This is an expansion of my original post Patient Dignity 16: From Mother Theresa to Dr. Mengele that examines how medical school creates sociopaths. Much of the insight is derived from research in to how seemingly normal people could become Nazis and commit such human atrocities.
The link to my insights into modern medical schools creating sociopaths is the fact that physicians had been the largest professional group to join the SS. The object of their acts were not how to rescue or cure, but to destroy and kill.
Table of Contents
Original Post: Patient Dignity 16: From Mother Theresa to Dr. Mengele
How to Create a Sociopath: Part 1
How to Create a Sociopath: Part 2
How to Create a Sociopath: Part 3
In regards to gender, patient dignity, etc., the focus of
healthcare has always been primarily about healthcare. Patients are
secondary. Just like the medieval guilds, healthcare sought narrow regulation
of the industry in order to restrain competition against encroachment from
outside competition. (Source: A Tale
of Two Theories: Monopolies and Craft Guilds in Medieval England and Modern
Imagination)
The first AMA Code
of Ethics, is all about the patient’s duties to the doctor, not what the
doctor owes the patient. To see more how healthcare view the patient in its
inception, read Victorian
medical ethics and the subordinate patient.
Society granted physicians status, respect, autonomy in
practice, the privilege of self-regulation, and financial rewards on the
expectation that physicians would be competent, altruistic, moral, and would
address the health care needs of individual patients and society. This
"arrangement" remains the essence of the social contract.
...The
professions arose in the guilds and universities of medieval Europe and
England. They had little impact on society until science made health care worth
purchasing and the industrial revolution provided sufficient resources so that
society could afford it. Some means of organizing health care was required and
society turned to the preexisting concept of the profession. This occurred in
the middle of the 19th century, when licensing laws were passed granting the
medical profession a monopoly over the use of its complex and expanding
knowledge base, thus establishing the basis of the modern social contract.
(Source: AMA
Journal of Ethics)
Let me demonstrate another example of "guilds"
looking out for their own self interest at the cost of human dignity:
PREA is the acronym for the Prison Rape Elimination Act.
After decades of societal indifference to prison rape, Congress, in a rare show
of support for inmates’ rights, unanimously passed the Prison Rape Elimination
Act in 2003.
The law describes prison rape as epidemic. It refers to“the
day-to-day horror of victimized inmates, and of the need for Congress to protect
the constitutional rights of prisoners in states where officials displayed
deliberate indifference.
It took almost a decade for the Justice Department to issue
the final standards on how to prevent, detect and respond to sexual abuse in
custody. And it took a couple of years more before governors were required to
report to Washington, which revealed that only New Jersey and New Hampshire
were ready to certify full compliance.
What took so long? Resistance was coming from (and still is)
from many correctional agencies. The 52 standards for prisons and jails apply
to everything from hiring and staffing levels to investigation and evidence
collection to medical treatment and rape crisis counseling.
With the second annual reporting deadline, advocates for
inmates and half of the members of the National Prison Rape Elimination
Commission (a bipartisan group charged with drafting the standards) say the
pace of change has disheartened them despite pockets of progress.
“I am encouraged by what several states have done,
discouraged by most and dismayed by states like Texas,” said Judge Reggie B.
Walton of United States District Court for the District of Columbia, who was
appointed chairman of the now-disbanded commission by President George W. Bush.
Some commissioners fault the Justice Department for failing
to promote the standards vigorously. Others blame the correctional industry
and unions for resisting practices long known to curb “state-sanctioned abuse,”
as one put it. All lament that Congress has sought to weaken the modest
penalties for noncompliance, and that five governors joined Governor Perry last
year in snubbing the standards. The other renegade states, as advocates called
them, were Arizona, Florida, Idaho, Indiana and Utah.
But states face only a small penalty, the loss of 5 percent
of prison-related federal grants, if they opt out of the process entirely.
There are a lot of carrots in PREA, and not enough sticks.
Texas’ opting out was considered especially significant,
however, because it has the largest prison population in the country and by far
the most reports of sexual assault and abuse. Texas had three and a half times
as many allegations as California in 2011, when California still had more
inmates than Texas (according to the federal data).
Texas state officials found some standards particularly
intrusive. Governor Rick Perry protested that limitations on cross-gender strip
searches, pat downs and bathroom supervision would force Texas to discriminate
against its female officers.
Read more at The
National PREA Resource Center
One of the lessons of The Third Wave experiment
(conducted by schoolteacher Ron Jones's which he created a proto-fascist
movement amongst his high school pupils in Palo Alto, California, in 1967) was
that organizations are self serving of their own best interests.
By the latter part of the 20th century, however, many
social scientists concluded that the profession had abused its privileged
status and public trust, and that its regulatory procedures were seriously
flawed. (Source: AMA
Journal of Ethics)
If healthcare really cared about the dignity of patients,
then Tuskegee would not have happened, pelvic exams on anesthetized women would
not have occurred and we would STILL been
having that conversation in 2012.
