Why Patients Dislike Rectal Exams

I came across the following article on the National Institutes of Health's PubMed website: Masculinity and the Body: How African-American and White Men Experience Cancer Screening Exams Involving the Rectum

These are the authors:

• Julie A. Winterich, Ph.D.,
• Sara A Quandt, Ph.D.
• Joseph G. Grzywacz, Ph.D.
• Peter E. Clark, M.D.
• David P. Miller, M.D.
• Joshua Acuña, B.A.
• Thomas A. Arcury, Ph.D.

The purpose was :

"Much of the research on prostate and colorectal cancer beliefs, knowledge, and screening finds that barriers to screening include African-American men’s perceptions that DREs are “embarrassing” and colonoscopies are “offensive,” but none of this literature investigates WHY men report these attitudes."

My first reaction was that that of disbelief. These are well educated people, how could they lack such common sense? But this is the paternalistic problem that medicine has; that just because someone wears a magic white coat or a magic stethoscope, the patient should readily accept what ever indulgences the provider has (no matter how invasive).

Then I looked at this scientifically. The first thing that struck me is the "why." One of my undergrad degrees is a counseling degree. We learned that you never ask "why," but you do ask what the feelings associated with the behavior, incident, object, procedure, etc. Here is a prime example for never asking "why:"

"A financial analyst was convicted Thursday of beating his wife to death with a rock and impaling her heart and lungs on a stake after she complained he had burned their ziti dinner." Source: Associated Press

In this instance, when asked why by a police officer, he said she complained he had burned the ziti again. As a counselor, I know that the complaining was the trigger. Another why is the mass suicide by the Heaven’s Gate,

"They weren’t killing themselves, they thought, but freeing their souls from their so they could ascend to a spacecraft flying in the wake of the Hale-Bopp comet – which at that point was passing by Earth – and were going to be taken to their new home in space." Source: Rolling Stone

The true underlying reasons were cult dynamics at the hands of a mentally ill leader. Why do healthcare providers not accept the reasons of "I just don't want to do that (and it is my RIGHT)" or "I don't like that (and that is just the way that I feel)?" Both are very valid answers, but when pressed, nobody can explain why they feel certain ways, they just know that the feelings are there.

One may not even know what they are feeling (let alone why). All emotions is that they don’t start out as feelings at all but as physiological sensations. So even when a person can’t comprehend their feeling experience, they’re typically aware of what’s happening to them physically. Source: Psychology Today

Emotions are an automatic process in the brain that happens behind conscious thought. We can share emotions with others but not understand what they’re feeling exactly.

When forced to explain something that they cannot, they feel like they are wrong and acquiesce to the provider. This is just one means of forcing compliance from patients. The definitive treatise on coercing patients into compliance with uncomfortable, invasive, or intimate procedures is Behaviour in Private Places: Sustaining Definitions of Reality in Gynecological Examinations by Joan P Emerson.

This summarizes the reasons of asking "why" are futile and fruitless.

It is well established that rectal exams are a barrier to many health screenings, even the annual physical. See: Digital rectal examination is barrier to population-based prostate cancer screening

The results of our study have demonstrated that DRE is a significant barrier to participation in PCa screening.

The invasive, uncomfortable nature of a digital rectal exam (DRE) is well known in healthcare. It is one of the main reasons that men avoid healthcare, especially the annual physical exam. (Reference: ) The DRE increases and reenforces the power differential between the patient and provider and increases the vulnerability of the patient.

Digital rectal exams (DREs) typify much of what’s wrong with our health care system. Men dread going to go get them, they’re unpleasant, they vividly illustrate the physician-patient hierarchy, and — oh, by the way — they apparently don’t actually provide much value. (Source: I Really Wish You Wouldn’t Do That)

The intimate exams are viewed as sexual by many patients despite what medical providers tell them. This again is our feelings and we can NOT tell our minds to simply not feel this way. Our feelings are what they are. See: Rectal exam mistaken for sodomy, a patients personal experience!

When forced upon patients, they see these things as a sexual assault or a rape. See: Rectal exam tried as assault One area that repeated intimate exams have risen to the level of abuse is with intersexed children:

Intersex activist Emi Koyama explains that various routine medical practices and procedures enacted on intersex infants, children, and adolescents constitute “ritualistic sexual abuse of children.” Two examples are the unnecessarily displaying of intersex children’s genitals to numerous other doctors and students, as if their bodies were side-shows to gawk at... Source:

Even the world health Organization (WHO) has deemed this behavior as torture, cruel, inhumane, and degrading. So if repeatedly, these constitute torture, why would they not de disliked?

This statement suggests that he doesn’t seem to fully recognize that the sexual abuse he committed was sexual abuse because it occurred in a medical context. Source: Sexual Assault in Medical Contexts

Indeed saying that this is a medical procedure does not change the feelings of the patient. If the exam is so benign and it is expected that patients willingly accept it, why do medical students no longer practice digital rectal exams on each other?

Policies of medical training institutions state:

"No examination of the breasts, genitals, or anorectal region are permitted between peers. Human patient models will be utilized for training in these aspects of the physical examination."

Concerns that physical exams are not just physically harmful, but also emotionally harmful through embarrassment, coercion or harassment. These concerns do NOT specifically apply to intimate examinations, but to all aspects of physical exams. Intimate exams carry their own additional concerns which medical students strongly oppose. 

All the studies and institutions conclude: "There is no role for peer genital, rectal, or female breast exams in the curriculum."

What about harming real patients? If these exams are so traumatic that medical professionals are unable to conduct on each other to further their education, why are they not traumatic for patients. Even the teachers do not use their bodies to train the students. (This demonstrates there is no existence of medical professionalism.)

