Patient Dignity 08: "I am a professional," and "I have seen everything before."

How many times has you as a provider said, or you as a patient heard "I am a professional," or "I have seen everything before" when (you as) the patient has been apprehensive about undressing or exposing a body part.

This is unprofessional, demeaning, uncaring, and offensive. These may produce some positive results for the caregiver but not the patient. One thing they do is shut down the dialogue prematurely.

Newsflash: It's NOT about how you feel, I is about how I, the patient, feels!

Unless I, the patient, am a work as a "standardized patient" or (perhaps) a porn star, I am NOT a professional and I have NOT shown it to a bunch of strangers. These statements nullify my feelings and marginalize my dignity as a human being. 

This demonstrates that you are as a incompetent as a provider, and borders on malpractice. 

Healthcare providers (physicians, nurses, PAs) are taught observation, auscultation, percussion, and palpation. The first two are look and listen! The patient is alerting you to a problem. Perhaps the patient does not understand the procedure, it has not been explained, or the patient has an underlying emotional trauma.

One never knows who has been sexually abused, (so please do not ever trivialize a patient's need to avoid unnecessary exposure). Missing the signs of possibly being a surviver of sexual abuse are no less egregious and incompetent as missing a tumor on a thyroid.

It is easy for you to dismiss the patient's feelings, fears, and anxieties about dignity and modesty when you are the one in the room wearing clothes. 

Nurse Ratched was a professional too...

"Operational efficiency" is not an acceptable answer. When it is genuinely argued (as opposed to disingenuinely justified) that patient exposure is necessary, then it is a valid reason. On the other hand, simply for the purposes of efficiency is NOT a valid reason.

"Because that is the way it is always done," is NOT a valid reason either. For years black people (not just of African decent) and white people were not allowed to legally marry "because that is the way it is always done." If you are going to site data or research, it better be current and it's premise (thesis) not called in to question by other research.

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

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

If you further reason infection-control has not studied this, that is NOT valid either. Other providers are looking at this, why not you. Patients will not accept "not your responsibility." Part of your job as a provider is to advocate for the patient, if you are not pushing for a study on this, you are not doing your job.

If you have initials after your name (MD, DO, PA, RN, LPN, etc.) and you use phrases like "I am a professional," "I have seen everything before," "because that is the way it is always done," or "operational efficiency," that only marginalizes you as a professional and nullifies all the time, money, effort, and study that you put into your education. If you are so smart and educated, how can you NOT understand my feelings and my point of view?

You are the professional, patients are NOT. Patients are real, live people who in all probability have never been in a hospital in their entire life and what happens is pretty distressing. This is your job, some would even say their home. You come here everyday, you are familiar with the sights, smells, and sounds.

You are not totally devoid of any curiosity, emotions or feelings.  You have the same feelings that we do, so you can't deny that to us as much as you try, and simply saying that you are a professional does not negate that.

First and foremost you are human. The patients are human too. We know what human reactions are. You can probably control them a little better than us, but you WILL have them.

It would help if you were naked while invading our privacy, but I guess thats just realistic.

One could say we have seen it all also so why not be naked in there with us? I know its stupid, but perhaps your getting the idea. It is soo much easier to be the clothed one while we have our gentiles exposed, worked on, and pontificate on our childish behavior.

If they’ve seen it all before, then they DON’T NEED TO SEE MINE!

This is how we really feel. When you refuse to acknowledge our feelings, you are lying to us. Why do we have to justify our feelings to you? It is common sense, we cannot understand why educated, intelligent people do not understand why we feel this way.

When we say things like "It would help if you were naked while invading our privacy," we are only trying to get you to understand us. Obviously you know what we say to be true, or you would not be so offended when we suggest this.

I have always stated: "Medical treatments and procedures would be radically different if the providers had to be in the same state of exposure as the patients."

You cannot argue that point. You would have to have a major mental defect or cognitive disability to believe otherwise. The tolerances for infection control would drop. Questioning of is that exposure necessary would predicate every protocol. Here is proof:

In the above example what  LDS Hospital in Salt Lake City, Utah, the WSJ article stated that a 15 year ER nurse saw behavior in patients that did not make sense. To understand the disconnect, she needed additional education (an MBA) that her nursing degree did not give her.

The healthcare system cannot comprehend that what they perceive as the patient's priorities, in fact are actually NOT the patient's priorities. They blame the patient for not having the (expected outcome) priorities that they expect. Physicians (providers) are to make decisions with out emotion, so that the decisions are based on sound, scientific principal. That is why they can not understand why a patient has an issue with being helpless and naked in front of a room full of people when they are undergoing a lifesaving procedure. All they think that is important is that your life is being saved.

 In the case of LDS Hospital, cost  and an increasingly competitive surgical market were the driving force for change. It was not about the patient, it was about money. Why was the option of patients keeping their underwear on not looked at when the initial infection control study was done? Answer: "Because that is the way it is always done."

Further proof: The Endoscopy Camera Capsule (info at: NY Daily News). This is another advancement that further preserves patient dignity. This was developed because many people were opting to forego the undignified process of a colonoscopy. Again it was "money first, not patient first." The PillCam costs $500, significantly less than the roughly $4,000 rate for colonoscopy.

Speaking of professional...

What was considered appropriate and professional 25+ years ago, would be UNACCEPTABLE today. Remember "strip-as-you-go" exams?

The fallacy of "Patient First"

How many times have you told a patient this? How many times have you said this to people who were not patients? Do you really believe this? If so, does your facility have a written policy that allows outpatients to keep their underwear on? No? I thought you said "Patient First?"

If you counter with something can go wrong, incase of emergency, ...blah...blah...blah, remember what I said about being up to date? As of 2014, despite thousands of outpatient procedures, not a single patient has died as a result of wearing underwear during an outpatient procedure. Confirmed by: LDS Hospital. 

Do Not Dismiss My Experiences

I know through my experience what happened to me and how I was treated. Trying to dismiss my experience tells me that I am wrong to feel the way I do. I do not choose my feelings, they are what they are.

Saying "that can never happen because medicine is a profession" or "that is impossible in a professional setting" only further undermines our trust in you and the system. Is it that you just don't believe me? Perhaps you are complicit in the cover up and system-wide denial that this does happen.

