suicide due to asphyxia," according to a statement from the Marin County, California, Sheriff's Office. (Source: CNN)

I chose the picture of Robin Williams from his role as "Patch Adams" because this tragedy not only is a wake up call for everyone but especially for physicians. Much of this blog so far has been about "Patient Dignity," part of the problem is "doctor burnout" (which can lead to physician suicide). Part of the solution for is freeing physicians from external forces and letting them heal.

Here is the plot summary of the 1998 film, "Patch Adams," starring Robin Williams:
This may be an old comedy, but its relevance is timeless. The message this film sends across is that love, laughter and affection can go a long distance in healing a person more than the usual doses of medicine. Well, there is a great difference between ‘cure’ and ‘healing’. A physical disease may be cured by the medicines prescribed by the physician. However, there is no guarantee that the person is healed. Healing has to do with the whole person and not just his or her physical ailment. Even a person with multiple physical ailments can be a completely healed person when he/she is completely free from within. (Source: Reading Films)
Ironically, the film deals with physicians, the humanity of the patient, paternalism, and suicide.

Hunter "Patch" Adams (Robin Williams) commits himself into a mental institution. Once there, he finds that using humor to help his fellow inmates gives him a purpose in life. Because of this he wants to become a medical doctor and two years later enrolls at the Medical College of Virginia (now known as VCU School of Medicine) as the oldest first year student. He questions the school's soulless approach to medical care and clashes with the school's Dean Walcott (Bob Gunton), who believes that doctors must treat patients as patients and not bond with them as people.  (Source: Wikipedia)

The Real Patch Adams: Art imitates life...

Adams had a difficult childhood. His father, an officer in the United States Army, had fought in Korea, and died while stationed in Germany when Adams was a teenager.[1] After his father's death, Adams returned to the United States with his mother and brother. Adams has stated that, upon his return, he encountered institutional injustice which made him a target for bullies at school. As a result, Adams was unhappy and became actively suicidal. After being hospitalized three times in one year for wanting to end his life, he decided "you don't kill yourself, stupid; you make revolution. (Source: Wikipedia)

Suicide Is Painless

Through early morning fog I see
Visions of the things to be
The pains that are withheld for me
I realize and I can see...
That suicide is painless
It brings on many changes
And I can take or leave it if I please.
I try to find a way to make
All our little joys relate
Without that ever-present hate
But now I know that it's too late, and...
That suicide is painless
It brings on many changes
And I can take or leave it if I please.
The game of life is hard to play
I'm gonna lose it anyway
The losing card I'll someday lay
So this is all I have to say.
That suicide is painless
It brings on many changes
And I can take or leave it if I please.
The only way to win is cheat
And lay it down before I'm beat
And to another give my seat
For that's the only painless feat.
That suicide is painless
It brings on many changes
And I can take or leave it if I please.
The sword of time will pierce our skins
It doesn't hurt when it begins
But as it works its way on in
The pain grows it grin, but...
That suicide is painless
It brings on many changes
And I can take or leave it if I please.
A brave man once requested me
To answer questions that are key
Is it to be or not to be
And I replied 'oh why ask me?'
That suicide is painless
It brings on many changes
And I can take or leave it if I please.
'Cause suicide is painless
It brings on many changes
And I can take or leave it if I please.
...and you can do the same thing if you please.

This is the lyrics to the theme song to the 1970 movie MASH. An instrumental version was used for the TV series (1972-1983). The lyrics were removed from the TV series because the issue of suicide was very controversial, especially since it aired during prime time. 

You can hear the song and see the "funeral" scene here:

The music for the "M*A*S*H" theme song was written by Johnny Mandel. The lyrics were written by Mike Altman, the 14-year-old son of the film's director, Robert Altman. It was originally penned for a scene in the movie, where a faux funeral was staged in hopes of talking a suicidal character out of his plans. Two of the men at the unit sang "Suicide Is Painless." An instrumental version of the song was subsequently used as the theme for the TV series. (Source: Yahoo TV)

Some people may say that this scene and song is inappropriate but it it is NOT.  The most important line of the song is: "And I can take or leave it if I please."This says that you DO NOT have to do it. There is hope.

A Physician Advocating for Physicians

Pamela Wible M.D., is a physician who suffered burnout. She found a way out. As a result, the care that she offers her patients is exactly what I advocate for. You can see her web site/blog here: She has a video on YouTube titled: "How to get naked with your doctor" (see below).

