Wednesday, February 23, 2011


It is our pleasure to introduce guest columnist Jan Henderson, PhD. She is a historian of science and medicine who writes about the history of the medical profession and changing attitudes towards health care. You can find more of her writing on her blog, The Health Culture. The following is the second of a two part series.

History of Patient Modesty, Part 2

Convincing patients to disrobe

Guest post by Jan Henderson, PhD

In part one of this post I explained how a new anatomical understanding of disease in the 19th century changed the practice of medicine. Prior to this insight, there was no need to expose the naked body to observation or to touch parts of the body that were normally clothed. In order to apply the anatomical theory of disease, doctors needed to discover what was happening inside the body. This required a new type of physical exam, with much greater exposure and invasion of the body. This was an abrupt and significant change in the tradition of patient privacy and modesty.

Making patients blush

Doctors welcomed both the new understanding of disease and new techniques, such as the stethoscope, that gave them useful information about the interior of the body. Understanding and technique alone did nothing to improve the ability to treat disease, by the way. That came much later. What doctors could do was provide a better prognosis, thus avoiding futile and painful treatment of the terminally ill.

How did patients react to this change in medical practice? Unfortunately, we have very little direct information. Most of the evidence we have comes from doctors, not patients. Doctors tend not to record the routine and taken-for-granted nature of a patient encounter. The private diaries of patients undoubtedly recorded reactions to the more invasive physical exam, but historians of medicine have typically been more interested in uncovering evidence of new medical discoveries than in noting patient experiences.

There is every reason to believe that women found the new physical exam deeply embarrassing. For example, a woman’s diary entry from 1803 reads: “Doctor Williams called and made me undergo a blushing examination.” In 1881, Conan Doyle recorded that a female patient would not let him examine her chest. “Young doctors take such liberties, you know my dear,” she told him.

The indirect evidence we have comes from efforts of the medical profession to convince patients that the new physical exam was necessary and proper. This took two forms: Emphasizing the professionalism of doctors and arguing for the scientific nature of medicine. These 19th century changes in the image of medicine contain the seeds of a new relationship between doctor and patient. They led to a style of medical practice today that increases rather than eases patient concerns about privacy and modesty.

Convincing patients to accept the new exam

The new physical exam was a sudden rupture of conventional modesty and privacy. We can infer the resistance of patients from efforts by the medical profession to create a new image of the doctor in the eyes of the public.

In the 19th century the medical establishment began to emphasize the professionalism of its practitioners. The American Medical Association was established in 1847. It promoted an image of its members as men of integrity with an upright social standing in the community. Doctors were said to have high ethical standards and to observe codes of proper conduct. Simply because they were professionals, they should be held above suspicion. It was this professionalism that entitled doctors to the confidence of their patients.

An apothecary, writing in 1817, expressed the following opinion:

It ought to be fully understood that the education, character and established habits of medical men, entitle them to the confidence of their patients: the most virtuous women unreservedly communicate to them their feelings and complaints, when they would shudder at imparting their disorders to a male of any other profession; or even to their own husbands. Medical science, associated with decorous manners, has generated this confidence, and rendered the practitioner the friend of the afflicted, and the depository of their secrets.

It’s one thing, of course, for women to confide their secrets to a doctor. Venereal disease was quite common at the time and preventing transmission required an honest discussion of sexual partners. But it’s something else to allow direct observation of the unclothed body. Yet this is exactly what doctors were beginning to do.

The comments of an English physician, writing in 1821, reveal the ambivalence of physicians when it came to conducting exams. He remarks on the reluctance of some of his colleagues to observe the unclothed body. When examining his own patients, he often found “plain and obvious disease entirely mistaken and mistreated, for months, — even years, — merely from the practitioner’s neglecting this simple but necessary measure!”

He urged fellow doctors to examine any part of the body where they suspected disease. The patient should be free of “every species of covering that can impede the necessary examination, — always by the hand, and often by the eye; and wherever the case is at all doubtful.” He acknowledges “the repugnance of our patients to the measure.” But he urged doctors to overcome this repugnance, “however great this may be, and however natural and proper we may feel it to be.”