Even worse is saying that "never happened to you." Just because it never never happened to you does NOT mean it didn't happen to me.

You are not me, despite how deep you pry into my lifestyle, history, an my past (while vehemently protecting your privacy) you do NOT know what I experienced, how I reacted, or how I feel. Does it matter, you are dictating my feelings to me anyway.

Do No Harm

Do you think that dismissing me as childish, nullifying my feelings, marginalizing me as a patient, or making this all about you does no harm? 

It is this attitude that has caused me not to trust the healthcare system or anyone in it. Before my previous first bad experience, I walked in trusting you. The subsequent bad experiences only reinforced that in me. I will not let myself get hurt like that again. Now I assume that you are bad. You can either reinforce what I know through my experience, or you can win back my trust.


Tips on How to Be a Better Provider

Here is "An open letter to all hospital staff" by  Carolyn Thomas,  a heart attack survivor> The letter details how she was treated and how providers can better serve the patient. She says,  It’s not so much that they were openly rude. It was their insufferable lack of people skills..." 

I wasn't born a difficult patient....I was turned into one

Thank you for thinking.

--Banterings

What Would You Do?

What Would You Do? 

Human Dignity 08: "I am a professional," and "I have seen everything before."

You are a resident at a internal medicine physician office. You are shadowing the physician who is a good doctor and has built rapport with his patients. He has given you much latitude and autonomy with his patients so that you will get use to dealing with people (notice I said people and NOT patients) and become a good doctor. 

It is the end of your first week with him. You are done early for the last day. There will be 2 hours for you to keep busy after this last patient. At this point you are (pretty much) conducting the histories and exams and he is (more) shadowing you. 

He has backed you with every decision you have made about tests, changes in treatment plan, education, everything that you recommended. Your next patient is a 48 year old white male. His chart shows that he had a "bad healthcare experience" in his 20's. He has not seen a doctor since. His wife convinced him seven years ago to begin getting annual physicals. 

For the first 2 years, she thought he was going. That was until the day he was suppose to go, his buddy called to cancel their fishing trip that day. He cam clean, he was afraid to go and it was easier to lie about it than to go. His first two visits, she accompanied him in the exam room. She was in the waiting room, she trusts that he will go, it is just to "calm his nerves."   

He had been seen here for the last five years. He is physically fit, 36" waist, labs good, in good health (better than most men his age) and no history or genetic risk factors. His blood pressure is higher than it should be, but the "Good Doctor" attributes that to "white coat syndrome." A typical visit checks HEENT, BP, lungs, bowel sounds, weight, history, previous labs reviewed, new labs ordered. 

The "Good Doctor" suspects a "specific phobia" to healthcare providers and some lingering PTSD symptoms from his bad experience over 20 years ago. Counseling was recommended, a trial of fluoxetine (Prozac) was offered. He refused. He has no problems taking his shirt off in front of you both to have his heart and lungs checked. Socially he is healthy too. He says that he "hates going to the doctor," but between his wife and fishing he can deal with it. "Besides, she goes away with me for the weekend following my annual, and following my blood draw."

The attending has given him the talk that "he wouldn't be doing his job" if he did not give him a complete physical exam." The patient's response was "I would just walk out." It took two years after the bad experience for the nightmares to go away. I will not go through that again, especially over a false positive. He is open, honest, and understands his feelings on the matter and the consequences.

You go over what he should be getting checked, he strongly agrees. You recommend a tetanus booster and influenza vaccine, his attending adds them to the lab orders. You say you want to check some of these things, he casually agrees to fast (you think), and seemingly to placate you. You explain that you need some additional history. He talks openly and honestly about personal matters. Sex life is good, no urinary issues...

You are too comfortable in your role, and this is where things begin to go wrong. You take a gown out of the drawer, place it on the table and say "I am going to step out for five minutes, I need you to undress completely and put this on."  He has the look of a deer in the headlights. You say "Did you understand the instructions?" He nods and says yes. You and the attending step out. 

You and the attending come back in. He is sitting in the same place, fully clothed. He even put his shirt back on. You ask if there is a problem. He angrily states, "I should say there is a problem, you don't tell me, you ask me; that's first." He alludes to the event 20 years ago, it is no secret, it should be in his records, then about being naked, people seeing his junk, his body, and nothing to see. You did not bother going back in his chart to see what the event was, you try to look for it as he is ranting.

It goes from bad to worse...

You are annoyed at this point. He just wasted 10 minutes of your time when he complied. Why not just tell you no. You remind him that the practice partners have a new patient consent form that he signed five years ago, in which he agrees to an initial and ongoing "complete physical exams." You go back and forth trying to show him how compassionate you are and this is to keep him healthy (as you were taught). He keeps going back to "his stuff handing out." You instinctively say without thinking those dreaded words;  "Don't worry, I am a professional, and I have seen all this before." Up to this point, you did not notice that he was a technical writer specializing in contracts. (He wrote contracts for lawyers.)

He very calmly sits down, calls you out on the biggest, most obvious (one of many) mistakes you just made. He lectures you, not angrily, but like a "Jewish Uncle." You want to apologize, but that was "beaten out of you." As a physician, you NEVER apologize. You say some PC BS you were taught like "I will try to be more aware of your feelings." You go over everything that you want to check, finishing with the DRE. You wait for the conflict to start back up, but nothing. 

He says he has never had his penis examined, especially his urethral meatus, what ever that is. As for plaque, he brushes regularly, so why do you have to touch his penis? He jokingly compares the DRE to the performer "Doctor Dre." He is calm, professional, frank in candor, asking intelligent questions, and even made a joke. Your professionalism saved the day. 

He is still not grasping the concept of what you want to do or the reasons why. He inquires if he can just get a CAT scan without all that poking and prodding. He has a basic concept of the organs in the body and every now and then drops a hint that he is holding back the amount of knowledge he really has.

He does let you know about his past history with healthcare, his feelings, and how the experiences affected his life. He tells you that it is all in his charts, and counseling and anti-anxiety medication was recommended for him, but there was no reason for that. Now you validate his feelings, assure him that it is normal to feel that way, and you had fears and apprehensions when you first started dealing with the human body. You were able to overcome your apprehensions, he could too, you would walk him through it.