The solution has been standardized patients: simulated patients are recruited from the general public to be examined by supervised medical students for teaching purposes in a clinical setting. Not every person can perform the task of enduring intimate exams.

A robotic rectum has been developed to help doctors and nurses detect cancer after only one man registered to allow medical students to examine his prostate. Source: Robotic rectum developed to help doctors get to bottom of prostate cancer

I came up with a modest proposal that would help these researchers find the answer to this question (that to everyone who has ever been a patient, the answer is obvious)...

First, the researchers should procure prostate exam trainer mannequins. The test subjects are instructed by qualified instructors on the proper technique for conducting a digital rectal exam and allowed to practice on the props until they have satisfactorily acquired the skill to properly perform the exam (not necessarily diagnose).

Each study participant will then perform a rectal exam on each of the researchers. Upon completion, the researchers will have gained the knowledge why patients dislike rectal exams.

But that is not going to happen anytime soon. (Maybe it should!)

Perhaps a better question to study is why the profession of medicine believes that patients would happily and readily accept rectal exams? 

Is it the magic white coat or the magic stethoscope?

The profession of medicine believes that patients should accept what ever whims the provider has. It just "ought to be..."

It helps us in determining what we are going to suggest you for treatment. So we can't do away with the physical exam. It's not a painful test, doesn't take a long time and really ought not to be a barrier to screening Source: Shunning Prostate Probe - Fear Of Anal Examination Puts Jamaican Men At Risk

This is paternalism. Traditionally, medical practice has been a paternalistic system, with the health care provider telling the patient what to do and making the final decisions regarding screening or treatment. This has been ingrained in the profession of medicine since it began.

There is the fact that the profession of medicine has exempted itself from the norm, expectations, and rules of society and does what it believes what is in the profession's best interest. This was done through the "Social Contract."

One of the most glaring examples of the profession exempting itself from the rules of society was the concept of self-regulation (which was a dismal failure by the profession). Medicine has granted itself absolute power over the patient.

The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness, to influence his attention to them. Source: American Medical Association's (AMA) initial Code of Medical Ethics (1847), under "patient obligations"

Another example of the profession doing what it wants to do and what is in its own best interest is the fact that teaching medical students pelvic examinations on patients under anesthesia without consent still occurs to this day. How can any rational person think that this is acceptable?

But the profession falls back on professionalism and science. But when the science is looked at, it finds that these procedures do very little in diagnosis of disease or to change the management of conditions. (See: Digital Rectal Exams: Worth the Trouble?) These, as other intimate exams that patients dislike, are found to be "more of a ritual than an evidence-based practice" when the data is examined.

Much of medical guidelines and what is recommended for patients is (so called) expert opinions and NOT evidence-based content. Then there is a question of comfort. If we can put a man on the moon (and soon Mars), why can't we find an alternative to digital rectal exams or make them less unpleasant.

We should do everything we can to make unpleasant things, well, less unpleasant: Physicians can’t just focus on reducing patients’ medical complaints but also should seek to reduce other complaints about their care. When patients dread having something done, and often use that as an excuse not to get services, that should be a tip-off that something needs to change. Source: I Really Wish You Wouldn’t Do That

What about teaching patients to do a self examination? (That takes the fun away from the provider to subjugate and humiliate patients.) It is possible, providers are not the only people with a magical power to perform rectal exams. See: Digital Anal Rectal Examination Performed by Patient (International Anal Neoplasia Society Guidelines for the Practice of Digital Anal Rectal Examination
)

Again, this question shows the lack of common sense that medical professionals have both in not knowing why patients dislike rectal exams and why they expect that patients just accept them. What is even more disturbing is why unnecessary voyeurs are brought in to the exam room to oogle and further humiliate the patient. If a provider can not be trusted to perform such an exam, then they should not be practicing.

(The thought) of having another person inserting their finger inside their anus can be very stressing for some men and makes them uncomfortable. Source: Shunning Prostate Probe - Fear Of Anal Examination Puts Jamaican Men At Risk


If one really needs a "why," then read: Reasons Why Patients Reject Digital Rectal Examination When Screening for Prostate Cancer.



Thank you for taking the time to read.

Please share this article with others.

A Disgusting Article

I am writing regarding the article, How Patient Modesty Affects Medical Care. This article is an affront to human dignity (patient dignity being a subset of this). 

I will make my argument why this is an affront to patient (human) dignity. 

Many patients avoid healthcare due to dignity (modesty) issues.

Today patients view themselves as customers and expect that their needs will be met. Yet, the paternalism that still infects medicine fights back against the concept that patients are customers and meeting the patients' needs.

Patient dignity is the correct term to use (as opposed to patient modesty). "Modesty" is no longer the correct term to use (in the same way that non-adherence" replaces non-compliant).

First let us establish some definitions.

mod·es·ty / ˈmädəstē /

noun Behaviour, manner, or appearance intended to avoid impropriety or indecency.

Source: Oxford Dictionaries

dig·ni·ty / ˈdiɡnədē /

noun The state or quality of being worthy of honour or respect.

Source: Oxford Dictionaries

The mercurial concept of human dignity features in ethical, legal, and political discourse as a foundational commitment to human value or human status. The source of that value, or the nature of that status, are contested. The normative implications of the concept are also contested, and there are two partially, or even wholly, different deontic conceptions of human dignity implying virtue-based obligations on the one hand, and justice-based rights and principles on the other.

Source: The Internet Encyclopedia of Philosophy (IEP) (ISSN 2161-0002) (peer reviewed)

My argument  is that referring to the human condition of not wanted to have one's (the patient) body exposed (being naked) as modesty can be construed as the patient is asking for something that they are not entitled to. The phrase that most demonstrates this is "You are being too modest."