One of the most repeated comments about this video is "I would get naked for her." That is because of the trust that she instills. It is because she treats her patients as human beings and NOT like living cadavers on an assembly line. I wish that she was on the East Coast because I would try to deal with my medical phobia by seeing her.

A Cry for Help

Suicide attempts are said to be a cry for help. Robin Williams suffered addiction and depression. These go hand-in-hand. Many times addiction is the result of trying to self-treat depression. Depression can also be the result of the hopelessness of enslavement to addiction.

Note: This is my opinion, not medical advice (take it for what it's worth):

I feel that thoughts of suicide are normal. Especially for people like physicians. They play countless simulations of "what if" scenarios in their head. That is how you solve problems. It is not surprising that suicide might be an option. This is actually healthy when you realize that suicide is a bad option, when you realize all the people you hurt with this choice.

Thoughts of suicide become unhealthy when they become reoccurring, persistent, or seem like a rational option. Just like "First, do no harm," remember all the people who will be hurt, feel guilt (for not being there for you), all the people you could have helped but won't (because you are not there, and so on...

Some people have argued with me on "thoughts being normal," but consider "do not resuscitate advanced directives" or cancer patients refusing chemotherapy. It is about "quality of life." There are certain circumstances where the choice of death is acceptable (even to providers). It is NOT acceptable when the body is healthy.

I deal with really bad industrial accidents. I have to interview survivors and make sure that they are referred to counseling if needed. Many are reluctant to "relive" the events, some suffer PTSD. I tell them two things: First, this was a horrible tragedy that you went through, but you are going to wake up tomorrow. They will get through whatever, it may hurt, but life goes on.

Second; acknowledge the pain, deal with the pain, get help, but don't dwell upon that. If their mind is on that, then they may get hurt at work or hurt someone else. The point is, it may hurt, but you will get through it. Getting help makes it easier. The worst thing is NOT to ask for help if you need it. 

Why Do I care?

First it is the right thing to do. I would feel awful if i could have helped someone and did not. Just as bad, if I caused someone mental distress and did not consider the possible consequences.  Our actions have consequences. As I said before, I am NOT against physicians.

 For I was hungry and you gave me food, I was thirsty and you gave me drink, a stranger and you welcomed me, naked and you clothed me, ill and you cared for me, in prison and you visited me.' Then the righteous will answer him and say, 'Lord, when did we see you hungry and feed you, or thirsty and give you drink? When did we see you a stranger and welcome you, or naked and clothe you? When did we see you ill or in prison, and visit you?' i And the king will say to them in reply, 'Amen, I say to you, whatever you did for one of these least brothers of mine, you did for me.' Then he will say to those on his left, 'Depart from me, you accursed, into the eternal fire prepared for the devil and his angels. For I was hungry and you gave me no food, I was thirsty and you gave me no drink, a stranger and you gave me no welcome, naked and you gave me no clothing, ill and in prison, and you did not care for me.' Then they will answer and say, 'Lord, when did we see you hungry or thirsty or a stranger or naked or ill or in prison, and not minister to your needs?' He will answer them, 'Amen, I say to you, what you did not do for one of these least ones, you did not do for me.' Matthew 25:35-45

I preach that providers do not realize the trauma that their actions cause patients. How could I not believe that what I say here, despite being the truth, could not harm someone? Imagine a physician (or other provider) realizing after reading my blog and (possibly) becoming a patient themselves, what I say is true and that for years the experiences that some of their patients may have had with them was the equivalent to being RAPED?

Take someone already depressed and show them that they "are a serial rapist." (I know this is an extreme view, but this is how many patients actually feel.) Still, we blame the system.

If you think you MIGHT need help, talk to someone: a friend, a priest, a family member... there are more people that love you and care for you than you realize. Don't say that you have no one that cares about you. If you think that, I am about to prove you wrong... to me because I care about you. 

The best choice is:

If you are in crisis, call 1-800-273-TALK (8255) 
National Suicide Prevention Lifeline


Thursday, August 7, 2014

Patient Dignity 14: Video Recording Patients

There has been some ongoing debate about teaching institutions recording patients for "research" or "teaching" purposes. I am not addressing those issues here. What I am going to address is that:


The patient can revoke consent at any time, should be given a copy of the "raw" recording, and must give final approval of the finished product.

On October 28, 2013, Bob Wachter M.D. posted an article on KevinMD titled: "How video can reduce medical errors and improve patient care." The article was originally posted on his web site "Wachter's World" titled "Lights, Camera, Action… In Healthcare" where you could buy his books, book him for a speaking engagement....