Again he apologizes for not comprehending. You can't understand how someone so intelligent can't grasp a simple concept like anatomy. You attribute that to your superior training as a physician. You explain the virtues of your profession of keeping people healthy, treating the sick, and educating the patient. You assure him that you are not like the provider that betray his trust, that was just "one bad apple" and most physicians are really good. You remember one of your professors holding a session about things that "you will never find in a book:" 

"If you have a noncompliant patient and he is debating your decision in a matter, pick an issue that the patient is blatantly at fault for, calmly and professionally switch to that subject. Once the patient has apologized for his transgression, reiterate it so he apologizes again. Then explain to him that this is never to happen again as you would to an adult child. Once the patient acknowledges this, the patient will be compliant. This will set the tone for the rest of the encounter. If the patient is not in a gown, have the patient don a gown even if it is not necessary. This will make the patient further submissive and easier to manage." 

He has continually apologized for not taking better care of himself, not learning about his body, or understanding your explanation. You have been using a picture on the wall, and usually you have a model of the male anatomy to educate the patient on where everything is, what, and how you check.  

Then he drops a bomb... In the interest of patient education, you can be the subject, "The Good Doctor" will demonstrate on you what will happen to him. He would feel very comfortable submitting to a full exam after seeing one done. It would also validate everything that you said about the GU part and that you were not hiding anything. 

You go into the mantra that this is not professional, blah... blah... blah... blah... blah... blah... blah... blah... blah...  He sits there silently listening. Then you say "We will just forego the complete exam." The whole time you have been waiting for "The Good Doctor" to jump in and undo this mess. He knows his patients better than you expected. He knew where this was going, and he let you "dig your own hole." The patient rebuts: 

"We are not finished here, you need to listen to me now... You never introduced yourself to me when you first came in here. I had to figure out who you were. You have all my information in the notes. I am open and honest how that experience has affected my life. I finally found a physician that I can trust. We work together. If you did not understand how this affected me you should have asked. You discounted my mental and emotional health and the consequences of you actions without explanation or maybe because you just don't care?" 

You want to jump in and say that is insulting, you do care, but after what just happened you listen. 

"I believe that you do care, or you wouldn't be doing this. You proceeded to disregard my feelings and made my mental anguish about you. If you want trust and respect, you need to give it. Then you order me to undress, not ask me. You did it as if you had a right to unfettered access to my body and person and I had no choice in the matter."  

"I have given you latitude ONLY because The Good Doctor" has allowed you to be here. Now you are tarnishing HIS reputation. Do you think that I do not know that I should be having complete physicals? I would like to, but it is not worth the worry, fear, and nightmares that it will bring."

"I know that it sounds silly to most people for a grown man to be afraid of the doctor,  more so to a physician, and it is easy to see why one may easily dismiss or question the validity of my feelings." 

"I can assure you that my feelings are very real. The physical feelings that follow are very real too; the sleeplessness, the fatigue, the chills from the worry. What compounds the problem is that your profession caused the problem and now refused to acknowledge it. I was ready to take a leap of faith, my trust was being restored and I wanted to see if you were willing to earn my trust back."  

"More than anybody I know how frightening and embarrassing it can be.  You extolled the virtues of your profession and preventative care, and I wanted to see if you believe what you say. Hence, I made that modest proposal. This will be a lesson that you never forget and make you a better physician. What this world needs is more good physicians, then you will have less people like me." 

"By refusing, you have told me that you you do not want to walk this path with me, you only want to tell me where to go. You give me the it's unprofessional excuse and blah... blah... blah... I know that. I don't want to see your ass anymore than you want to see mine. I would respect you more if you told me your real feeling on the matter. I know what they are because that is how I feel about it." 

"Finally, I feel lied to. You tell me it is not that bad, I will survive it, blah.. blah... blah..., then you avoid it like the plague. What are you not telling me, it is worse than you said, you are withholding information."   

"I can see your reasons are disingenuous. I know that "not professional" is valid reason, but it does not acknowledge my feelings again. Tell me you fear it as much as me, it is embarrassing, and you can hide behind "not professional. It is that attitude that made me the patient today. It is not just one pad physician, it is the whole system, and you are only proving that." 

What Would You Do?

You may think this absurd. I know that everybody will say no. But ask yourself HONESTLY, why you would say no. I'm sure that the real reason is that you have the same feelings as the patient. So if you expect the patient to "get over" their anxiety, why can't you?

You cannot use the excuse "how this affects the doctor-patient relationship." This is your patient right now YES, but the issues you point to are for long term doctor-patient relationships.

You may not believe it, but there are patients who will say this. There are two main reasons that they say this; first they want you to empathize with them. For some reason, you are not convincingly relaying your empathy (whether your empathy is real or fake). Second, there is research that shows people are more comfortable being exposed (naked) when there are other people exposed with them.

Patient Dignity 07: A Broker Addressing Malpractice As Medicine Addresses Modesty

Let me start off by saying I am qualified to talk insurance premiums. For what I do, I decided to get all the insurance licenses my home state offered. It was a CYA move, so that I did not want risk being accused of being involved in insurance transactions without a license. At one point, I was a licensed broker in 20 states (for a specific project). I did not do health insurance, my specialty dealt with "work comp" insurances. 

 This is a cumulation of most of the complaints that patients have about the treatment of their dignity. This is satyrical and always, from the patient's point of view.  Most providers are just good people caught in a bad system. Changes that I advocate not only ensure patient dignity, but frees the physicians from the system to ensure the protection of patient dignity.

As more practices that were partnerships can't afford med mal/liability, they are selling to large healthcare corporations. Practitioners of the Healing Arts are becoming employees. I chose this narrative because you as a provider feel that you have been treated in this manner. You may have had some of the same, exact experiences and infractions committed against you.

I realize that some references may seem silly, but you are an intelligent, educated professional, and you will get the gist.



As a physician and a partner in a practice, would you find this aceptable???

An Insurance Broker Tells His Physician Practice Clients, in a Letter, What Really Happens

Dear Physician Practice Client,

Recently there has been posts on many internet blogs by physician practice groups bashing brokers and agencies. While most brokers and their support staff are honest, caring, professional, people, there are some (more than we like to admit, even more than we know), who give our profession a bad name.

