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:)

Pressure

  • 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?

ABUSE IN CHILDBIRTH: PARALLELS WITH DOMESTIC ABUSE  
According to domesticviolence.org (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.


--Banterings



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