Dignity on the other hand takes into account the intrinsic value of a human being that makes the person deserving of being treated in an absolute, respectful, and dignified manner that is not open to interpretation or negotiation. To treat one in this manner is often not the easiest option and can be inconvenient.

The basis for human dignity (by non-atheists) is that we are endowed with it by our Creator (God). For Judeo-Christians (such as myself) the concept is furthered in that we believe that we were "created in the image of God."

This was rejected because the thread has been titled "Patient Modesty" and a change would some how create a disconnect. This is nothing more than marketing fluff. I will expand on this.

As an online resource for "reliable, understandable, and up-to-date health information," you use correct terminology, especially in regards to medical terminology as well as human anatomy. Not only does this keep the procedure medical in nature (as opposed to being sexual), but it also denotes the professionalism of the physician (provider) by showing that they are (properly) educated in the correct terminology.

By using the term modesty instead of dignity, it is making one look less professional and less educated.

The term "modesty" blames the victim. The patient can be accused of being too modest.

Modesty is taught to girls at some of the youngest stages of their lives. Modesty as projected by the person (patient) is t different levels. (Read about how New Jersey 'Mormon Prom' Draws Hundreds Of Teens For Celebration Of Modesty.) Modesty is about one choosing to be modest.

Teens were required to sign a pact agreeing to dress and behave modestly, to dance “appropriately” and to abstain from using alcohol or drugs...

The nearly 300 students abandoned several conventional prom practices — including arriving in limousines and wearing expensive outfits. (Organizers encourage attendees to be modest in their spending as well.) Most were dropped off by their parents, and some of the girls swapped or borrowed dresses to keep down the cost...

The problem in healthcare is that providers are taught to respect patient modesty and NOT patient (human) dignity. Let me expand...

An anesthetized patient (technically) has no modesty. [Everybody line up to practice rectal exams on the anesthetized patient.] An anesthetized patient DOES HAVE dignity. The lack of consciousness negates the presence of modesty being practiced, requested, or displayed.

I bet you know where I am going next...

A cadaver has no modesty. A cadaver DOES HAVE dignity. Increasingly, medical schools are having ceremonies honoring the sacrifice that people made leaving their body to science. This is to humanize the cadavers where traditionally (and still today) the cadavers were de-humanized. This is what happens when medical providers are taught to respect modesty and NOT taught to respect dignity:

...Last month, Stony Brook University Medical Center in Long Island announced it was developing a revised ethics policy after a student posted a photo on Facebook of a classmate posing with a thumbs up next to a cadaver. The State University of New York Upstate Medical University in Syracuse also is updating its ethics curriculum after a former resident posted a snapshot of an exposed brain on Facebook...

Let us also NOT forget the Denver 5...

By using the term modesty instead of dignity, nullifies and disregards the basic intrinsic value that human beings have and deserve being sentient beings and as endowed by our Creator. This is akin to calling a black man "boy."

...One, it's the ultimate sign of disrespect, and is often more offensive than calling them the N-word. For years black men were summarily dismissed and treated with disregard. It was as if their stature was diminished when someone white called them a boy...

Do you remember the images from the sanitation strike that the Rev. Dr. Martin Luther King Jr. was leading in Memphis in 1968? The most striking visual was that of the male protestors wearing signs saying, "I Am A Man!"

This mirrors the profession of medicine. Just as the hidden curriculum, the use of the patient gown, and teaching the term "modesty," helps retain and the paternalistic power that physicians are desperately trying to hold on to. It makes the doctor-patient relationship resemble the parent-child relationship.

For at least 2,500 years, the doctor-patient relationship has resembled the parent-child relationship. The norms of medical ethics, codified in historic documents or perpetuated as informal traditions, encouraged doctors to shield patients from bad news and from general medical knowledge. While Western medical tradition has always included some patient protections, such as informed consent (and its antecedents), doctors have possessed broad powers to withhold treatments that patients desired and, at times, to mislead patients for what they perceived to be the patients’ own good...

Even the term "doctor-patient relationship" attempts to consolidate and preserve physician power br putting the doctor first. I prefer the term "patient-physician relationship" because it puts the patient first, and recognizes the difference between a doctor (PhD) and a physician (medical doctor).

In the evolution of the doctor-patient relationship, such outdated terms are replaced with the correct term. The new terms show a respect for patient (human) dignity. One such example is noncompliance vs. nonadherence. Noncompliance as a term is a slur against patients. Nonadherence has become the preferred term to use.

The British have what I believe to be a much more acceptable term: “concordance.” This term recognizes that health care providers serve as consultants to their patients (or “clients,” as our psychology colleagues call them). Concordance implies a more equal relationship, in which the health care provider offers input, the patient offers input, and together they discuss, negotiate, and reach agreement on the most appropriate management plan for the patient.

Noncompliance painted a picture of a paternalistic provider mandating the rules of play, while the patient cowered below as a disobedient subordinate. It also implied that the patient did something wrong by breaking the rules and that the actions of the patient ought to be modified to fit the rules, rather than the other way around. On the other hand, non-adherence signified that the patient was a contributing partner in the development of the treatment plan and, further, that he may be justified for not abiding by the terms of his plan.

Many facilities have ordered the term noncompliance with nonadherence. There is a current movement to do away with the term nonadherence (along with noncompliance), because they can interfere with treatment.

Non-adherence used to be called noncompliance, which sounded too paternalistic. Now some experts are shifting to an even less judgmental language of "medication abandonment."

Now let me show how this practical application of the term "dignity" benefits providers.

There is no question that providers' modesty is respected in the healthcare setting (they wear white coats OVER their clothes, where patients remain half-naked wearing only a gown). Now if the profession of medicine was set up to respect patient dignity (human dignity), it would notice and correct the affronts to provider dignity (physician burnout, mental illness, EHR, etc.).