There’s an interesting clue here in the words “always by the hand, and often by the eye.” One can palpate a hernia by slipping a hand underneath a garment. It’s another matter to expose the groin to unobstructed view.

Whether the examination of the vagina was done by the hand or the eye, it was criticized as a threat to decency. The American gynecologist J. Marion Sims, writing in 1868, countered this criticism: “There can be no indecency, and no sacrifice of self-respect in making any necessary physical examination whatever, if it be done with a proper sense of delicacy, and with a dignified, earnest, and conscientious determination to arrive at the truth.”

Justifying medical practice as a science

The medical profession also emphasized the scientific nature of medicine. Biomedical research in particular (bacteriology, the germ theory of disease) was increasingly recognized as scientific by the end of the 19th century. The public’s esteem for science was growing. It was only natural that medical practitioners, who were in a position to apply scientific research, would want to be regarded as scientists themselves.

Medical authorities argued that the physical exam was simply an “imperative of science.” Patients were impressed by diagnostic instruments, which seemed to give doctors a magic not previously available. Medicine’s association with science enhanced the doctor’s image and helped legitimize the physical exam.

The exam was transformed into a scientific ritual. A patient’s visit to a doctor was no longer the interaction of two people with a lifelong relationship. There was a distinct role for the doctor and a different role for the patient. The role of the doctor included special privileges, such as the right to ask intimate questions and to examine intimate parts of the body. The role of the patient was to comply with the doctor’s requests, while admiring his increasingly superior knowledge. Ritualization of the exam made it more abstract and impersonal. In the eyes of doctors, at least, this served to reduce the sense of a violation of patient privacy.

When the power relationship between doctors and patients shifted – when doctors became less dependent on the patient’s account of symptoms — the doctor/patient relationship began to change. The emphasis on the scientific nature of medicine intensified this shift. The objective nature of science required that doctors create an emotional distance from patients.

We see here the origins of the change that evolved into what patients complain about today – the cold, impersonal, and insufficiently attentive nature of modern medicine. Affronts to patient modesty are intensified by this impersonal atmosphere. With the passage of time, patients have come to accept the new lack of privacy. But the sense of embarrassment remains undiminished.

Today’s medicine: Coldness and occasional empathy

When the tools available for a physical exam were limited to the stethoscope, percussion, and visual scopes, doctors obtained the information they needed through direct interaction with their patients. This is much less true today.

The doctor’s time is extremely precious. As medical technology advanced, doctors found they could delegate the collection of medical data to skilled employees who required fewer years of medical education. Much of a patient’s time in the modern health care setting is spent with members of these new occupations, from the receptionist, nurse, and lab technician to the men and women who operate the machinery that views or otherwise records the interior of our bodies. At the beginning of the 20th century, one out of three health care workers was a physician. By 1980, the ratio was one out of thirteen.

Dr. Friedman, the female physician who disclosed her discomfort in anticipation of a colonoscopy (see part one), goes on to describe more of her experience as a patient that day. She compares a reassuring moment of warmth from her doctor with the impersonal treatment she received from the rest of his medical staff.

Of all the … personnel who followed suit, reviewed the data set, and performed medication reviews, vital sign measurements, intravenous catheter insertion, and completion of endless subsets of paperwork, not one asked how I was feeling. None delivered sincere eye contact. All were proper, methodical, pleasant, and yet somehow detached.

She makes a brief visit to the restroom, clutching her skimpy, open-back hospital gown.

Upon return to my slot, I was dismayed to find that Dr. T had arrived during my urologic escapade. Sensitive to the multiple demands on his time and sorry to have caused him delay, I scrambled back onto my gurney so he too could complete his preprocedure process. As I did, Dr. T spontaneously engaged in battle with the curtains to enclose us and ensure my privacy. He bent to cover my exposed legs with a blanket and then looked directly at me to ask how I was doing. With three such simple acts, the man about to see and invade the parts of me about which I am most shy and protective endeared himself and earned my deep gratitude.