He starts out by telling the store of how he improved his golf swing with video recording. He goes on to list the beneficence of video recording. He states:
Yet we hardly ever use this extraordinarily powerful tool in healthcare. Thankfully, that’s beginning to change. Earlier this year, Johns Hopkins surgeon Marty Makary published a JAMA article entitled “The Power of Video Recording.” It’s a thoughtful and eye-opening piece, well worth a read.

It seems that Johns Hopkins is leading the nation in the video recording of their patients. Take another Johns Hopkins advocate of video recording patients: Dr. Nikita Levy.

Dr. Nikita Levy had secretly taken videos and photos of his patients' sex organs. A federal investigation led to discovering roughly 1,200 videos and 140 images stored on computers in his home. 
This is one of the largest on record in the U.S. involving sexual misconduct by a physician, $190 million. It seriously threatened the reputation of one of the world's leading medical centers (that advocates video recording of patients).  
62 girls (children) were among the victims, and that Levy violated hospital protocol by sending chaperones out of the exam room.   
Hopkins sent out letters to Levy's entire patient list last year, apologizing to the women and urging them to seek care with other Hopkins specialists (who also video record patients, maybe?) 
But hundreds were so traumatized that they "dropped out of the medical system," and some even stopped sending their children to doctors, the victims' lead attorney, Jonathan Schochor said.

You can read more about Dr. Levy here:

Update: Auguse 14, 2014

I just came across the following article, "Google Glass Enters the Operating Room" on the New York Times website.

DURHAM, N.C. — Before scrubbing in on a recent Tuesday morning, Dr. Selene Parekh, an orthopedic surgeon here at Duke Medical Center, slipped on a pair of sleek, black glasses — Google Glass, the wearable computer with a built-in camera and monitor. 
He gave the Internet-connected glasses a voice command to start recording and turned to the middle-aged motorcycle crash victim on the operating table. He chiseled through bone, repaired a broken metatarsal and drilled a metal plate into the patient’s foot. 
Dr. Parekh has been using Glass since last year, when Google began selling test versions of its device to thousands of handpicked “explorers” for $1,500. He now uses it to record and archive all of his surgeries at Duke, and soon he will use it to stream live feeds of his operations to hospitals in India as a way to train and educate orthopedic surgeons there. 
“In India, foot and ankle surgery is about 40 years behind where we are in the U.S.,” he said. “So to be able to use Glass to broadcast this and have orthopedic surgeons around the world watch and learn from expert surgeons in the U.S. would be tremendous.” 
At Duke and other hospitals, a growing number of surgeons are using Google Glass to stream their operations online, float medical images in their field of view, and hold video consultations with colleagues as they operate. (Source: NY Times website)

Surgeon tests Google Glass in the operating room

SEATTLE -- When Dr. Heather Evans, a trauma surgeon at Seattle's Harborview Medical Center, stepped into the operating room wearing an eyeglasses-like, Internet-connected device known as Google Glass, she quickly realized its potential and its pitfalls... 
...Like other surgeons, Evans is excited about the potential of this new device. But she also has learned that Glass has technical issues that, for now, make it less than ideal in the operating room, as well as difficult privacy concerns.
Some arise because of complex federal privacy laws, which govern the transmission of patient information, including photographs or videos. Other privacy issues come up just from wearing Glass. 
If she wore Glass down the hospital hallway, Evans said, she could be accused of violating privacy. 
Glass has particularly prickled privacy advocates, even earning its own Urban Dictionary epithet -- "Glasshole" -- for those who flaunt their early access, wear Glass into private spaces such as restrooms or instruct the device -- "OK, Glass, take a video" -- in public.Despite such fears, Evans had some specific tasks for Glass in mind when she applied to be an early explorer. 
To win her spot, she linked to a YouTube video showing an event rarely caught on camera: a man's heart attack and resuscitation. A BBC crew, shooting a documentary on an emergency helicopter service, had just arrived at its office when the dispatcher suddenly slumped. 
The crew kept the cameras rolling as emergency workers gave the man CPR and shocked him with a defibrillator, saving his life. (Source: TH Online)

I can see the advantages that Google Glass to look up something quickly, I can even see the advantages for teaching. Here is the problem:

All information is transferred and stored on Google's servers, if a violation occurs, there no way to delete and guarantee the images/video are deleted.