Trisha Torrey tells patients to "get over it" despite their reasons. This is very unprofessional and borders on malpractice for providers for not taking history of past abuse into account. 

This article also is contradictory to trauma informed care, especially trauma from healthcare providers.

Gender This or Gender That

Recently, on the Bioethics Discussion Blog, Dr. Maurice Bernstein asked the question:

The Other View: "Gender This or Gender That" but one (the medical system) may argue, it is not about patient gender but it is all about "Disease and Disorder: Diagnosis and Treatment". It's all about skill by physicians and nursing staff. Shouldn't that be what patients are looking for? 


JR who runs the blog Issues 4 Though, had the best response (she beat me to it):

While what you said may be justified in a medical setting but medicine needs to recognize there are other components that make up how to successfully treat a patient. Mental needs have to be met or else the physical treatment will not be successful or will fail. Cured the ailment but killed the patient because they neglected the mental health of a patient. No patient should come out of hospitalization with PTSD. The physical treatment of the patient by staff should not be so abusive and horrific that the patient is forever mentally injured. Is that not a failed treatment and a side effect that is not mentioned? Even RXs mention some potential side effects. Procedures mention some possible side effects. However, they do not mention that because they may treat you less than humanely you may suffer from PTSD.

For some it is not that some female nurse sees their penis or a male nurse sees the breast(s) of a female patient. It is the manner in which it is done-with permission, for a valid medical purpose, & done with the patient's dignity & respect in mind. It is the ambushing of male patients of having an audience during an intimate exam of 2 or more females (some chose a female dr. & are fine with her but not with the nurse, MA, etc.), it is not having the same choice as female patients do in ultrasounds or even ward care, it is about how callously the exposure of a male patient is done & oftentimes done excessively or unnecessarily, it is being told it doesn't matter if we see you naked but society and religion teaches it does matter, it is made to feel you have no choice.

Why it is Patient DIGNITY and NOT patient modesty.

First let us establish some definitions.

mod·es·ty / ˈmädəstē /

noun Behaviour, manner, or appearance intended to avoid impropriety or indecency. 

Source: Oxford Dictionaries

dig·ni·ty / ˈdiɡnədē /

noun The state or quality of being worthy of honour or respect. 

Source: Oxford Dictionaries

Human Dignity

The mercurial concept of human dignity features in ethical, legal, and political discourse as a foundational commitment to human value or human status. The source of that value, or the nature of that status, are contested. The normative implications of the concept are also contested, and there are two partially, or even wholly, different deontic conceptions of human dignity implying virtue-based obligations on the one hand, and justice-based rights and principles on the other. 

Source: The Internet Encyclopedia of Philosophy (IEP) (ISSN 2161-0002) (peer reviewed)

My original argument (previously) was that referring to the human condition of not wanted to have one's (the patient) body exposed (being naked) as modesty can be construed as the patient is asking for something that they are not entitled to. The phrase that most demonstrates this is You are being too modest."

Dignity on the other hand takes into account the intrinsic value of a human being that makes the person deserving of being treated in an absolute, respectful, and dignified manner that is not open to interpretation or negotiation. To treat one in this manner is often not the easiest option and can be inconvenient. 

The basis for human dignity (by non-atheists) is that we are endowed with it by our Creator (God). For Judeo-Christians (such as myself) the concept is furthered in that we believe that we were "created in the image of God."

This was rejected because the thread has been titled "Patient Modesty" and a change would some how create a disconnect. This is nothing more than marketing fluff. I will expand on this. 

The word doctor (Latin, an agentive noun of the Latin verb docere 'to teach') medical doctors teach their patients and students to use correct terminology, especially in regards to human anatomy. Not only does this keep the procedure medical in nature (as opposed to being sexual), but it also denotes the professionalism of the physician (provider) by showing that they are (properly) educated in the correct terminology. 

One example of this is the use of the terms anus (the opening at the end of the alimentary canal through which solid waste matter leaves the body.), rectum (the final section of the large intestine, terminating at the anus.), and the colon (the part of the large intestine that extends from the cecum to the rectum). 

By using the term modesty instead of dignity, it is making one look less professional and less educated. 

The patient can be accused of being too modest. 

Modesty is taught to girls at some of the youngest stages of their lives. Modesty as projected by the person (patient) is t different levels. (Read about how New Jersey 'Mormon Prom' Draws Hundreds Of Teens For Celebration Of Modesty.) Modesty is about one choosing to be modest. 

Teens were required to sign a pact agreeing to dress and behave modestly, to dance “appropriately” and to abstain from using alcohol or drugs...

The nearly 300 students abandoned several conventional prom practices — including arriving in limousines and wearing expensive outfits. (Organizers encourage attendees to be modest in their spending as well.) Most were dropped off by their parents, and some of the girls swapped or borrowed dresses to keep down the cost...

The problem in healthcare is that providers are taught to respect patient modesty and NOT patient (human) dignity. Let me expand...

An anesthetized patient (technically) has no modesty. (Everybody line up to practice rectal exams on the anesthetized patient.) An anesthetized patient DOES HAVE dignity. The lack of consciousness negates the presence of modesty being practiced, requested, or displayed.

I bet everyone knows where I am going next...

A cadaver has no modesty. A cadaver DOES HAVE dignity. Increasingly, medical schools are having ceremonies honoring the sacrifice that people made leaving their body to science. This is to humanize the cadavers where traditionally (and still today) the cadavers were de-humanized. This is what happens when medical providers are taught to respect modesty and NOT taught to respect dignity:

...Last month, Stony Brook University Medical Center in Long Island announced it was developing a revised ethics policy after a student posted a photo on Facebook of a classmate posing with a thumbs up next to a cadaver. The State University of New York Upstate Medical University in Syracuse also is updating its ethics curriculum after a former resident posted a snapshot of an exposed brain on Facebook...

