Wednesday, March 30, 2016

How to Create a Sociopath: Part 5

How to Create a Sociopath: Part 5

This is an expansion of my original post Patient Dignity 16: From Mother Theresa to Dr. Mengele  that examines how medical school creates sociopaths. Much of the insight is derived from research in to how seemingly normal people could become Nazis and commit such human atrocities.

The link to my insights into modern medical schools creating sociopaths is the fact that physicians had been the largest professional group to join the SS.  The object of their acts were not how to rescue or cure, but to destroy and kill.

Table of Contents

Original Post: Patient Dignity 16: From Mother Theresa to Dr. Mengele 

How to Create a Sociopath: Part 1
How to Create a Sociopath: Part 2
How to Create a Sociopath: Part 3

In regards to gender, patient dignity, etc., the focus of healthcare has always been primarily about healthcare. Patients are secondary. Just like the medieval guilds, healthcare sought narrow regulation of the industry in order to restrain competition against encroachment from outside competition. (Source: A Tale of Two Theories: Monopolies and Craft Guilds in Medieval England and Modern Imagination)

The first AMA Code of Ethics, is all about the patient’s duties to the doctor, not what the doctor owes the patient. To see more how healthcare view the patient in its inception, read Victorian medical ethics and the subordinate patient.

Society granted physicians status, respect, autonomy in practice, the privilege of self-regulation, and financial rewards on the expectation that physicians would be competent, altruistic, moral, and would address the health care needs of individual patients and society. This "arrangement" remains the essence of the social contract. 

...The professions arose in the guilds and universities of medieval Europe and England. They had little impact on society until science made health care worth purchasing and the industrial revolution provided sufficient resources so that society could afford it. Some means of organizing health care was required and society turned to the preexisting concept of the profession. This occurred in the middle of the 19th century, when licensing laws were passed granting the medical profession a monopoly over the use of its complex and expanding knowledge base, thus establishing the basis of the modern social contract. (Source: AMA Journal of Ethics)

Let me demonstrate another example of "guilds" looking out for their own self interest at the cost of human dignity:

PREA is the acronym for the Prison Rape Elimination Act. After decades of societal indifference to prison rape, Congress, in a rare show of support for inmates’ rights, unanimously passed the Prison Rape Elimination Act in 2003.

The law describes prison rape as epidemic. It refers to“the day-to-day horror of victimized inmates, and of the need for Congress to protect the constitutional rights of prisoners in states where officials displayed deliberate indifference.

It took almost a decade for the Justice Department to issue the final standards on how to prevent, detect and respond to sexual abuse in custody. And it took a couple of years more before governors were required to report to Washington, which revealed that only New Jersey and New Hampshire were ready to certify full compliance.

What took so long? Resistance was coming from (and still is) from many correctional agencies. The 52 standards for prisons and jails apply to everything from hiring and staffing levels to investigation and evidence collection to medical treatment and rape crisis counseling.

With the second annual reporting deadline, advocates for inmates and half of the members of the National Prison Rape Elimination Commission (a bipartisan group charged with drafting the standards) say the pace of change has disheartened them despite pockets of progress.

“I am encouraged by what several states have done, discouraged by most and dismayed by states like Texas,” said Judge Reggie B. Walton of United States District Court for the District of Columbia, who was appointed chairman of the now-disbanded commission by President George W. Bush.

Some commissioners fault the Justice Department for failing to promote the standards vigorously. Others blame the correctional industry and unions for resisting practices long known to curb “state-sanctioned abuse,” as one put it. All lament that Congress has sought to weaken the modest penalties for noncompliance, and that five governors joined Governor Perry last year in snubbing the standards. The other renegade states, as advocates called them, were Arizona, Florida, Idaho, Indiana and Utah.

But states face only a small penalty, the loss of 5 percent of prison-related federal grants, if they opt out of the process entirely. There are a lot of carrots in PREA, and not enough sticks.

Texas’ opting out was considered especially significant, however, because it has the largest prison population in the country and by far the most reports of sexual assault and abuse. Texas had three and a half times as many allegations as California in 2011, when California still had more inmates than Texas (according to the federal data).

Texas state officials found some standards particularly intrusive. Governor Rick Perry protested that limitations on cross-gender strip searches, pat downs and bathroom supervision would force Texas to discriminate against its female officers.

One of the lessons of The Third Wave experiment (conducted by schoolteacher Ron Jones's which he created a proto-fascist movement amongst his high school pupils in Palo Alto, California, in 1967) was that organizations are self serving of their own best interests.

By the latter part of the 20th century, however, many social scientists concluded that the profession had abused its privileged status and public trust, and that its regulatory procedures were seriously flawed. (Source: AMA Journal of Ethics)

If healthcare really cared about the dignity of patients, then Tuskegee would not have happened, pelvic exams on anesthetized women would not have occurred and we would STILL been having that conversation in 2012.