The medical profession in the 19th century may have believed that an objective and dispassionate ritual would somehow satisfy the patient’s need to feel comfortable with the more invasive liberties of new physical procedures. The opposite may be the case, however. Not only is it appropriate for a doctor to step outside the dispassionate and objective professional role and take a moment to connect with the patient. It is highly desirable. Treating the patient as an individual human being reduces the stress associated with patient concerns about privacy and modesty.

Patients need respect and compassion from all medical professionals

The sheer number of individuals a patient is exposed to as part of a modern medical encounter – during much of which the patient may be inadequately and awkwardly covered by a hospital gown – has grown exponentially. Any medical professional, from hospital director to hospital orderly, can ease a patient’s concerns for privacy and modesty by treating the patient with courtesy and respect. There’s no difference between the humanity and compassion of doctors and that of any other health care employee. The problem for everyone is that time constraints have made courtesy and respect a vanishing resource.

Dr. Friedman summarizes her colonoscopy experience:

On the one hand, the quality of care was excellent. … On the other hand, sincere caring was lacking. I had predominantly felt more like a product on the fast-moving conveyor belt of a health care factory than a human being. Among all of the processes and gestures that had been so vivid, only Dr. T’s had comforted. Despite whatever other stressors were at play for him that morning, he had personally managed to empathize with me at the center of the surrounding vortex of objectives and deliverables consuming the rest of his team.

Too often it feels like we health care professionals have surrendered our souls in succumbing to demands for increasing efficiency, minimization of time spent at every node along the pathway, and rapid shuttling of patients in and out of facilities. We often strip them of critical remnants of personalization – specifically to meet regulations. Having learned that treating patients like human beings does not facilitate reimbursement, we have capitulated. After all, the delivery of tender loving care (TLC) consumes time and prevents one’s ability to accomplish other competing tasks.

How has the pendulum swung this far? Why do we tolerate an environment in which a reticent but unafraid patient emerges from an uncomplicated encounter feeling dispassionately processed rather than embraced?

In any organization, the values and philosophy of those at the top are communicated – directly and indirectly – to those below. As one moves down the hierarchy of health care industry occupations, there is no logical reason why respect and compassion should be considered inappropriate or unnecessary. In the modern health care climate, however, they are seen as inefficient. When efficiency is the paramount value of an organization, then it’s up to the innate humanity of each employee to assert his or her own values by showing the respect and compassion each patient needs and deserves.

Wednesday, February 16, 2011

History of Patient Modesty, Part 1

It is our pleasure to introduce to this blog guest columnist Jan Henderson, PhD. She is a historian of science and medicine who writes about the history of the medical profession as well as changing attitudes towards health care on her blog, The Health Culture. The following is the first of a two part series.