Let us also NOT forget the Denver 5...

By using the term modesty instead of dignity, nullifies and disregards the basic intrinsic value that human beings have and deserve being sentient beings and as endowed by our Creator. This is akin to calling an African-American man "boy."

...One, it's the ultimate sign of disrespect, and is often more offensive than calling them the N-word. For years black men were summarily dismissed and treated with disregard. It was as if their stature was diminished when someone white called them a boy...

Do you remember the images from the sanitation strike that the Rev. Dr. Martin Luther King Jr. was leading in Memphis in 1968? The most striking visual was that of the male protestors wearing signs saying, "I Am A Man!"

There was a reason they were wearing those signs...

This mirrors the profession of medicine. Just as the hidden curriculum, the use of the patient gown, and teaching the term "modesty," helps retain and the paternalistic power that physicians are desperately trying to hold on to. It makes the doctor-patient relationship resemble the parent-child relationship.

For at least 2,500 years, the doctor-patient relationship has resembled the parent-child relationship. The norms of medical ethics, codified in historic documents or perpetuated as informal traditions, encouraged doctors to shield patients from bad news and from general medical knowledge. While Western medical tradition has always included some patient protections, such as informed consent (and its antecedents), doctors have possessed broad powers to withhold treatments that patients desired and, at times, to mislead patients for what they perceived to be the patients’ own good...

Even the term "doctor-patient relationship" attempts to consolidate and preserve physician power by putting the doctor first. I prefer the term "patient-physician relationship" because it puts the patient first, and recognizes the difference between a doctor (PhD) and a physician (medical doctor). 

Dignity has 3 definitions, all with subtle nuances.

The state or quality of being worthy of honor or respect. a man of dignity and unbending principle

a composed or serious manner or style. he bowed with great dignity

a sense of pride in oneself; self-respect. it was beneath his dignity to shout

As to the person who acts as he has no dignity; it is important to realize subtle nuances. First off, he is acting in an undignified manner. The lack of dignity is this example is labelling how his actions assail the dignity of those around him and society. 

By one having dignity (worth as a human being), one will (should) act in a manner worthy of that dignity. Part of our human dignity is respecting the dignity in others (even if they do not respect others' dignity). This is the second nuance of acting with no dignity.

These definitions all involve the actions of the actor, behaving in a way that elicits respect (or disrespect) of observers. The "state or quality of being worthy of honor or respect" can be achieved by behaving in such a way, for example having good manners (saying please and thank you). 

The "state or quality of being worthy of honor or respect" as in human dignity is intrinsic, and can not be given up or taken away, only disregarded and disrespected. In fact, one giving up their dignity can lead to them creating a state of higher dignity beyond intrinsic, human dignity. Think of the Christian martyrs. 

When we speak of patient dignity, we are referring to that intrinsic, human dignity. Patient dignity is a subset of human dignity. Going back to my example, human burial rites going back to prehistoric times recognize intrinsic, human dignity in the manner that the corpse is treated. By contrast, the Nazi concentration camps failed to recognize that intrinsic, human dignity and the corpses were used as manufacturing material (lamp shades, pillows, etc.), as a source of wealth for the riches (possessions) to be mined from the victims, and as refuse to be efficiently disposed of in incinerators and mass graves. 

The true horror of the Holocaust was NOT the brutal acts committed, but how the philosophy of the Holocaust and human beings (many of them nurses and physicians) ignored that intrinsic, human dignity of the Holocaust victims. 

Just as the use of the term "patient modesty" allowed providers to use it against patients (by saying you are being too modest), patient dignity can be used against them by focussing on the dignity derived from the patients own actions (as opposed to the intrinsic, human dignity as a subset of human dignity). Providers may also say that dignity does not apply to (what has been previously called) modesty/exposure issues either from a lack of comprehension of the subject or to confuse the issue (as to deny the patients their full human rights in regards to modesty/exposure issues).

Finally providers run the risk of narcissism (such as the issue of burnout) by saying "what about my dignity?" As previously stated, surrendering one's own dignity can elevate their dignity and status. 

Another risk is the provider "crying the blues" to the patient how the hospital, healthcare system, MOC, etc., tramples the patient's dignity. Due to the power differential, the sick patient can care less. If the system changes to be dignity driven, then that prosperity will spread and the atmosphere will improve for providers as well. 

It has been a while. I am still fighting the good fight. I started a (long over due) Twitter page.

https://twitter.com/MadmanBantering

How to Create a Sociopath: Part 1

UPDATE 2020-12-30: My research has been validated by Anthony J Mazzarelli, MD, JD, MBE, co-president and C.E.O. of Cooper University Health Care and by Stephen W Trzeciak, MD, MPH.

Cooper University Health Care brought in consultants to suggested ways for the hospital to strengthen its bottom line. One idea: the hospital should focus on improving patient experience and physician engagement. Some of these recommendations had to do with the relationship between doctors and patients. 

Mazzarelli, realized that most of what he was being asked to do was to get doctors to show more compassion. Now, you might assume that most people who choose medicine as a profession do so in part because they are compassionate (at least that they’re taught compassion during medical school). 

If that’s the case, where does it go? Does compassion somehow evaporate over time? If so, was there a viable way to increase it? And can compassion even be measured? Before doing anything, what Mazzarelli needed was some research.

Mazzarelli  turned to Cooper's #1 N.I.H.-funded researcher, the person with the most publications, the most N.I.H. dollars: Stephen W Trzeciak, MD, MPH.

TRZECIAK: So, I never doubted that compassion was essential. And I don’t know anyone in healthcare that feels otherwise, or at least no one that would admit to it. It’s what we ought to do. The way that we ought to treat patients. But does it actually move the needle on outcomes in a measurable way? That’s what I was skeptical about.