The AMA Journal of Ethics alludes to there being something other than gender in Patient Requests for a Male or Female Physician. It refers to a study published in Pediatric Emergency Care in 2005 entitled "'Doctor' or 'Doctora': Do Patients Care?" One of the study survey questions was:

"If you had a choice, would you prefer to have a male doctor, a female doctor, or the doctor with the most experience?"

This throws in to the mix another trait; qualification. Those who defend the gender neutrality of healthcare (on this and other blogs) usually say something to the effect, " I don't care if the doctor is male or female, I just want the most qualified."

So I ask, if by the nature of having initials after your name (MD, DO, RN, PA, NP, etc.) negate patient choice, why should qualification (or what we perceive as qualification, like intelligence, education, experience, etc.)? Remember the old joke, "Q: What do you call the person who graduates last in his class from med school? A: Doctor."

Why should all patients, even those in in the healthcare field, NOT just accept the first doctor or surgeon available?

Studies of the effects of physician gender on patient care have been limited by selected samples, examining a narrow spectrum of care, or not controlling for important confounders. 

...Physician gender potentially affects the physician-patient relationship and its outcomes in a variety of ways. Physician gender differences in personality and attitudes, especially with regard to gender roles, might influence interactions with both male and female patients. Patients also may have differential expectations of their physician based on gender. For example, they might expect the female physician to be more supportive and empathic and, thus, to disclose more information. Another way in which physician gender might be important is in the status relationship between patient and doctor. As gender is a substantial component of social status, same-gender physician-patient dyads may be closer in social status (greater status congruence) than opposite-gender dyads.

Source: Physician Gender, Patient Gender, and Primary Care

And where does perception come in to all this? Sociologists and social psychologists have long known that there is a widespread perception shared by many people that physically attractive people are more intelligent and competent, as well as hold many other desirable characteristics.

A large number of experiments over the years have shown that, when asked to rate the intelligence or competence of unknown others, people tend to rate attractive others as more intelligent and competent than unattractive others. (Source: Psychology Today)

So competence is associated with attractiveness. Then the inverse is that people who are less attractive (or creepy) are perceived not as qualified (and not the best doctor).

To further the concept that there is more than gender, why do we not see physicians with visible piercings and tattoos? Answer; dress affects people's perception of physicians. See "Preferences of parents for pediatric emergency physicians' attire" and "Effect of doctor's attire on the trust and confidence of patients.."

But should it? Should patients not just have trust in a physician because they have initials after their name? Is that not what patients are told about gender.

Creepiness is very real. Our “creepy” reaction is both unpleasant and confusing, and according to one study (Leander, et al, 2012), it may even be accompanied by physical symptoms such as feeling cold or chilly. The little bit of research that was at all relevant focused on how we respond to things such as weird nonverbal behaviors, and being socially excluded. These studies did not use the word creepiness, but their results implied that our “creepiness detector” may in fact be a defense against some sort of threat.

So, what is creepiness?

A recent study (currently under review for publication) by Knox College social psychologist Francis McAndrew and his student Sara Koehnke takes a stab at unpacking exactly what creepiness is.

Creepiness universal human response related to the “agency-detection” mechanisms proposed by evolutionary psychologists. These mechanisms evolved to protect us from harm at the hands of predators and enemies. If you are walking down a dark city street and hear the sound of something moving in a dark alley, you will respond with a heightened level of arousal and sharply focused attention and behave as if there is a willful “agent” present who is about to do you harm. If it turns out to be just a gust of wind or a stray cat, you lost little by over-reacting, but if you failed to activate the alarm response and a true threat was present, the cost of your miscalculation could be high.

We evolved to err on the side of detecting threats in such ambiguous situations. Creepiness is anxiety aroused by the ambiguity of whether there is something to fear, and/or by the ambiguity of the precise nature of the threat—sexual, physical violence, or contamination, for example—that might be present.

Gender plays a role:

Note the rating of traits of creepiness, in this chart of the study results (Likelihood of a creepy person to possess certain characteristics), include gender (opposite 4.01, same 2.41).

95% of survey participants thought creeps were more likely to be male than female — a perception that was equally held by both male and female survey respondents. Women were also more likely to perceive a sexual threat from people they deemed creepy.

See a visualization of creepiness in "The Lonely Island's" song "The Creep."

As to every study done on gender preference of a physician (or other healthcare provider), they are ALL flawed! The flaw simply asks for the preference of a male or female physician. There are so many other variables that affect the decision beyond just gender. Here are examples:

In the study, "The role and impact of gender and age on children's preferences for pediatricians," the sample was taken when coming for an outpatient visit to a university-sponsored, urban pediatric practice. This is a population that is are regular patients at selected practices. These patients are already conditioned (or have developed coping mechanisms to deal with that as a traumatic event).