We are just as guilty as them because we were brought up in a system that teaches us to ignore human emotions, we just look at the body of numbers. We attribute these infractions to the atmosphere we work in: big corporate agencies trying to run insurance like a fast food chain, insurance companies that keep negotiating lower and lower commissions, excessive workloads, the constant threat of Errors and Omissions lawsuits, continuing education credits, and so on.

I also do not see that many of these criticisms are valid, but I am looking from the inside out. Because I don't believe that they are valid, I don't try to see them either despite the overwhelming evidence staring me in the face.


We are accused needless ignorance or calloused disregard of the client's emotional well being going through a difficult process. We are not working in garage on automobiles here but with real live people who in all probability have never been through the initial application process and what happens is pretty distressing.

Renewals are easy, just sign and accept. You will definitely have to go through this process again if you get dropped. The "Big Insurance Association" recommends that even if you are getting renewed to go through the complete application process, annually to prevent future problems.

Many of my decisions on your coverage use to be influenced by commission rates, bonuses, MGA contracts, and contests with vacation prizes. Those days are pretty much gone. Being a carrier rep does not have the prestige that it use to.

I am sorry that  your malpractice/liability/work comp/EPLI/D&O/E&O insurance expires and is being non-renewed. I know that this is a scary situation that you may not be familiar with, but as your licensed insurance broker, I am charged to serve you, the partners, and the practice; my client,  first, in your best interest, professionally, and ethically.

You may feel humiliated being in front of me and my team with no insurance to cover you. That is only to be expected. You need to realize that we are working to save your practice, you need to stop being silly and put your feelings aside. We don't see the value of your feelings in this matter when you may lose your practice.

The first thing that I need to do is put together an application. I am going to have to ask you some very personal questions about the practice and the people working there. You may think that these questions are unrelated to your application, but as a professional, I need this information as part of the application process.

I will be asking you about education, finances, accreditations, employment practices, billing, accounting, criminal backgrounds, and so on of the partners, the practice, and the employees. This is necessary for me to look for any red flags that might pop up. We may have to run some tests on your employment policies. These may be unpleasant, but again all we are focusing on here is you not losing your practice.

I will also be examining some very intimate parts of the practice, like the finances of the practice and of the partners. I will try to remember to tell you everything that I do before I do it. At any time if you are uncomfortable, I will stop. I may not realize that you are uncomfortable about these issues, I may not be talking with you during this, just pushing foreword.

You may feel embarrassed about what I find, but don't worry, "I am a professional and I have seen it all before." I will try not to expose areas unless I have to. You need to realize that in order to do my job properly and serve you completely, I need to look at these areas even though other brokers might not and it might even not be necessary. Yes I can put together an application without them, but I do a complete forensic exam, my choice. If you are uncomfortable with that, perhaps you should seek out another broker.

I tell all my clients "I can tell a lot about your business by examining these intimate parts." We can get a healthy picture of the practice now, it will be easier to diagnose and prevent problems in the future. I may also request records from previous providers, like audited financials from your accountant. It is my choice how I conduct my application process.

I create a file about your practice with all my info, notes, application, and I may even come out to your practice to take pictures. We may identify certain rooms in your practice, but we do not take pictures of anything that identifies your practice. We may use the pictures and information we collect on your practice in scholarly studies to predict future risk, but you already agreed to all that in the "broker of record" form that you signed.

Very few people are comfortable having a complete stranger see their very private tax returns and other stuff, but I was taught the correct way to do this, so you have nothing to worry about. They are just numbers. I am not judging you based on this. I only look at one section at a time. I know that some people on the internet describe this as an anal probe and say it is too intrusive based on their financial modesty issues.

To make you feel better about your embarrassing situation of not being covered (by insurance), I may have this chap, alone, from my office with me when I have your folder open, looking at your stuff and doing the application procedure. This is for your protection and for mine. I don't want to be accused of "fudging your numbers" or "having my hand in your cookie jar." You might be more uncomfortable with this, but rest assure, I am not (it's NOT my stuff being looked at).

I keep this information in a manilla folder to protect your financial modesty. I know that manilla envelopes can open accidentally and expose your stuff, but as a "matter of efficiency," that is what we use. Yes, there are "interoffice clasp envelopes, but they are too inconvenient for us. Manilla envelopes cover enough up.

There are also going to be other members on your team here getting your submission together, you really don't need to meet everyone of them. They should introduce themselves when dealing with you, but they may not because they have too many clients heaped on them. Just so you know, they will be poking through your stuff. This also includes carrier reps who may be with me looking at your stuff showing me how to fill out a new insurance application.

We also have interns (trainees). These are people studying to get their insurance licenses. There is an obligation to train new brokers, so we have them working with us. They will be poking through your stuff too. Most brokers won't tell you they have trainees or who they are so that clients just assume they are brokers too. That saves us having some uncomfortable conversations with the clients. 

I know that you want to know about my finances and lifestyle, but that is my personal information, and it is not professional for me to share. Even though it would build enormous trust by me filling out an application, showing you my tax returns, putting my money where my mouth is, I wont because I don't have too. I have this plastic model of an application or a brochure that I can show you.

Negotiating our professional relationship, involving you in decision making, foregoing some painful parts of the process, giving you more control, and going through the process WITH you would build trust, alleviate your fears, and allow you to endure some of the painful and humiliating parts that you thought you would refuse.

But that means giving up control. I am a sales professional, a type A personality. I was taught that as soon as you get resistance from a client, get their information in a manilla folder and the humiliation and power imbalance will make them compliant. It also helps that I am in a suit, looking like a professional and you are in your pajamas (scrubs). In the good 'ole days, you would come in, show me your stuff, and I was in control from there.

I will also politely order you to do certain things, like "sign here." If you refuse, then I just repeat the order, in a stern, matter-of-fact voice until you comply. I am the authority figure, and I need to act as such.  Asking, although more respectful, gives you the opportunity to say "no." Then I need to explain myself, you are deluded in thinking that you can refuse. Again I was taught this too, but you will not find it in any book.

When I went to school, we never did applications on each other. Although it would have made us better brokers, given us a better understanding of what you go through, our paternalistic attitude prevented us from doing that. We did do superficial stuff, like figuring out the SIC codes of where we currently worked, but that is all.

Some teachers allowed us to process applications with their personal information. Mostly we had actors come in and we practiced on them . Other than that, you get experience as an intern. The broker who taught me would wait until the client was out (of the building), then me and four other interns would pull back his manilla folder and poke through his stuff.