Trzeciak and Mazzarelli began to focus on the science of compassion, they started a program at Cooper Health System to mentor physicians on how to connect and communicate with patients. Mazzarelli, true to what he’s learned during his compassionomics journey, was careful to note that, "Of course we can only report association rather than definitive causation from these data."

Trzeciak and Mazzarelli wound up writing a book that tries to answer these questions. It’s called Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference.

You can hear a podcast on Freakonomics Radio on December 16, 2020, by Stephen J. Dubner.

While the compassionomics research does not look at the causes or the loss of compassion and empathy, it validates that there is a deficit of compassion and empathy by healthcare providers. My research looks at the beginnings (causes) of the loss of compassion and empathy during the medical education. Much of the research that I rely upon came from the Nuremberg Trials, specifically the Physicians' Trials and wondering how such apparently compassionate people could commit such atrocities.

*End of the Update* 

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

How to Create a Sociopath: Part 4

How to Create a Sociopath: Part 5

Let us to have to look at the healthcare system from a forensic psychosocial and an organizational psychological perspective. At what point do these standards become the universally accepted standard of care (the hundredth monkey effect)?

To a certain extent it is group dynamics where individuals with similar characteristics band together to strengthen and protect the group. The group develops an "us-and-them" mindset to protect the group from outsiders. This is hardwired into our brains after millions of years of evolution stemming from when the first humans huddled together in a cave. A very good illustration of this is The Third Wave (a social experiment undertaken by history teacher Ron Jones with sophomore high school students Cubberley High School in Palo Alto, California, during the first week of April 1967).

View the documentary on YouTube here:

I believe that the answer can be gleamed if we can simply answer one of the largest ethical dilemmas faced recently by healthcare: the justification of pelvic exams on anesthetized female patients.

Dr. Peter Ubel writes, "I felt a woman’s uterus without her permission." We all know that the research he did in to the subject changed laws. What about all the other physicians who graduated medical school more than 20 years ago?

What is more disturbing is that beyond losing their license or criminal charges, no physician that I know of (other than Ubel... maybe), that has stood up, admitted what they did, and apologized. Whether it be eugenics, the Holocaust, Tuskegee, or the CIA use of physicians for torture after 9/11. So what do they really believe? Physicians are entitled to a patient's body but don't get caught? I know (what I think to be) many good, ethical physicians who are truly empathetic to patients.

This begs a serious question about the ability of healthcare providers ethical decision making, just by the nature that there has be no apologies. It seems that the outliers in respect to the pelvic exams are Dr. Peter Ubel, Dr. Michael Greger, and Hilary Gerber are the outliers.

The 1847, the inaugural Code of Ethics of the American Medical Association (AMA) stated, “The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness, to influence his attention to them.

Let me also address "Great men are almost always bad men". That is the complete quote of John Emerich Edward Dalberg-Acton. I think the better quote is "Power tends to corrupt, and absolute power corrupts absolutely."

Another issue that these theories of "The Lucifer Effect" that we are exploring here fails to address the issue of "great men." The reason for this is that there are 2 groups that dehumanize patients in the healthcare setting; those born sociopaths and those suffering "The Lucifer Effect" (out-group sociopathy, situational sociopathy, or learned sociopathy, perhaps...).

The first group, those who are sociopaths before entering the medical profession also tend to be megalomaniacs. Healthcare is just a way that they can disguise their deviant behavior and avoid being caught. There is a certain amount of truth in the portrayal of Hannibal Lecter and other modern sociopaths having a connection to the medical/psychological professions. Even Jack the Ripper was thought to be a surgeon.

The second group are just ordinary people. I think they are best described by Admiral William (Bull) Frederick Halsey Jr.; 
“There are no great men. Just great challenges which ordinary men,out of necessity, are forced by circumstance to meet.” These are the people that we call "great." Many such Mahatma Gandhi and Mother Theresa would describe themselves as very ordinary people. Perhaps that is the problem, coming from ordinary, that newfound power is like an addictive drug or an aphrodisiac.

Let me illustrate with Shakespeare's "The Tempest," transformed in this landmark science-fiction film; Forbidden Planet (1956).

Space men travel to a planet ruled by expatriate Pidgeon who has built a kingdom with his daughter and obedient robot Robby. There the good doctor is plagued by his mad quest for knowledge through his "brain booster" machine. Ostrow explains to Adams that the Great Machine was built to materialize anything the Krell ( the original alien inhabitants) could imagine, projecting matter anywhere on the planet. However, with his dying breath, he also says the Krell forgot one thing: (Freudian) "Monsters from the id!" Adams asserts that Morbius' subconscious mind, enhanced by the "plastic educator", can utilize the Great Machine, recreating the Id monster that killed the original expedition and attacked the C-57D crew.

Note: this is a possible explanation of the evolution of "The Lucifer Effect." I will further simplify my example: A physician/resident/clerk, acts ethically in treatment of patients, one day encounters a patient who does not need an intimate exam. The provider pushes for the exam and justifies it to the patient and perhaps to himself as medically necessary. Think Dr. Stanley Bo-Shui Chung (accused of dozens of unnecessary intimate exams on female patients) If for no other reason, then just out human curiosity, he uses the inherent power and achieves the intimate exam. He may not be aware that his motives are non-medical, he may ascribe it to "medical curiosity" or "being thorough." Subsequently, it becomes easier to "push" these exams when the curiosity arises. He feels a sense of satisfaction when these are completed, again he may ascribe the satisfaction not as "sexual" but as "medical."

Eventually there becomes a desensitization to seeing women, to satisfy that nagging curiosity, he progresses to doing this to men too and eventually children. Having been taught to put emotion on the side and rely on logic, he justifies this. The definition of a sociopath is a person who lacks a sense of empathy, moral responsibility, or social conscience, and devoid of emotion. Lacking emotion and conscience, logic is the only tool used to make decisions. The goal that logic is direct to is determined solely by our pleasure drives (the id).