Don't believe me? Consider Google's own policy on the Glass:

Google accused of hypocrisy over Glass ban at shareholder shindig 
Google's directors were accused of hypocrisy over a regulation banning attendees at its annual shareholder's meeting in California from wearing Google Glass hardware at the event. 
"Cameras, recording devices, and other electronic devices, such as smart phones, will not be permitted at the meeting. Photography is prohibited at the meeting," attendees were told, something that rankled with Consumer Watchdog's privacy policy director and Google shareholder John Simpson. 
"Google Glass is a voyeur's dream come true," Simpson said, citing the need to protect children. "It seems to me to be a little bit hypocritical to actively abet and aid possible privacy violations by so many others outside but so jealously protect your own privacy." (Source: Iain Thomson, The Register)

A Voyeur's Dream Come True

The potential for abuse is staggering and there are very few laws to protect people.

Existing laws need to be rewritten as they are not phrased well enough to deal with these immoral and reprehensible acts. The Massachusetts highest court ruled last week that a man who took cellphone photos up the skirts of women riding the Boston subway did not violate state law because the women were not nude or partially nude. The court ruled that existing Peeping Tom laws protected people from being photographed in dressing rooms and bathrooms when nude or partially nude, but did not protect clothed people in public area. (Source: Lucius on Security)

 Even Nudists Fear Google Glasses
Nudists already know about the way that camera-equipped cell phones have altered the balance of privacy on beaches and in clubs.  While clubs have rules regulating their usage, it’s not always easy to tell the difference between someone holding a normal conversation and one who is trying to invade others’ privacy by taking unwanted pictures.  Imagine if the world becomes heavily populated with people who depend on their Google Glasses for directions and communications.  Now imagine trying to determine whether someone wearing such glasses on a nude beach is simply texting a friend or uploading footage to a You Tube account. (Source: Bare Platypus Blog)

Google glasses prompt personal privacy fears
Nick Pickles, director of privacy campaign group Big Brother Watch, said: “Google Glass doesn’t just challenge our assumptions about consent, it challenges whether we even have a choice any more. 
“It makes it seem perfectly normal to collect data on other people, without ever asking their permission and that is a dangerous step that poses a fundamental threat to our current notion of privacy. 
“People wearing Google Glass don’t own the data, they don’t control the data, and they definitely don’t know what happens to the data.
“This is turning members of the public into a Google army, collecting data for the sole benefit of selling advertising and boosting Google’s profits.” (Source: Irish Examiner)

Video Voyeurism is a Crime in Some Places Already

Before his original March 11 sentencing on five counts of video voyeurism, Hughes, 28, apologized for sneaking around with his smartphone and recording about 30 videos in the women's bathrooms at Patch Reef and Red Reef parks. 
In his April 30 motion for a reduced sentence, the attorney asked Burton to consider that another judge on April 3 imposed only a one-year jail sentence and five years probation on former Florida Atlantic University librarian Seth Thompson, 40, of Lake Worth. 
Thompson secretly filmed men while they urinated in campus bathrooms and then uploaded videos onto pornographic websites, according to court records. (Source: Sun Sentinel)

Patients expect more privacy in a hospital/doctor's office than in a public restroom. What else can I say???

--A. Banterings

Wednesday, August 6, 2014

Patient Dignity 13: Virginia Doctors Make Fun of Patient Under Anesthesia

FAIRFAX, Va. (CN) - Doctors mocked an unconscious colonoscopy patient, joking that he has syphilis and talking about firing a gun up his rectum, says a man whose cellphone allegedly captured audio of the entire affair.

     Plaintiff D.B. sued Safe Sedation LLC and Safe Sedation Management in Fairfax County Court, alleging defamation and infliction of emotional distress.

     "On April 18, 2013, during a colonoscopy, plaintiff was verbally brutalized and defamed by the very doctors to whom he entrusted his life while under anesthesia," the complaint states.

     D.B. claims that Tiffany Ingham
, M.D. and Soloman Shah, M.D., who are not named as defendants, mocked him from the second the anesthesia kicked in.

     D.B. claims he had inadvertently left his phone in the room, set to record, having neglected to turn it off after recording instructions for post-operative care.

     "The moment that plaintiff became unconscious, Tiffany Ingham, M.D. commented to all of the others in the operating room 'Oh - Oscar Mike Goss.' That is a thinly disguised substitute for the expression 'OMG', which is an expression of both exasperation and mockery, and is a well-known abbreviation for 'Oh my God,'" the complaint states.

     It adds: "Tiffany Ingham, M.D. started to mock, and then continued to mock, the amount of medicine required to anesthetize plaintiffs.