At first I had a problem doing this, but my mentor said that since we were affiliated with a business school, this was a teaching agency. There was also informed consent, in the fine print in paragraph 49 in the "broker of record" agreement that the client signs.

You may feel depersonalized. We are taught to do this to solely make choices based on logic, fact, observation, science, and the numbers. You need coverage, and this is the coverage that you need. You don't want the deductible, but you won't get coverage without it.

We are all insurance professionals, but we are human first and foremost. That means we have curiosity, stresses, and make mistakes. Most of our administrative assistants are young, female, and immature. We will tell you they are professional. They will look through your stuff, will gossip about it, laugh about it, and may even post it on FaceBook.

If you are a middle aged man or older, or fat, you will be a source of entertainment for some of these young people, especially the women. If your manilla folder is bigger than most, they may be calling other admin assistants to look at it. They will present with a legitimate reason to look, and they are most likely entitled to look, so deal with it in the furtherance of education.

We  expect them to act as professionals. We can do more, but that takes time and money. Besides, we feel that we are doing enough to protect your privacy. I am not sure either exactly how often this happens, so it may not be a problem at all. The industry never studied this.

If you are a woman that is a partner in a practice, and especially if you are attractive, you may notice brokers coming over to talk to your broker. Your broker may even call a consult with other brokers if he feels that he needs to. This is normal. You should not feel uncomfortable, they are all professional.

The fact of the matter is that most of our brokers are men. Most of our admin assistants are female. We would like to hire male admins and female brokers, but their numbers are limited, therefore your choices and wishes are limited too.

In a busy office, people will see your stuff. That is just a fact of life. We could do more; private offices, clasp envelopes, better training, but we don't. That is because WE don't see a problem with your stuff being exposed. If you have a problem with it, then there must be something wrong with you.

If you come into my office, you consent to my entitlement to dig through your business. If you don't follow my directions, then you are noncompliant and I cant work with you. Here is the phonebook, good luck finding another broker, after being labelled a "bad risk."

I know that you want more, but I don't know what "more" is. That is because I never bothered to ask. I assumed that we are doing enough by saving your practice. To be honest, your emotions and financial modesty are just interfering with the process.

The Internet talks about making insurance consumer driven, but as an educated, licensed professional, and an arrogant SOB, I reject that. You are not a consumer, you are an "insurance client." Besides, I don't work for you, the insurance company pays me (commission).

You do have options. This is not extortion. There are many out there doing without vaccine insurance. There is speculation that this is due to backlash against the industry. Sorry, but if you don't have  vaccine insurance, I can't take you on as a new client or I will have to drop you if you are already a client.

I have seen predictions that a future trend will be many practices choosing the "Florida option," that is walking away from agencies because they are unhappy about the way they feel that they are being treated.

Welcome to our agency.

Patient Dignity 06: The Fallacy of a Patients' Bill of Rights

Most healthcare providers have a "Patients' Bill of Rights" publicly available. A patient's bill of rights is a list of guarantees for those receiving medical care. It usually takes the form of a non-binding declaration. This means that the "Patients' Bill of Rights" posted by the provider MEANS NOTHING!!! It amounts to nothing more than a piece of advertising.

Typically a patient's bill of rights guarantees patients information, fair treatment, and autonomy over medical decisions, among other rights. In the United States there have been a number of attempts to enshrine a patient's bill of rights in law, including a bill rejected by Congress in 2001.

On June 22, 2010, President Obama announced new interim final regulations, the Patient’s Bill of Rights, that include a set of protections that apply to health coverage starting on or after September 23, 2010, six months after the enactment of the Affordable Care Act. This deals with finances, insurance coverage, it does NOT cover the individual's right to self-determination or modesty issues.

Some Patients' Bill of Rights may include items which are enacted into law (such as "receive emergency care if you need it" which is federally enacted under EMTALA). Just because a Bill of Rights references a binding law, it does not make the Bill of Rights binding.

The State of New York has enacted a Patients' Bill of Rights (which can be seen here:). Again the list is deficient. For example: 

(2) Receive treatment without discrimination as to race, color, religion, sex, national origin, disability, sexual orientation, source of payment, or age.

This does not cover gender. Technically, a provider can refuse a transgender individual. It also does not address modesty issues, filming of procedures, or about medical student participation. The last may be implied under: 

(6) Know the names, positions and functions of any hospital staff involved in your care and refuse their treatment, examination or observation.

But there is no mention of being able to refuse them OR determine who is involved in your care. "This is Bob, he will be filming your rectal exam, and this is Fred, Alice, Mike, Lisa, Joe, Habib, Apu, Roselita; all students who will be practicing on you..." Furthermore, the NY Patients' Bill of Rights only applies to hospitals.

Another (shady) tactic is to have a document called "Patients' Rights and Responsibilities." This attempts to create grounds that you as a patient cannot refuse. Consider the "Patients' Rights and Responsibilities"from the Geisinger Healthcare System (found here:) 

The first line states:

Being a good patient does not mean being a silent one.

Now they are going to tell you how to be a "good patient," as they see a "good patient," and not necessarily a self-determining human being with inalienable rights. It is implied by this (one-sided) agreement that you are giving up rights in exchange for "lesser" rights which they are giving you. Furthermore they do not define what a "good provider" is.

Let's examine some more rights. My commentary in bold type.