History of Patient Modesty - Part 1: How Bodily Exposure Went from Unacceptable to Required
Guest post by Jan Henderson, PhD
Even doctors can be embarrassed when it comes time to expose their private parts to medical personnel. In an essay that appeared in The Journal of the American Medical Association, a doctor describes her discomfort as she arrives for a colonoscopy appointment.
[A]s a person not exactly looking forward to the morning’s adventure, I found the receptionist’s demeanor and lack of eye contact wrapped me tight within a cold, impersonal cocoon. I was a subject. Though I hadn’t shared my sentiments with anyone, I felt both vulnerable and completely sheepish about having a very human reaction to such a common procedure. But this was my bottom and I was not happy to share it with others. Here to be exposed and invaded, in truth I was embarrassed and sought compassion. As anyone else would, I wanted to know that my discomfort, self-consciousness, and loss of control were understood. Instead, she exuded efficiency and delivered transparent quality assurance and poise.
The need to reveal private and intimate parts of our bodies is a routine occurrence in medical practice today. Though it may offend our modesty, we take it for granted that the embarrassing moments of a colonoscopy, a Pap test, or a prostate exam are necessary for our health.
Has it always been so? Have doctors always expected patients to disrobe? Have young male technicians always exposed the chests of female patients in need of a routine EKG? Have patients always been willing to allow doctors and their staff to view parts of the body normally seen by only the most intimate of partners?
The answer is a resounding no. Exposing the body for medical purposes is a relatively recent development. It began in the 19th century, before anyone now alive can remember. Prior to that time — for thousands of years — doctors considered it socially unacceptable and morally improper to examine an unclothed patient, especially a woman (the doctors at the time were all men). Over a period of just decades, however, doctors began to place stethoscopes on ladies’ bosoms and use visual scopes to examine the bladder, rectum, and vagina.
This was a significant change, both in the practice of medicine and in the experience of patients. How and why did this change come about? Part of the explanation comes from a change in the medical understanding of disease. A contributing factor was the erosion of a sharp distinction between physicians and surgeons. In what follows I give a brief account of why the practice of medicine changed and – in part 2 of this post — how the medical profession sought to convince patients to accept the change.
When physicians listened to patients
The practice of Western medicine, from the time of the ancient Greeks and Romans to the early 19th century, was based on the humoral theory of health and illness. The theory asserted that the interior of the body was filled with four humors or fluids: blood, yellow bile, black bile, and phlegm. When the humors were in balance – in a stable equilibrium – the individual was healthy. When out of balance, the patient became ill. This may seem quaint to us today, but note that this theory of internal balance lives on in traditional Chinese medicine and continues to inform the contemporary practice of acupuncture.
According to humoral theory, each individual could fall out of balance in a unique way, depending on the history and current circumstances of his or her life. Physicians might group illnesses into broad categories, such as fevers, fluxes (dysentery), or dropsies (edema), but the idea that many people could have the same disease (appendicitis, cirrhosis, diabetes) – though proposed in the 17th century — was not accepted until the 19th. In effect, there were as many “diseases” as there were patients.
To diagnose an illness, therefore, the physician needed to listen carefully to the patient’s account of sensations, symptoms, and life events. The patient’s narrative was considered much more important and revealing than any signs or symptoms a physician might observe. If the diagnosis was in doubt, the patient’s account took precedence over the physician’s observations.
The physical exam prior to modern medicine
In the era of humoral medicine, physicians practiced four methods of diagnosis, none of which required observing the unclothed body or touching the patient on a part of the body that was normally unexposed. The first, and most important, was eliciting the patient’s account of his or her own history.
The second was observation of the patient’s appearance, with special attention to the eyes and the face. This might include a look inside the mouth, including the tongue. Physicians would note the skin color and any peculiar behavior, listen to a cough or a wheeze, and note the smell of putrefaction, if present.
Occasionally a physician would feel an exposed part of the body for heat. Thermometers had been available since the 17th century, but the evidence they provided was not valued. A patient’s temperature did not always correspond to a subjective sense of warmth — a patient could have a fever, but feel chilled. And the patient’s account was paramount.
The third method was to feel the pulse at the wrist. Physicians did not count the number of beats in an interval of time. They listened for the quality of the pulse – how the pulse hit the fingers or varied over time. Again, this is similar to the practice of traditional Chinese medicine today.
The fourth method was to perform a visual inspection of various bodily excretions, such as urine, feces, sputum, pus, vomit, or blood.
How did such a physical exam lead to treatment of an illness? In a word, it did not. Based on experience, physicians were often able to offer a diagnosis – too much blood, too much bile – and a prognosis – a quick recovery or an imminent decline. Patients considered the prognosis valuable, since it was useful to know how long one might expect to be incapacitated.
The few treatments available – primarily bloodletting and purging – probably did more harm than good. This period is called the era of “heroic” medicine: Those who survived the treatment were heroes. For good reason, patients typically consulted physicians only when an illness seemed life threatening.
So, one reason physicians were highly respectful of patient modesty up until the 19th century was that the prevailing theory of disease did not require the patient to disrobe. Another part of the explanation involves the status of physicians in society and their social superiority to surgeons.
When surgeons got no respect