     "Referring to plaintiff, Soloman Shah, M.D. commented that a teaching physician known to both him and Tiffany Ingham, M.D. 'would eat him for lunch.'

     "Tiffany Ingham, M.D. agreed that plaintiff would be 'eaten alive' and also jokingly discussed a hypothetical of firing a gun up a rectum."

     D.B. claims his phone caught Ingham talking to his unconscious self, saying, "And really, after five minutes of talking to you in pre-op I wanted to punch you in the face and man you up a little bit."

     The tape allegedly caught the doctors discussing D.B.'s prescription medication and an irritation on his penis.

     "A medical assistant at GMA touched plaintiff's penis during the colonoscopy," the complaint states. "Although plaintiff's penis is not involved in a colonoscopy, the medical assistant noted there was not 'much of a penile rash.' Tiffany Ingham, M.D. responded, 'No, you'll accidentally rub up against it. Some syphilis on your arm or something.' Solomon Shah, M.D. responded, 'That would be bad. That would be real bad.'"

     The complaint adds: "Tiffany Ingham, M.D. then stated to all present in the operating suite that, 'It's probably tuberculosis in the penis, so you'll be all right.'"
     D.B. says he doesn't have either disease.

     The complaint states that the doctors talked about "misleading and avoiding" him after he woke up.

     "A female medical assistant at GMA recalled that plaintiff had earlier warned that he passes out when looking at the placement of an IV, to which Tiffany Ingham, M.D. asked 'Well, why are you looking then, retard?' the man claims. "Tiffany Ingham, M.D. also described plaintiff as a 'big wimp.'"

     He claims the doctors continued to discuss how to avoid him after he woke up, and mocked him for going to Mary Washington College, suggesting that "it was unsurprising that plaintiff attended a college that at one time was a 'women's college,' a 'girl's school,' and wondered if plaintiff was gay."

     The complaint states: "Tiffany Ingham, M.D. stated, 'Are you implying that he's gay? Because I know gay men that have more manliness than' the plaintiff. 'And I'm sure I know gay men in the military who just haven't let it be known that they're gay who are manly.'"

     In a final remark caught on tape, Ingham allegedly said she would make a note on the man's file that he had hemorrhoids even though he didn't.

     D.B. claims that he and his wife discovered that the procedure had been recorded on their ride home, listening in disgust.

     "Plaintiff has suffered distress, including embarrassment, loss of sleep, and mental anguish, as a direct and proximate result of the conduct of defendant's agent Tiffany Ingham, M.D.," he says.

Tiffany Ingham, M.D. also described plaintiff as a 'big wimp.' 

Monday, August 4, 2014

Patient Dignity 12: Does a Patient Have the Right to Choose the Level of Care He Wishes to Receive?

Does a Patient Have the Right to Choose the Level of Care He Wishes to Receive?

Why is it "All or Nothing" "My Way or the Highway?"

Medicine recognizes a Patient's Right to Self-Determination (and the right to choose the level of service they receive) in "Advanced Directives." But very often physicians ignore advanced directives (see: NY Times Article here). A study published in the Oncology Times (here) also supports this.

If as a patient I just want my heart, lungs, BP, cholesterol, and sugar checked, WHY DO I HAVE TO SUBMIT TO A PROSTATE EXAM?

If I refuse a prostate exam, I do expect you to talk to me about options: PSA test, ultrasounds, etc. I don't expect you to diagnose me if I get prostate cancer and refused ALL tests. Just because a patient refuses a procedure (DRE), does NOT mean that they refuse prostate health.

If I have lung cancer, I would expect that you catch that.

Resistance of the Patient as a Consumer

Providers resist the idea that patients are consumers. I agree (believe it or not). So why do patients fall back on this notion? Because the lack of respect for our self-determination. You can not deny that healthcare is subject to some of the forces that govern the economics of trade: supply and demand for instance.

If providers respected patients' rights to self-determination, to choose the level of car we wish to receive, each individual's definition of what our (individual) definition of dignity is, and accommodate it to the extent possible (NOT to the extent that it is convenient), then we would not see ourselves as consumers.


The problem is inconsistency. Many patients can have a positive, caring, trusting relationship with their provider and never take their pants off.  We hear the phrase, "I can't give you the best care if you don't..."