 2. A patient has the right, upon request, to be given the name of his attending physician, the names of all other physicians directly participating in his care, and the names and functions of other health care persons having direct contact with the patient. But apparently no right to refuse. What about being told the name of the technician repairing a machine in the operating room while you are having rectal surgery? 
3. A patient has the right to every consideration of his privacy concerning his own medical care program. Case discussion, consultation, examination, and treatment are considered confidential and shall be conducted discreetly. 
5. A patient has the right to know what hospital rules and regulations apply to his conduct as a patient. Rules may require things contrary to the patient's rights.
8. The patient has the right to full information in layman's terms, concerning his diagnosis, treatment, and prognosis, including information about alternative treatments and possible complications. When it is not medically advisable to give such information to the patient, the information shall be given on his behalf to the patient's next of kin or other appropriate person. What is "not medically advisable?" 
11. A patient has the right to refuse drugs, treatment, or procedure offered by the hospital, to the extent permitted by law, and a physician shall inform the patient of the medical consequences of the patient's refusal of drugs, treatment, or procedure. "To the extent permitted by law" means that there is a legal way around this.
13. A patient has the right to medical and nursing services without discrimination based upon race, color, religion, sex, sexual preference, National origin or source of payment. But transgender people can be discriminated against.
15. The hospital shall provide the patient, or patient designee, upon request, access to all information contained in his medical records, unless access is specifically restricted by the attending physician for medical reasons. Like the attending physician made a mistake. Is that a medical reason?
16. The patient has the right to expect good management techniques to be implemented within the hospital considering effective use of the time of the patient and avoid the personal discomfort of the patient. If this applies to modesty issues, GOOD JOB!
23. A patient has the right to participate in the development and implementation of his or her plan of care. Participate, ultimately it is the decision of the physician (see responsibilities below:)
24. A patient or his or her representative (as allowed under Pennsylvania law) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment, in accord with applicable law and regulation. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.  "Deemed medically unnecessary or inappropriate," like modesty issues!
33. A patient has the right to an environment that preserves dignity and contributes to a positive self image. A patient has the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation, or harassment. A patient does NOT have the right to have their body covered or modesty issues respected because "we" do not consider that abuse.
38. A patient has a right to have his or her cultural, psychosocial, spiritual and personal values, beliefs and preferences respected. "Respected," (only) NOT followed!
40. A patient has the right, without recrimination, to voice complaints regarding his or her care, to have those complaints reviewed, and, when possible, resolved. Resolved "when possible." We won't be able to get to your issue for another 2 weeks, you have to go through with this as we say, then in 2 weeks we will see if we were right or wrong. 

Now the Responsibilities:

• Help your doctor, nurse, and healthcare support staff in their efforts to care for you by following their instructions and medical orders. Following their orders. I thought the patient was involved with the decision making. Orders like "get undressed now?"
• Accept medical consequences if you do not follow the care, service, or treatment plan provided to you. Consequences like the healthcare system dropping you as a patient?

The Rights Giveth, and the Responsibilities Taketh Away

You think that you are getting something in the "Rights," but the "Responsibilities" nullify or take away those rights. Here are some of the ways to take away "rights," of course remember that it is only what you perceive as rights.

• To follow rules, regulations and policies affecting patient care and conduct.  This subjects you to additional rules (not listed in the rights and responsibilities). Not following these additional rules is also a failure of you following your responsibilities.
• To recognize that a teaching institution has a commitment to the education of future health care professionals. Patients receiving care are a part of this process. This means that you must comply to being examined by students AND not having the right to refuse being examined, observed, and recorded (audio/video). 
• To follow the treatment plan recommended by the health care provider responsible for your care. This includes following the instructions of the other health team members, such as nurses and physical therapists, as they carry out the coordinated plan of care. It is your responsibility to tell your health care provider whether or not you can and want to follow the treatment plan recommended for you. The most effective plan is one in which all participants agree is best and which is carried out exactly.  This means that you can participate in decision making (via rights), the doctor does NOT have to include you in the final decision of the course of treatment. You can refuse the treatment, but then you are at fault for not following the physician's wishes. This nullifies your participation in any decision making.
• Patients should cooperate fully with providers in complying with mutually accepted treatment regimens. Statements like these leave out the actors. Mutually accepted by who? The physicians? Everyone except the patient?
• ...within the capacity of the medical center.  This means what we feel like giving you. If we don't want to give it to, we won't have it.
• Provide accurate and complete information about current health care problems, past illnesses, hospitalizations, medications, and other matters relating to your health. If we ask it, it must be relevant...  
• To refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. "Deemed medically unnecessary or inappropriate," by us, the hospital. Your level of modesty issues are "medically unnecessary, because if they were we would already accommodate them. 
• In accordance with applicable law and regulation... Means there is a way around this, usually  by interpretation. By then it is too late.
• Patients should pursue lifestyles known to promote positive health results, such as proper diet and nutrition, adequate rest, and regular exercise. Simultaneously, they should avoid behaviors known to be detrimental to one's health, such as smoking, excessive alcohol consumption, and drug abuse. Of course, the hospital determines what they see as a healthy lifestyle. They do not take into account what the patient can AFFORD to do.
• To cooperate with the members of the health care team who provide care to you.  You must comply with them, even if they are violating your rights. 

I want to expand on the last issue a little with an example. This example is based on the NY Presbyterian Hospital forced rectal exam of Brian Persaud:

A patient comes in with a head injury. The attending assumes that the patient lacks capacity, when the patient actually has capacity. The attending attempts to force a rectal exam. The patient being battered, fights back. The physician has the patient charged with assault and battery. 

The "responsibilities" expect the patient to comply, even when the providers are in the wrong or the patient is being assaulted and battered. The hospital does not want you to defend yourself.

They may say you have the "right to a safe environment," "a respectful environment," "the right to file a complaint," and even "the responsibility to report any safety violations, unsafe conditions, dangers, or hazards." There is nothing about you protecting yourself.

Update 2014-08-18

Patient Rights & Responsibilities and Patient Visitation Rights (Source: Skyridge Medical Center)

Rights:

• To participate in ethical decisions that may arise in the course of care including issues of conflict resolution, withholding resuscitative services, foregoing or withdrawal of life sustaining treatment, and participation in investigational studies or clinical trials. You can ONLY participate in ethical decisions, not in deciding your treatment. That is up to the paternalistic physicians.
• If the healthcare facility or its team decides that the patient's refusal of treatment prevents him/her from receiving appropriate care according to ethical and professional standards, the relationship with the patient may be terminated. This is listed as a right. Again, the paternalistic physicians decide what is best for you.

Patient Responsibilities:

• To follow the plan of care established by his/her physician, including the instructions of nurses and other health professionals as they carry out the physician's orders. PATERNALISM!

If the patient has a responsibility to follow the physician's treatment plan, then does the patient not have the right to a treatment plan that will cure the disease?

Patient Dignity 05: Why Physicians and Providers Should Support This Initiative

The view I take in regards to human dignity is that from the patient. "Do no harm" is proof that the patient comes first. That means that the patient has the right to "self-determination" and ultimately the right to say "NO."