Data from students participating in the Commonwealth Fund 1997 Survey of the Health of Adolescent Girls, only asks the question of preference of the physician (provider) gender, but NOT necessarily for an intimate (genital) exam.

The study, "PHYSICIAN Gender Preference in Adolescent Males within an Inner-City Youth Population," does ask preference of the physician gender, for a genital exam. The problem is that there is an assumption that a GE is absolutely required, the patient has granted informed consent (including knowing that it can be refused without retaliation).

Note: The only absolute indication for a genital exam is a specific genital complaint. Even then, many diagnostics do not require direct genital examination. Many genital conditions can be diagnosed through urinalysis, blood tests, self-collected specimens (swabs), self-exams, imaging, etc. They are not necessary for "mandated" wellness exams (just as wellness exams are no longer necessary). 

One example is a guidline for testicular cancer from "Teaching the TesticularExam:AModel Curriculum From“A”to “Zack”" which states:

"Patient preference would then determine whether these men would be screened by physician examination and/or TSE."

This is like the situation where somebody is wronged erroneously. The wronged person asked the one who committed the infraction, "Head or stomach?" (The inference is that to "make things right," the wronged party is going to give the perpetrator a "punch." They are being polite in letting them choose the "correction.")

One can study this situation and conclude that a certain percentage of people prefer to be punched in the head and a certain percentage prefer the stomach. Let us hypothetically say 80% prefer the stomach. I can then use this to justify me punching people in the stomach. This is what healthcare has done with gender and intimate exams.

In AAP publications dealing with genital exams, their guidelines all state:

"Routinely examining the genitals from childhood through adolescence can help the male patient understand the routine nature of this examination component." (Example: Male Adolescent Sexual and Reproductive Health Care

Note in the study "Shoe Size Changes - Layman's Marker of Onset of Puberty," 23% of the children refused the SMR exam.

To properly study this question the first question should be: "When going to the doctor, for a genital exam I:
C.) would refuse a genital exam
B.) prefer a male doctor
C.) prefer a female doctor
D.) have no preference if the doctor is male or female
E.) would make my choice on some other factor

An ongoing issue in healthcare is the failure of physicians to acknowledge that these situations are humiliating, can have severe negative side effects, let patients know that they can refuse them without retaliation (whether recommended by guidelines or not), and follow guidelines that call for omitting them.

Discussion about sensitive topics and sexual organs can be uncomfortable for both physicians and patients. If not appropriately addressed, this discomfort can result in inadequate patient education about self-examination of sexual organs, with failure to detect early warning signs of cancer. Discomfort may also result in patients feeling physically and psychologically exposed and humiliated, increasing the possibility of withholding important information or even avoiding the physician completely,1 which could potentially delay cancer screening and/or early diagnosis. Source: Teaching the TesticularExam:AModel Curriculum From“A”to “Zack”

Finally, this humiliation can be the source of many frivolous lawsuits. Consider this conclusion from one of the best articles that recognizes Shame and humiliation in the medical encounter:

I believe that most patients who are angry at their physician or at the medical profession are responding to perceived experiences of shame and humiliation. The specific complaints are not that the doctor makes mistakes, misses the diagnosis, causes too much pain, or charges too much. The complaints are that "the doctor does not listen to me," "the doctor tells me I am too fat," "the doctor seems too busy for me," "the doctor treats me like a piece of meat," "the doctor is sexist," "the doctor insults my intelligence," "the doctor thinks my problem is all in my head." Underlying these complaints, I contend, are the emotions of shame and humiliation.

Social scientists argued that medicine had abused its monopoly to further its own interests, had self-regulated poorly, and that its organizations were more interested in serving their members than society.
Source: AMA Journal of Ethics, "Professionalism and Medicine's Social Contract with Society"

...By the latter part of the 20th century, however, many social scientists concluded that the profession had abused its privileged status and public trust, and that its regulatory procedures were seriously flawed. Standards were considered to be weak, variable, and inconsistently applied, and physicians were further accused of using collegiality as a means of shielding poorly performing peers. Medicine was further criticized for its lack of openness and transparency in regulatory procedures and for the absence of public involvement in them. In short, the system appeared to lack accountability, and it was suggested that an informed public should participate in medicine's regulation. Many of these criticisms proved to be accurate and had an impact on both public policy and on the level of trust that the profession enjoyed.

...Since the medical profession's rights to self-regulation are delegated by society via federal and state legislation, society can, if it becomes dissatisfied with the performance of the profession, alter the terms of the social contract and reclaim some of these powers. Following major lapses in self-regulation and a consequent decrease in trust, society has already diminished the scope of medicine's powers (eg, the Office of the Inspector General's new guidelines for physicians' relations with industry)
Source: AMA Journal of Ethics, "The Medical Profession and Self-Regulation: A Current Challenge"

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