In ancient Greece and Rome, the theories of the physician and the practical skills of the surgeon were combined in one practitioner. Starting in the Middle Ages, however, when the lost writings of antiquity were rediscovered, a division occurred. Physicians acquired their medical training in universities, whereas surgeons learned their skills by serving an apprenticeship. Physicians, whose studies required proficiency in Latin, were highly regarded for their book learning and mental acumen. Surgeons, on the other hand, worked with their hands, an activity beneath the dignity of the gentleman physician.
Physicians and surgeons each treated a different class of patients. Physicians preferred members of the well-to-do upper classes. Surgeons attended to those who couldn’t afford the more expensive physicians. Each practiced medicine in a manner appropriate to their social standing and to the social standing of their patients. Physicians used their minds to theorize. Surgeons used their hands to lance boils. It would have been totally improper for a physician to ask a lady to remove her garments.
Surgeons, of necessity, did observe unclothed parts of the body. Before anesthesia and asepsis, surgery was of course quite limited. But surgeons operated on hernias, bladder stones, and anal fistulas. Even surgeons, however, were obliged to honor the wishes of a patient who was unwilling to submit to direct visual inspection or a manual exam.
In an 18th century account, a surgeon describes his treatment of a female patient. It took eight days before the patient revealed she had a tumor in her groin. “She would not allow me to see it, but told me it was as big as a small hen’s egg, and by gentle pressure of the hand receded, and never gave her any pain.” It took another four days — and then only because there was increasing pain — before the surgeon “prevailed upon her to let me see it.”
The idea that transformed medicine
In certain European countries – northern Italy, the Netherlands – the sharp distinction between physicians and surgeons began to break down in the 18th century. These new, modern doctors were willing both to theorize and to perform autopsies.
Human autopsies had been done as early as 1600. The ancient Greek understanding of human anatomy was based on animals, so human autopsies greatly improved anatomical knowledge. The most significant contribution of autopsies in the 18th century – the one that led to modern scientific medicine – was not anatomical knowledge, however. It was that physician/surgeons began to correlate the patient’s symptoms before death with what an autopsy revealed when the patient died.
The idea that a disease might be associated with a specific location in the body – in an organ or in localized tissues – had been proposed by Giovanni Battista Morgagni in his book The seats and causes of diseases investigated by anatomy, published in 1761. The “seats” in the title refers to bodily locations. Morgagni’s assertion — that internal lesions were located at specific bodily sites – was accepted only gradually over the next 100 years. This turned out to be the idea that transformed medicine from the humoral theory to the scientific medicine we know today.
Patient modesty inspires the invention of the stethoscope
Once medicine subscribed to this new anatomical approach to disease, the question became: How can we determine what’s happening inside the body by examining the outside? The attempt to answer this question prompted the invention of techniques such as percussion (tapping), auscultation (listening), and succussion (shaking the body and listening for a splash). It also led to the invention of diagnostic instruments. One of these instruments was the stethoscope, and its invention was prompted by the need to accommodate patient modesty.
In 1816, a French doctor, Rene Laënnec, was consulted by a young woman suffering from heart disease. Laënnec first tried to use percussion – tapping on the chest with the fingers – to gain information about the internal organs. This was not satisfactory, however, partly because the patient was female and partly because she was obese, which interfered with the production of meaningful sounds.
The doctor next considered an ancient technique – one that goes back to Hippocrates –that was currently making a comeback: auscultation. By placing an ear on the chest, one could listen to the sounds of the heart. In his account of the stethoscope’s discovery, Laënnec writes that he found this technique “inadmissible” because the patient was a young woman.
Then he had an inspiration. He was aware that sound can travel through a solid body, such as a piece of wood. If you scratch one end, you can hear the sound at the other end. Spying a square of paper lying nearby, he rolled it into a cylinder, placed one end on the woman’s chest near her heart, and placed the other end at his ear. He was “not a little surprised and pleased” with how clearly and distinctly he was able to hear the sounds of the heart.
An initial rift in the doctor/patient relationship
This first primitive stethoscope underwent a number of improvements over the ensuing years. It was another 20 years, however, before it was generally accepted by the medical profession. By allowing a respectable distance between doctor and patient, the stethoscope was able to overcome prevailing social conventions of modesty – at least with regard to listening to sounds inside the body.
One early stethoscope was several feet long and allowed the doctor to stand in a separate room. Most patients did not require such extremes. In 1829 a practitioner wrote of the flexible stethoscope – which allowed a greater distance than the original rigid instruments — that it could be used with ladies “in the highest ranks of society without offending fastidious delicacy.”
The stethoscope ushered in other hands-on diagnostic techniques. Percussion, for example, had been described and recommended to physicians more than 50 years before the invention of the stethoscope. It became an acceptable practice, however, only after the stethoscope’s use became common practice.
Other instruments for examining the body were developed in short order, many of them much more of an infringement on patient modesty than holding a stethoscope to the chest. Doctors were soon using scopes and specula to examine the bladder, vagina, and rectum.
The introduction and acceptance of the stethoscope was a major landmark in the history of medicine. This was not simply because of the information it provided — that was available by placing an ear on the chest. The stethoscope initiated a shift in the power relationship between doctor and patient.
No longer was the patient’s account of symptoms of primary importance. Doctors were increasingly able to diagnose an illness without any input from the patient. They became much more independent of their patients when it came to formulating a diagnosis. Medical professionals began to adopt a more self-reliant view of their abilities. This distance between doctor and patient became a salient characteristic of modern medicine.
Continued in part two.