The physician needs to be free of any external influences to make decisions that are in the best interest of the patient. Ultimately, the physician and the patient need to determine the course of treatment, openly and freely, without coercion or external influences.

That means that the physician myst be free of external, 3rd party influences. So who are these 3rd parties that influence physicians?

Insurance companies, corporations that own hospitals, quotas and policies set by these corporations, provider networks, other departments in the hospital, the employers of the physician. If a hospital has a policy that a physician feels will harm the patient, the physician myst adhere to that policy and potentially harm the patient OR be unable to treat the patient, thus harming the patient.

The physician must also be free from repercussions of that decision. That is not to say that the physician is not accountable. The physician may have to explain his decision making. In being accountable to a 3rd party should be treated similar to a patient's right to refuse treatment: as long as the physician has capacity, the decision must based on logic.

For example if a corporate hospital system has a quota for physicians to refer to radiology, a physician may logically forego radiology with a certain condition where the physician has diagnosed the problem and radiology is not necessary. If the physician misses his quota, then he should not be sanctioned if he can show that all his cases from that month did not need radiology by his logic.

This places the care in the hands of the physician to be tempered, guided, and ultimately decided by the patient. I have no problem in absolving the doctor from liability when the patient directs care, but only so far as reasonable. OPTIONS must be part of the decision making.

A physician can't say the prostate cancer patient is refusing ALL surgery, so I didn't bother telling him that his appendix burst. A physician also can't say "this is the best way, so it is the only way (or else no way)" OR "this is my preferred way (or else no way)."

Thank you for reading.

Robotic Surgery: An Ethical Dilemma?

Our local hospital has a "da Vinci Xi Surgical System", you can learn more about it here: There are only 10 units doing surgery as of July 2014. This is the future, today. I have been hammering the healthcare system with my series of posts on "Patient Dignity" (a.k.a. patient modesty). When I saw the "da Vinci Xi" (pictured below), I was thinking that this is a good thing! But, I was thinking in terms of "Patient Dignity" (same gender care, draped properly, no unnecessary people in the room, etc. Then I realized that this is a piece of advertising.

Of course it looks good, that is what it is designed to do. Just look at "11 Ways Advertisers Make Food Look Delicious" (on mentalfloss.com). So I decided to put aside the issue of "Patient Dignity" in regards to robotic surgery. I have to assume less people in the room is a good thing for the dignity of the patient.

But there is a pitfall: How many on the hospital staff are going to want to see this "wonder of medicine" in action? How many people will be "popping in?" Will they broadcast live video, rebroadcast it, and do this in an "Operating Theater?" Who will get to see it, medically licensed professionals only? Will the manufacturer want video of it in action for promotional pieces, will medical schools want video for educational reasons? Will the corporation that owns the hospital want video for promos?

What say will the patient have in spectators permitted and the procedure being videoed or not? This circus of spectators reminds me of the 1889 oil painting by Thomas Eakins, "The Clinic of Dr. Agnew."

Can the hospital ethically say:

"We need to film your procedure to further learning of medical students, if you refuse we cannot schedule you for robotic surgery, you must have traditional surgery. Based on the principle of utilitarianism (John Stuart Mill), spectators and video taping cures you, promotes learning, and we received this unit at a discount by providing the manufacturer with video of procedures, otherwise it would not be here."

I believe that robotic surgery is the same as any surgery in regards to patient dignity. So I will leave that issue for my series on "Patient Dignity." So other than the issue of patient dignity, there are no other ethical issues, and it is a good thing. Maybe not...

There are pros and cons to robotic surgery, and specifically to the "da Vinci Xi." I will list the pros and cons to both robotic surgery and specifically the "da Vinci Xi" together:

Pros:

• For the patient, there's usually less blood loss, a shorter hospital stay and less reliance on postoperative pain medication. There's also the cosmetic benefit of no big scars: As in laparoscopic surgery, the instruments enter the body through small incisions.
• For surgeons, the procedures can be less tiring. They don't have to bend over an operating table, they can sit in front of a screen with a magnified, full-color 3-D view of the surgical field. For maneuvering in very tight spaces, the enhanced screen image makes it much easier to see. 
• Overall costs to patients: A robotic procedure may mean less need for pricey items like blood transfusions and post-op pain meds. Patients may also spend less time in the hospital and have a lower chance of readmission for complications.
• Robot hands don’t shake and they can twist and rotate in more directions than human hands. 
• By 2009, 85% of the 85,000 U.S. men who had prostate-cancer surgery to have their prostates removed by the da Vinci system (Source: Intuitive Surgical Inc. of Sunnyvale, California).
• The robotic arm can make finer, more precise movements, with greater accuracy than the human hand.
• A map of the organ or structure, developed from radiology images, with landmarks or surgical points highlighted, can be superimposed over the realtime endoscopic video.
• The endoscope allows the surgeon a better view of the organ or structure.

Cons:

• Da Vinci robots were approved by the U.S. Food and Drug Administration (FDA) in 2000. Since its approval, there have been 4,600 adverse events reported to the FDA, which amounts to an average of one problem per day by June 2013.
• Robotic surgery complication rates may be no better than those of traditional laparoscopic surgery, according to an article published in the Journal of the American Medical Association (JAMA).
• Cost: A study published last year by surgeons at Brigham and Women's Hospital in Boston showed these average total patient costs for different types of hysterectomies: $49,526 for a robotic procedure, $43,622 for abdominal, $28,312 for laparoscopic and $31,934 for vaginal.
• More chance of nonessential people (non-medical personnel, students, medical personnel not directly involved in the care) wanting to see the technology in action. 
• More chance of the procedure being filmed.
• No expert consensus on how much training is needed. A 2010 New England Journal of Medicine essay by a doctor and a health policy analyst said surgeons must do at least 150 procedures to become adept.
• Machines break, power can go out, computers can freeze; even though there is redundancy built in, things can still go wrong.