The AMA Journal of Ethics alludes to there being something
other than gender in Patient
Requests for a Male or Female Physician. It refers to a study published in
Pediatric Emergency Care in 2005 entitled "'Doctor' or 'Doctora': Do
Patients Care?" One of the study survey questions was:
"If you had a choice, would you prefer to have a
male doctor, a female doctor, or the doctor with the most experience?"
This throws in to the mix another trait; qualification.
Those who defend the gender neutrality of healthcare (on this and other blogs)
usually say something to the effect, " I don't care if the doctor is male
or female, I just want the most qualified."
So I ask, if by the nature of having initials after your
name (MD, DO, RN, PA, NP, etc.) negate patient choice, why should qualification
(or what we perceive as qualification, like intelligence, education,
experience, etc.)? Remember the old joke, "Q: What do you call the
person who graduates last in his class from med school? A: Doctor."
Why should all patients, even those in in the healthcare
field, NOT just accept the first doctor or surgeon available?
Studies of the effects of physician gender on patient
care have been limited by selected samples, examining a narrow spectrum of
care, or not controlling for important confounders.
...Physician gender
potentially affects the physician-patient relationship and its outcomes in a
variety of ways. Physician gender differences in personality and attitudes,
especially with regard to gender roles, might influence interactions with both
male and female patients. Patients also may have differential expectations of
their physician based on gender. For example, they might expect the female physician
to be more supportive and empathic and, thus, to disclose more information.
Another way in which physician gender might be important is in the status
relationship between patient and doctor. As gender is a substantial component
of social status, same-gender physician-patient dyads may be closer in social
status (greater status congruence) than opposite-gender dyads.
Source: Physician Gender, Patient
Gender, and Primary Care
And where does perception come in to all this? Sociologists
and social psychologists have long known that there is a widespread perception
shared by many people that physically attractive people are more intelligent
and competent, as well as hold many other desirable characteristics.
A large number of experiments over the years have shown
that, when asked to rate the intelligence or competence of unknown others,
people tend to rate attractive others as more intelligent and competent than
unattractive others. (Source: Psychology
Today)
So competence is associated with attractiveness. Then the
inverse is that people who are less attractive (or creepy) are perceived
not as qualified (and not the best doctor).
To further the concept that there is more than gender, why
do we not see physicians with visible piercings and tattoos? Answer; dress
affects people's perception of physicians. See "Preferences of parents for
pediatric emergency physicians' attire" and "Effect of doctor's attire on
the trust and confidence of patients.."
But should it? Should patients not just have trust in a
physician because they have initials after their name? Is that not what
patients are told about gender.
Creepiness is very real. Our “creepy” reaction is
both unpleasant and confusing, and according to one study (Leander, et al,
2012), it may even be accompanied by physical symptoms such as feeling cold or
chilly. The little bit of research that was at all relevant focused on how we
respond to things such as weird nonverbal behaviors, and being socially
excluded. These studies did not use the word creepiness, but their results
implied that our “creepiness detector” may in fact be a defense against some
sort of threat.
So, what is creepiness?
A
recent study (currently under review for publication) by Knox College
social psychologist Francis McAndrew and his student Sara Koehnke takes a stab
at unpacking exactly what creepiness is.
Creepiness universal human response related to the “agency-detection”
mechanisms proposed by evolutionary psychologists. These mechanisms evolved to
protect us from harm at the hands of predators and enemies. If you are walking
down a dark city street and hear the sound of something moving in a dark alley,
you will respond with a heightened level of arousal and sharply focused
attention and behave as if there is a willful “agent” present who is about to
do you harm. If it turns out to be just a gust of wind or a stray cat, you lost
little by over-reacting, but if you failed to activate the alarm response and a
true threat was present, the cost of your miscalculation could be high.
We evolved to err on the side of detecting threats in such
ambiguous situations. Creepiness is anxiety aroused by the ambiguity of whether
there is something to fear, and/or by the ambiguity of the precise nature of
the threat—sexual, physical violence, or contamination, for example—that might
be present.
Gender plays a role:
Note the rating of traits of creepiness, in this chart of the
study results (Likelihood
of a creepy person to possess certain characteristics), include gender
(opposite 4.01, same 2.41).
95% of survey participants thought creeps were more likely
to be male than female — a perception that was equally held by both male and
female survey respondents. Women were also more likely to perceive a sexual
threat from people they deemed creepy.
See a visualization of creepiness in "The Lonely
Island's" song "The
Creep."
As to every study done on gender preference of a
physician (or other healthcare provider), they are ALL flawed! The flaw
simply asks for the preference of a male or female physician. There are so many
other variables that affect the decision beyond just gender. Here are examples:
In the study, "The role and impact of
gender and age on children's preferences for pediatricians," the
sample was taken when coming for an outpatient visit to a university-sponsored,
urban pediatric practice. This is a population that is are regular patients at
selected practices. These patients are already conditioned (or have developed
coping mechanisms to deal with that as a traumatic event).