Take the issue of having to remove your underwear for outpatient hand surgery. Consider the the standard procedure for prepping a patient for all surgery, including outpatient: naked wearing only a gown, wheeled into the OR on a gurney. Consider what LDS Hospital in Salt Lake City, Utah did as part of their overhaul of healthcare delivery in 1998:

SOME PATIENTS were especially bothered to spend half the day without underwear -- for shoulder surgery, say. Ms. Lelis was convinced this longstanding practice was meaningless as a guard against infection, persisting only as the legacy of a culture that deprived patients of control. "If you're practically naked on a stretcher on your back," she says, "you're pretty subservient." The nurses persuaded an infection-control committee to scrap the no-underwear policy unless the data exposed a problem; they have not. Source: The Wall Street Journal

So if LDS Hospital in Salt Lake City, Utah has been doing this since 1998, why are all hospitals NOT doing this? When providers give us ANY EXCUSE (NOT REASON), it boils down to "this is how we have always done it." As patients we know the real reason, we know that you are lying, and we don't trust you. 

Building Trust

It would be far better to allow us as patients to choose our level of healthcare that we are comfortable with. Then build our trust, work with us, and if you have earned that trust, we WILL TAKE A CHANCE ON YOU. 


Patient Dignity 11: Fear of Doctors

 While it is normal for anyone to have a certain level of discomfort or fear related to medical exams or  procedures, some people fear them so much that they will avoid medical treatment altogether, or exhibit other forms of avoidant or anxious behavior.

Tomophobia: refers to a severe and irrational fear of surgery or surgical operations. While it is natural for anyone to be nervous when they know they have an impending surgery, surgery represents a situation far too dangerous and life threatening to undergo for the tomophobic.Nosocomephobia: is overwhelmingly afraid of hospitals. Nosophobia: is an uncontrollable fear of a specific disease, versus other phobias that are fears of all diseases.Pharmacophobia: is a fear of medication, usually pills or injections.Trypanophobia: is the extreme fear of hypodermic needles or injections in medical procedures.

Fear vs Phobia

Fear has been described as a normal response to threatening stimuli, and involves three response systems:
  • physiological arousal
  • covert feelings and thoughts and
  • overt behavioural reactions.
Often this arousal is disproportional to the actual stimuli or even completely misapprehended in the actual situation.
Think of  FEAR as an acronym for: "False Expectations Appearing Real".
Phobias, however, can be described as unreasonable responses to a benign stimulus which results in one of the three elements of fear being excessively and persistently activated.
(Source: The Nurse Path)
When we are ill or just to try and stay in good health, visiting a physician or doctor seems to be the obvious choice. During these examinations, professionals are able to recommend proper treatments. If we make the personal choice to avoid medical exams and treatments, our health will obviously suffer.

However, avoiding medical treatment is much more of a choice for some than it is for others. For some, receiving medical treatment can be absolutely terrifying and a catalyst for anxiety attacks. Medical experiences can cause a person severe panic attacks and usually leads to an avoidance of healthcare, even when it is needed.

Recognizing Phobias in the Healthcare Setting

A 2009 study, "Tomophobia, the phobic fear caused by an invasive medical procedure - an emerging  anxiety disorder: a case report physiological arousal covert feelings and thoughts and overt behavioral reactions,"came to the following conclusion:
Due to the rising number of surgical interventions in modern medicine, as well as the high number of  unrecognized cases of tomophobia, this common but underdiagnosed anxiety disorder should be  highlighted.