Here are some facts about Robotic surgery:

• The term "robotic surgery" refers to "robotic assisted surgery." A surgeon sits at a computer console in the operating room, directing the long robot arms with hand controls. The arms are tipped with tiny surgical instruments and one has a video camera that lets the surgeon view the operation on the computer screen.
• The world’s first surgical robot was the ‘Heartthrob’, which was developed and used for the first time in Vancouver, BC, Canada in 1983.
• Robotic surgery devices generally include 3 critical tools which include a robotic arm, endoscope and monitor, and a tele manipulator which enables the doctor to simulate their hand movements with the movements of the robotic arm.
• Major advances aided by surgical robots have been remote surgery, minimally invasive surgery, and unmanned surgery. 
• The surgical robots that have been developed for use include Da Vinci Surgical System, ZEUS Robotic Surgical System, and the AESOP Robotic System.
• Robotic surgery gained popularity first among prostate surgeons, who like its precision in working with delicate male organs.
• The U.S. Food & Drug Administration (FDA) web page about robotic surgery can be found here:

The "da Vinci Xi" at first glance reminded me of Number "Johnny" 5, from the 1986 movie "Short Circuit." It can be scary to look at to some people. Some patients may feel dehumanized being treated by a robot.

This also reminded me of a theory that science fiction predicts future technologies.  Studies have shown that cultures with rich collection of science fiction prose, have greater technological advances. These include ancient cultures to modern day cultures. Here are some sources of this theory:

• Thomas Clareson: "Science Fiction Criticism" (Kent, OH, 1972) 
• Roy C. Amara and Gerald R. Salancik; "Forecasting: From Conjectural Art Toward Science" The Futurist (April 1969)
• Albert Somit: "Political Science and the Study of the Future" (Hinsdale, 11., 1974)
• Dennis Livingston; "Science Fiction as a Source of Forecast Material," Futures, I (March 1969)

Proof of this comes from the 1960's television series "Star Trek." The communicators predict cell phones. Motorola's "StarTAC" cell phone not had an uncanny resemblance to the Star Trek communicator, but the name closely resembled the title "Star Trek." There are also flatscreen television, the tricorder (see the iphone in medicine here:), and laser pointers.

I think the most realistic look into the future of medical robots comes from the movie "Star Wars Episode III: Revenge of the Sith"(2005)  and "Prometheus" (2012), part of the movie "Alien" (1979) franchise.

In "Star Wars Episode III: revenge of the Sith," Darth Vader then engages Obi-Wan Kenobi in a lightsaber duel which ends when Obi-Wan severs Vader's legs and remaining organic arm mid-air. Vader then slides too close to a lava flow and sustains life-threatening third-degree burns. Darth Vader is saved by medical droids (robotic surgery) who treat his injuries and reconstructed his body with the cybernetic limbs and the black armor. Also note the use of cybernetic limbs.

The second vision of robotic surgery coves from "Prometheus." I believe that this is a more realistic view of what is to come. The medical droids in "Star Wars" were totally autonomous and to some extent "self aware." (See reference of self awareness here:) The term "droid" is "Star Wars" nomenclature and short for android;  a robot with a human appearance.

The surgical robot in "Prometheus" is called the "Medical Pod 720i." The definition of "pod" is self-contained unit on an aircraft, spacecraft, vehicle, or vessel, having a particular function. The "Medical Pod 720i"is semi-autonomous. It needs to be directed by a human being, when there is a conflict (machine doesn't know what to do), then a person has to resolve the conflict with in the machine's capabilities.

Essentially the "Star Wars" droids direct the examination, diagnosis, decision on treatment/procedure, and treatment the medical condition. They can be overridden by humans. In "Prometheus" the person directs the "Medical Pod." The human can examine or request an examination. The machine can suggest a diagnosis and treatment, but the person must ultimately decide the diagnosis and treatment. The person also direct the treatment or procedure. Here is a YouTube video of the "Medical Pod 720i" from  the movie "Prometheus" in action:

This is how I see the evolution of robotic surgery:

1. The surgical instrument: the first extension of the human hand being.
2. Power assisted mechanical surgical instruments (surgical drill).
3. Mechanical laparoscopic surgical instruments.
4. X-Rays, MRI, CTs, laparoscopic video, etc.; advances in imaging.
5. Energy surgical instruments (surgical laser).
6. Powered laparoscopic surgical instruments (da Vinci Xi).
7. Powered laparoscopic surgical instruments with advanced imaging. 
8. Hands free powered laparoscopic surgical instruments. 
9. Computerized diagnosis and treatment recommendations.
10. Hands free powered laparoscopic surgical instruments with advanced imaging. 
11. Hands free powered laparoscopic surgical instruments with advanced imaging, body mapping, and organ recognition. 
12. Hands free powered laparoscopic surgical instruments with advanced imaging, body mapping, organ recognition, and preprogrammed procedures ("Medical Pod 720i").
13. Autonomous medical robots ( "Star Wars" medical droids).

Ethically it comes down to the doctor's diagnosis and recommendations, patients' choice, full disclosure, patient dignity, and "NO STRINGS ATTACHED." 

By doctor's diagnosis and recommendations, I mean the doctor diagnosis the disease and ONLY recommends the course of treatment. This includes if the patient is a candidate for robotic surgery, if there is a less invasive technique, or if "hands on" surgery is the best route. The best example of  "hands on" surgery that I can think of is plastic surgery which is just as much art as science.

At this point the patient chooses which treatment. A patient may prefer "hands on" surgery. It must be the patient's choice. When I say full disclosure, I do not mean the fine print on page 18 of the admission form that the patient signs at 5AM when being admitted on the day of surgery. This is beyond the risks, this is about who will be in the room, who is necessary to be in the room. There should be NO "maybe's, only "in the event of's."

Patient dignity has special considerations in robotic surgery due the the "wow factor" of the technology. It should not be broadcast world wide on pay-per-view. It should not be done at Madison Square Garden. If the unit records video from the endoscope, the patient should have full disclosure as to what happens with that video, and full control as to who is allowed to view it.

No strings means "NO STRINGS AT ALL!" Ethically, strings are the same as coercion. If a patient wants no spectators, students, or recordings, they CANNOT be denied robotic surgery. Saying "the unit automatically records video and we can't do nothing about it" is a STRING! Pre-negotiated contracts with third parties (such as the manufacturer) for things that are in the realm  of patient control are STRINGS! A discount to the hospital from the manufacturer for a video of all procedures is a STRING (and coercion).

The conditions (other than direct health related) on receiving robotic surgery should be no different than that of receiving laparoscopic surgery.

Me, I welcome robotic surgery, and at my insistence, it will NOT be a spectator sport for me.

Thank you for reading.