Data
from students participating in the Commonwealth Fund 1997 Survey of the Health
of Adolescent Girls, only asks the question of preference of the physician
(provider) gender, but NOT necessarily for an intimate (genital) exam.
The study, "PHYSICIAN
Gender Preference in Adolescent Males within an Inner-City Youth Population,"
does ask preference of the physician gender, for a genital exam. The problem is
that there is an assumption that a GE is absolutely required, the patient has
granted informed consent (including knowing that it can be refused without
retaliation).
Note: The only absolute indication for a
genital exam is a specific genital complaint. Even then, many diagnostics do
not require direct genital examination. Many genital conditions can be
diagnosed through urinalysis, blood tests, self-collected specimens (swabs),
self-exams, imaging, etc. They are not necessary for "mandated"
wellness exams (just as wellness exams are no longer necessary).
One example
is a guidline for testicular cancer from "Teaching the
TesticularExam:AModel Curriculum From“A”to “Zack”" which
states:
"Patient preference would then determine whether these men would
be screened by physician examination and/or TSE."
This is like the situation where somebody is wronged
erroneously. The wronged person asked the one who committed the infraction,
"Head or stomach?" (The inference is that to "make things
right," the wronged party is going to give the perpetrator a
"punch." They are being polite in letting them choose the
"correction.")
One can study this situation and conclude that a certain
percentage of people prefer to be punched in the head and a certain percentage
prefer the stomach. Let us hypothetically say 80% prefer the stomach. I can
then use this to justify me punching people in the stomach. This is what
healthcare has done with gender and intimate exams.
In AAP publications dealing with genital exams, their
guidelines all state:
"Routinely examining the genitals from childhood
through adolescence can help the male patient understand the routine nature of
this examination component." (Example: Male Adolescent
Sexual and Reproductive Health Care
Note in the study "Shoe
Size Changes - Layman's Marker of Onset of Puberty," 23% of the
children refused the SMR exam.
To properly study this question the first question should
be: "When going to the doctor, for a genital exam I:
C.) would refuse a
genital exam
B.) prefer a male doctor
C.) prefer a female doctor
D.) have no
preference if the doctor is male or female
E.) would make my choice on some
other factor
An ongoing issue in healthcare is the failure of
physicians to acknowledge that these situations are humiliating, can have
severe negative side effects, let patients know that they can refuse them
without retaliation (whether recommended by guidelines or not), and follow
guidelines that call for omitting them.
Discussion about sensitive topics and sexual organs can
be uncomfortable for both physicians and patients. If not appropriately
addressed, this discomfort can result in inadequate patient education about
self-examination of sexual organs, with failure to detect early warning signs
of cancer. Discomfort may also result in patients feeling physically and
psychologically exposed and humiliated, increasing the possibility of
withholding important information or even avoiding the physician completely,1
which could potentially delay cancer screening and/or early diagnosis. Source: Teaching the
TesticularExam:AModel Curriculum From“A”to “Zack”
Finally, this humiliation can be the source of many
frivolous lawsuits. Consider this conclusion from one of the best articles that
recognizes Shame
and humiliation in the medical encounter:
I believe that most patients who are angry at their
physician or at the medical profession are responding to perceived experiences
of shame and humiliation. The specific complaints are not that the doctor makes
mistakes, misses the diagnosis, causes too much pain, or charges too much. The
complaints are that "the doctor does not listen to me," "the
doctor tells me I am too fat," "the doctor seems too busy for
me," "the doctor treats me like a piece of meat," "the
doctor is sexist," "the doctor insults my intelligence,"
"the doctor thinks my problem is all in my head." Underlying these
complaints, I contend, are the emotions of shame and humiliation.
Social scientists argued that medicine had abused its
monopoly to further its own interests, had self-regulated poorly, and that its
organizations were more interested in serving their members than
society.
Source: AMA
Journal of Ethics, "Professionalism and Medicine's Social Contract with
Society"
...By the latter part of the 20th century, however, many
social scientists concluded that the profession had abused its privileged
status and public trust, and that its regulatory procedures were seriously
flawed. Standards were considered to be weak, variable, and inconsistently
applied, and physicians were further accused of using collegiality as a means
of shielding poorly performing peers. Medicine was further criticized for its
lack of openness and transparency in regulatory procedures and for the absence
of public involvement in them. In short, the system appeared to lack
accountability, and it was suggested that an informed public should participate
in medicine's regulation. Many of these criticisms proved to be accurate and
had an impact on both public policy and on the level of trust that the
profession enjoyed.
...Since the medical profession's rights to
self-regulation are delegated by society via federal and state legislation,
society can, if it becomes dissatisfied with the performance of the profession,
alter the terms of the social contract and reclaim some of these powers.
Following major lapses in self-regulation and a consequent decrease in trust,
society has already diminished the scope of medicine's powers (eg, the Office
of the Inspector General's new guidelines for physicians' relations with
industry)
Source: AMA
Journal of Ethics, "The Medical Profession and Self-Regulation: A Current
Challenge"
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