Here are excerpts from the case:
The patient was a 69-year-old Caucasian man without a history of mental illness or any previous psychiatric treatment. He was initially transferred to a medical emergency department with marked dyspnoeic symptoms and tachycardia, where an acute coronary syndrome was diagnosed. After laboratory testing and an electrocardiogram a non-ST elevation myocardial infarction (NSTEMI) was diagnosed. The following coronary angiography (an intervention that was endured by the patient with enormous dread), revealed severe three-vessel disease. 
The patient was informed of the urgent indication of a bypass operation, which was planned as an emergency intervention on the same day. At the end of the angiographic intervention, this information caused a severe panic reaction with hyperventilation, tachycardia and the feeling of loss of control, which was successfully treated with benzodiazepines. He described an intensely irrational and unavoidable fear of putting himself in the hands of others -surgeons and anesthetists in this case. Moreover, the fear of losing control of his body through loss of consciousness or compromise of physical integrity during an operation or surgical intervention was reported. The patient was not able to give his agreement for the operative intervention because of overwhelming panic and anxiety. Due to his intense fear he eventually refused the bypass operation...
...The psychopathological findings at the time of psychiatric exploration were limited to intense fear in relation to the forthcoming surgical procedures and interventions. During the psychiatric exploration, the patient was polite, friendly, and honest. Compulsive symptoms were limited to the repeated checking of electric appliances. As a consequence of his lifelong avoidance strategies he seemed not to feel oppressive limitations in everyday life. Until then, he had never consulted a psychiatrist or a psychotherapist regarding his phobic symptoms. He described being ashamed of his unreasonable fear symptoms. Panic disorder symptoms were not observed at any time during the psychiatric exploration. No history of syncope was found. Family history revealed a suspected anxiety disorder in the patient's father, although he reportedly never consulted any physician or other healthcare professional. Further examinations of the patient such as laboratory tests, duplex sonography, an electroencephalogram and a cranial magnetic resonance imaging were entirely normal. A Specific Phobia was diagnosed according to DSM-IV criteria... 
...Our patient neither experienced syncope nor symptoms of massive disgust while being confronted with the phobic stimuli, but he complained of intense fears related to the impending operation. Considering the absence of disgust response and fainting, the assignment to the situational subtype or a combined form of phobia could be the more appropriate diagnostic category for the reported case of tomophobia. 
Bienvenu et al. reported a study of 1920 subjects, which showed a prevalence of the "blood-injection-injury" phobia of 3.5%. None of these patients was receiving mental health treatment specifically for phobia [6]. With regard to tomophobia, the number of undiagnosed cases might be much higher than the number of cases that are actually diagnosed, possibly because repression and avoidance of feared situations are the leading behaviour of these phobic patients. The majority of patients suffering from specific phobia do not seek professional psychiatric or psychotherapeutic help (only 12-30% do) unless they have a comorbid disorder [1]. In addition, the presence of "blood-injection-injury" related symptoms worsen the prognosis of panic disorder and agoraphobia [7]. 
Due to progress in the development of invasive treatment and an increased number of established intervention procedures in modern medicine, cases of diagnosed tomophobia might increase in the near future. Above all, surgeons and general physicians may be increasingly confronted with patients who refuse medically urgent procedures due to tomophobic fears. Our patient became symptomatic when he was informed about the indication of the necessary operation. The patient's refusal of the surgical intervention can be comprehended as typical avoidance behaviour as a result of his permanent phobic disorder. The patient was always cognitively capable of understanding the consequences of his unreasonable decision, but the fear of impairment of physical integrity and of losing control while accepting the bypass operation was greater than the fear of dying as a consequence of the detected heart disease... 
...Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Another Article

There is an article on WebMD, "Beyond 'White Coat Syndrome.'"I realize the amount of skepticism providers put in WebMD, but it was reviewed by an MD. Here are some excerpts from that article:
When Dorothea Lack was a little girl, she hid under a doctor's desk to avoid a vaccination. Undaunted, the doctor crawled under the desk and vaccinated her then and there. Lack said the incident provoked a fear of doctors that followed her into adulthood. "I didn't feel I could trust them," says Lack, PhD, now a psychologist who performs research on doctor-patient relations. 
It's a rare soul who truly enjoys visiting the doctor. But for a significant minority of the population, fear and anxiety prevents them from getting vital care. The problem has grown in importance with medicine's increasing emphasis on preventive care. Screenings such as mammograms, colorectal exams, cholesterol checks, and digital rectal exams can save lives, but only if people are willing to submit to uncomfortable procedures well before symptoms have emerged... 
...Our health care anxieties have many sources, Consedine (Nathan Consedine, PhD, a health psychology researcher at Long Island University) says. We fear the prospect of a painful procedure; we're embarrassed about being naked or being touched; or we fear being criticized for unhealthy behavior. The most common fear is of a bad diagnosis, which helps to explain why as many as 40% of women who receive abnormal mammogram results do not submit to a follow-up test as recommended by a physician, Consedine says. "People just want to stick their heads in the sand." 
Lack believes the American health care system tends to exacerbate these anxieties. Doctors are busier and less likely to build long-term relationships with their patients, and news stories about medical errors abound. The result is a reduction in trust in doctors and hospitals that can frighten people away from care. One of Lack's patients who suffered a bone fracture avoided a hospital because of news about the prevalence of hospital-based infections. As a result, the bone healed improperly, Lack says... 
Needle-phobes experience panic attacks, lightheadedness, or fainting when exposed to a needle, according to the author, James G. Hamilton, MD. (Hamilton says that 80% of patients with needle phobia also report the fear in a close relative, suggesting the phobia has a genetic component.) 
A 2006 study showed that 15 million adults and 5 million children reported high discomfort or phobic behavior when faced with a needle. Nearly a quarter of those 15 million adults said they refused a blood draw or recommended injection because of fear. (The study, which extrapolated from a survey of 11,460 people, was commissioned by Vyteris, Inc., a company that makes a patch, called LidoSite, designed to relieve needle pain.) Hamilton estimates that needle phobia "affects at least 10% of the population." 
"Blood tests are one of the most important diagnostic tools modern medicine has at its disposal," Mark Dursztman, MD, a physician at New York Presbyterian Hospital, said in a news release announcing the study findings. Fear of needles, therefore, is "an important public health issue." 
Hamilton says needle-phobic patients deserve to be recognized as suffering from an involuntary condition rather than being made to feel like "wimps" or "oddballs."