(Reference: Id, Ego and Superego .)

That is because a medical education conditions the Superego out of decision making because the Superego makes mistakes. It makes choices that counter logic (the Ego). Logical thinking is encouraged. The Ego grows and the Superego is reduced. The medical education takes no account for the ID. Saying that medical students are taught ethics does nothing, that would be the ID, which is repressed by the medical education.

The pattern of escalation follows that of a serial killer to the point where the devient behavior has become normative. (See: John E. Robinson, Sr.: The first Internet Serial Killer and Serial Killers: The Method and Madness of Monsters.) This endless line of patients satisfies the massive amounts of desire that the Id produces. A few remain unsatisfied and need to progress beyond the professional boundaries. That is where we get our Dr. Melvin D. Levine's (via NY Times), Dr. Nikita Levy's (via CBS), and Dr. William Ayres' (via Mercury News).

Perhaps this can shed light (or vice-versa) on the contemporary and controversial topic of "Radical Islam" I have very good friends who practice Islam, and they, like most Muslims, are good people who condemn these terror acts for what they are. Yet how can some, even Americans, be swayed? Let us look at that culture and see parallels with a medical education. Replace "Islam" with "medical education" and "America/the west" with "patients demanding dignity" and you will see the similiarities.

...While many Muslims adapted to the fast-paced changes common to Western industrialization and modernization, some Muslims rejected them. Instead, they created a rigid ideology imbedded in the traditional values and laws of the Koran. This is the phenomenon known today as Islamic fundamentalism, or Islamism...Islamism came to be seen as a struggle to return to the glorious days when Islam reigned supreme. It represents a yearning for the "pure" Islam as practiced by the prophet. Not unlike the American Amish, the movement rejects much that is innovative. Islamists, however, take the rejection of modernity a step further. They perceive those who have introduced these innovations (the West) as its enemy...Source:

...In some cases, Islamic extremists even describe sharia as a superior form of “democracy” ...Acts of Islamic extremism includes terrorism, human rights abuses, the advancement of sharia-based governance, bigotry towards non-Muslims and rival Muslims and overall hostility to the West and, in particular, Western democracy. ...Islamic extremism is the primary national security and human rights concern of the world today... It is firstly the primary motivator of acts of terrorism worldwide. Secondly, as Islamic extremists gain power and rule, human rights abuses – including oppression of women, homosexuals and religious minorities as well as governmental tyranny, sectarian warfare and bigotry inherent in sharia law – come to the fore...Not all Islamic extremists carry out violent acts. Islamic extremists can advance their goals using non-violent tactics such as activism, developing interfaith coalitions with unsuspecting non-Muslims, fundraising, building political influence and the overall spreading of the ideology. These extremists follow a doctrine called gradualism. The largest Islamic extremist group to use this method is the Muslim Brotherhood.>Source:

Perhaps like paternalism, radical Islam is what we get when when the group refuses to relinquish the archaic rules that solidified their power and status and the subservience of those to whom they were suppose to serve. Just as many radical Muslims were educated in western schools and had western values, they were replaced by a sociopathic ideology that they justify.

I respectfully submit this for critical debate.

Note: I will use the term "pathy" now until I comment on the difference between sociopath and psychopath. This is the article Ray referenced, "How to Tell a Sociopath from a Psychopath" that I will be referencing.

I differentiated between the learned in medical school "pathy" and the born-that-way (psycho)path. The latter being very few in number and more of an anomaly. This will also explain why I used the term "sociopath."

Edwin Sutherland’s Differential Association Theory is one of my favorites. It is where we get the axiom "Prisons don't reform, they make professional criminals." I always finish that with "I went to Catholic School for 12 years, what does that make me?

In regards to psychopath and sociopath i like the differentiation that psychopathy is biological and sociopathy is result of socialization. I think that when "normal" people are socialized, psychopaths are socialized too, but instead of growing empathy for others, they learn how not to get caught. The article that you referenced also stated:

...sychopaths are often well educated... psychopaths carefully plan out every detail in advance and often have contingency plans in place. Unlike their sociopathic counterparts, psychopathic criminals are cool, calm, and meticulous. Their crimes, whether violent or non-violent, will be highly organized and generally offer few clues for authorities to pursue... Psychopathy is related to a physiological defect that results in the underdevelopment of the part of the brain responsible for impulse control and emotions.

That fits perfectly with the Banterings' Theory of Superego Repression (Nullification).

Theories of socialization such as Charles Horton Cooley's Looking-glass Self, George Herbert Mead's Social Behaviorism, Sigmund Freud's Id, Ego, and Super-ego, James Henslin's Gender Socialization and others (Klaus Hurrelmann, Lawrence Kohlberg, Carol Gilligan, Erik H. Erikson, George Herbert Mead, Judith R. Harris) are important for two reasons: First looking at how psychopaths socialize (this is when they learn to mimic emotions among other things) validates the second. The second is we look at how providers are re-socialized to a learned sociopathy (if you will).

Two of these socialization theories stand out in relationship to this thread. Sigmund Freud's Id, Ego, and Super-ego which Banterings' Theory of Superego Repression is based upon. This also takes Freud's theory one step further in that the Ego is attributed as the logic center (the brain) and is separate from the "self." The "self" is a combination of the consciousness, Id, Ego, Super-ego, memories, experiences, and other components.

This being said, logic needs to be taught as well. Teaching a child 2+2=4 does nothing for the Superego or Id. Perhaps teaching addition is "adding" is a better statement and 2+2=4 is a truth (Superego). Banterings' Theory of Superego Repression acknowledges that the Ego can be grown. This then leaves us with providers who have a repressed Superego, a strong Ego, and the Id =we all have. With the repressed Superego, the Id is not balance hence the dehumanization of patients.