Sunday, February 6, 2011

Modesty vs Morals
Guest post by Suzy Furno-Maricle

The various aspects pertaining to the issue of medical modesty can be daunting. While investigating the black and white of it one can trip over an array of gray stumbling blocks. So much so that advocates prefer to keep the subject within one hue, and simply color it “Modesty”. While that is an excellent stand with which to advocate the general subject, many people/patients/clients find that it does not truly express their views. The word ‘modesty’ may not fully convey their needs and struggles for acceptance or understanding regarding respectful care. For them, it really is a moral choice. These decisions need not be faith-based, but are still fully and ethically who and what people choose to be. Or, perhaps these convictions are based on religious edicts, and people have spent their lives protecting that “eternal” path from being carelessly shattered.
Here lies the dilemma of ‘medical modesty’. Have we condensed the modesty issue to such a degree that the significant messages of moral convictions are not being heard? If we insist that modesty be the issue’s main thrust, are caregivers given the opportunity to see the passionate side of morality and damages caused by disregarding it?
The truth is that the medical arena will not respect or defend the decisions of your body the same as you would. Most do not even feel the need to protect your ethical standards unless backed by protocols to avoid legal issues. Instead, they assume the role of psychologist stating that any mental harm while within their walls can be easily discarded. Or perhaps the role of medical pope, absolving you of any actions you deem immoral that they may inflict on you. And marriage councilor, finding any marital damage that stems from their actions to be petty and unwarranted jealousy. Their beliefs become your prison, and this self-serving attitude inflicts damage. So they send broken people home after promising “no harm”, never accepting responsibility for the tornado of emotional or spiritual damage that is now your life.
Caregivers may state that they simply do not have time to consider all of these harms. It certainly seems that if they have time to discount them then they have already found time to consider them. So let’s try to put accountability in their ethics. Let’s let them know the full range of damage that occurs while on their watch. Only when all possibilities are exposed and out of the closet will caregivers ever understand the full ramifications of their actions. Then we can truly and simply color the picture as ‘Modesty’ with full and honest understanding of all the grays.

Suzy Furno-Maricle (aka swf) blogs at Patient Modesty Solutions