I like how the subject of the WebMD article (Dorothea Lack, PhD, psychologist) acknowledges that it was her experience being vaccinated as a child that lead to her fear of doctors. Nathan Consedine, PhD, a health psychology researcher at Long Island University acknowledges the fear some people have of being naked or being touched.

Some of these experiences may be traumatic, especially for children. Many people who suffer from fears, phobias, or PTSD from healthcare trace their roots to childhood experiences. What may not seem scary to an adult (like a vaccination or being exposed for a physical exam) may be terrifying to a child. The event becomes when the child is forced to endure it. Being exposed for a physical exam further traumatizes the patient when there are additional people in the room (students, chaperones, nurses).

How Trauma Disorders Form And What Causes Them

Trauma disorders form after major events that are deemed traumatic to a patient; while many trauma survivors don’t form disorders, those who do can display many different symptoms. “Trauma” is arguably subjective.

The Symptoms Of Post-Traumatic Conditions

People with trauma disorders may display a wide range of symptoms. The type and extent of symptoms may help to diagnose the disorder. Some symptoms include feelings of disassociation and depersonalization or forming a new identity. These occur after major trauma, but other coping mechanisms may be less severe or noticeable. 

The Conflict

The major issue that people suffering from fears, phobias, or PTSD are labelled as "mentally ill." While the  DSM-IV listing legitimizes these fears, healthcare BLAMES the patient, especially when it is healthcare that caused the problem.

We'll create the cure; we made the disease,  (song: Misery, by artist: Soul Asylum, 1995)

Most doctors are good doctors in the eyes of most patients. Patients want to trust their doctors. A article in the British Journal of Medicine, titled "Patients' views of the good doctor," states:
Patients increasingly expect to participate in decisions about their care, but these aspirations are rarely met...
...Themes that were most commonly mentioned included honesty, openness, responsiveness, having one's best interests at heart, and willingness to be vulnerable without fear of being harmed.

If a good provider does everything correctly (by that I mean meeting the patient's needs, and not traumatizing the patient, that only affects the next (single) encounter, traumatize the patient, and that affects ALL the subsequent  encounters with ALL providers.

Why is this so hard to grasp for most providers?


Patient Dignity 10: Paternalism and Pretending to Care

I recently read a very disturbing article on titled, "Incorporate empathy in patient interactions."

It seems like a good idea one would think, until you read the article. The second sentence in the second paragraph states, "The greater the sense of trust, the more likely the patients will be compliant."

Empathy is used Machiavellianly to achieve patient compliance. That is paternalism at it's worst. That is no better than one person saying "I love you" to a partner just to get them to buy gifts. How could the empathy be genuine then?

This shows the worthlessness of the "patient's bill of rights" that all providers have. They are in fact worthless, they are NOT a binding contract. They just make the patient feel warm and fuzzy like they are actually participating in their own healthcare.

The "patient responsibilities" part, which always include "follow the physician's plan for treatment" are a direct contradiction to the "patient participation" part. The "patient responsibilities" only allow the physician to give the patient a "demerit" or justify firing them as a patient.

The beginning of the article only reenforces my point; do you think the insurance company is actually empathizing with people or just trying to get them to buy insurance?

If a physician reads this article and the next day tries to empathize with patients, don't you think they will see right through that. Physicians who actually care don't need to be told this. And there are many physicians who do actually care (and empathize) about their patients.

How would physicians feel about an article that tells patients to pretend to follow their physician's treatment plan, then return and say it is not working. Suggest a hybrid plan of the physician's plan and yours. The physician may suggest staying on the course of treatment or change it to something different. You may have to do this a couple times. Once he concedes to the hybrid plan, report that you feel better (but not enough), but you want to try altering the course of treatment.

Forgive me for saying this, but when is healthcare going to figure out that it is about the view of the patient?