The second is James Henslin's Gender Socialization. This has bearing because of the issue of gender choice in healthcare, or better yet the lack of gender choice in healthcare. This implies that there is a de-socialization then re-socialization of providers. I do not believe that you can unlearn the morals that we were socialized with as children, we can learn more and grow the Superego, we can't erase it and rewrite it. We can repress it though.

This can be seen in children whose mothers were abused growing up to be abusers. This was what was put in their Superego at that critical time when it was empty and needed to be filled. We can also explain that children who reject the premise of abuse have grown their Ego to reason that this part of their Superego is corrupted. Although they may not abuse ever, they have a tendency or predisposition to.

I do not like the description of the sociopath as being a trailer park dweller. I think that this is an incorrect assumption because sociopathy is attributed usually to a childhood trauma. Therefore they have had their socialization interrupted. They never learn empathy or how to fake (mimic) it.

Sociopaths tend to be nervous and easily agitated. They are volatile and prone to emotional outbursts, including fits of rage. They are likely to be uneducated and live on the fringes of society, unable to hold down a steady job or stay in one place for very long.

So what about healthcare providers? Most were normally socialized but they are taught to repress their Superego, hence Sociopathy being learned. Sociopaths tend to be nervous and easily agitated. They are volatile and prone to emotional outbursts, including fits of rage. How many surgeons does this describe?

In 2008, The Joint Commission became so concerned about “behaviors that undermine a culture of safety” that it issued a Sentinel Event Alert on the topic and developed a Leadership standard requiring all hospitals to have a code of conduct as well as a process for managing disruptive and inappropriate behaviors. Now there is compelling evidence that some behaviors contribute directly to medical errors. This was a prominent finding in Rosenstein and O’Daniel’s work,1 in which respondents commonly indicated a reluctance to call or interact with certain doctors to clarify or question orders for fear of provoking a hostile response...

In its Sentinel Event Alert, The Joint Commission describes disruptive and intimidating behavior as including “overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities,” and it goes on to say that “intimidating and disruptive behaviors are often manifested by health care professionals in positions of power... Source:

I think that taking the 2 definitions (sociopath and psychopath) we can put together a good definition of providers that dehumanize patients:

Provideropaths tend to be nervous and easily agitated. They are volatile and prone to emotional outbursts, including fits of rage. It is difficult but not impossible for them to form attachments with others. Many are able to form an attachment to a particular individual or group, although they have no regard for society in general or its rules. In the eyes of others, they will appear to be very disturbed. 

Provideropaths are unable to form emotional attachments or feel real empathy with others [outside their group, i.e. patients), although they often have disarming or even charming personalities. They are very manipulative and can easily gain people’s trust. They learn to mimic emotions, despite their [repressed ability] to actually feel them, and will appear normal to unsuspecting people. They are often well educated and hold steady jobs. 

When committing [infractions to patient dignity], Provideropaths [are following] carefully planned out in advance [protocols/guidelines] and often have contingency plans in place. They are cool, calm, and meticulous. Their [infractions to patient dignity], will be highly organized and generally offer few clues for authorities to pursue [as a crime]. Intelligent Provideropaths [are] excellent white-collar criminals and "con artists" due to their calm and charismatic natures.

There are providers that reject the suppression of the Superego. I present Dr. Peter Ubel and the Harvard Medical School students refusing to do pelvic exams on anesthetized female patients. Perhaps in the growth of their Ego, they realized the consequences of repressing their Superego. More simply that it was wrong to do pelvic exams on anesthetized female patients because the Ego (logic) showed that there was no medical necessity and that contradicted "First, do no harm."

Using Banterings' Theory illustrates the mechanics of the Lucifer Effect, the Stamford Prison Experiment, Milgram Experiment, Pavlov's Dogs, the Asch Conformity Experiments, etc. are the tools used in the mechanics of the repression of the Superego. "Power tends to corrupt, and absolute power corrupts absolutely." This shows the predisposition that human beings have to making the situation favorable to themselves (the Id) when they can make the rules. " Great men are almost always bad men." This is the time when human beings ARE able to make the rules.

Philosophies like Machiavelli's "The Prince," Karl Marx's "Communist Manifesto" are just reinforcements of the Ego to justify atrocities done. Along with being the logic that chooses what to do (balancing the Superego and the Id), the Ego also logically evaluates the logic that it (the Ego) uses in decision making. Atheists (or more appropriately agnostics) see no physical proof (pure logic) of God, therefore they do not believe in God. That is not good or bad at face value, it is just their logic. Believers tend to reason that statistically (also pure logic), the chances of life have had to be guided by at the very least "Intelligent Design."

Banterings' Theory thus explains the Holocaust. Germany after WWI, with the economy and whole social structure in ruins called people to question traditional logic. The Reichstag fire of 1933 satisfied the Superego in saying this was wrong and the Id this was wrong as an attack on the Id and not morally wrong). When, in the rare instances, the Id and Superego are in concert, there is a tendency NOT to regulate the Id [as much] because it seems to be in check by nature of agreeing with the Superego. That is how (and when) "An eye for an eye" is justified.

This can explain medical students in "you are saving lives." The Superego says saving lives is morally right. The Id says "saving lives makes me feel like God." Repression of the Superego (how else can one justify cutting off all the clothes of a person) along with the Id not regulated as much (Superego and Id agree on saving lives), the patient's requests to be covered with a sheet for dignity are ignored by the provider's Id because it is an attack on the provider's power (the Id) and on their altruism (Superego) of saving the patient's life.

This is a lot to digest and follow, I realize that. My theory does explain many situations of abuse.