Pediatric examination standards I don't understand

advo-kate2 · Jul 31, 2010

i commend you 'shuck'. not only for being brave enough to ask the questions that need to be asked, but for having the backbone to approach a provider for answers.

i think most of us by now have read enough research that speaks to this provider's attitude. the "old way of thinking" leads to millions of boys becoming men who do not seek healthcare.

good job!

tbrd450 · Jul 31, 2010

Just a thought, but does this person's supervisor know about such practice? Do the parents of these kids know about this?

We far too often, generally speaking, accept whatever care or "practice" we encounter under the rationale that since it is medical service, whatever happens is supposed to happen. This is particularly true when the patient is male.

Boys never learn how to look out for their own dignity when it comes to issues like modesty consideration... the extent of most boys' education on this is the realization that "his" lifelong focus on such matters has centered exclusively around respecting girls and women.

Boys are typically taught to desensitize themselves ... to such an extent that it becomes "silly" to complain about such matters. Then, through the years after enough desensitization over enough experiences, our boys become desensitized men -- men who then later claim not to really understand why they hate going to the doctor's office so much.

BluegrassRN · Jul 31, 2010

Perhaps you should post this in the pediatrics section, and find out what the standards for this exam are in other areas and offices. That way, if you need to discuss this with your NP, you know what your talking about. Rather than a "This doesn't seem right..." you can say "The standard of care in most practices is..." If you find the way the exam is being conducted in your office needs to be updated, it won't be just this one practitioner who needs to update, they all will.

tbrd450 · Aug 1, 2010

Perhaps you should post this in the pediatrics section, and find out what the standards for this exam are in other areas and offices. That way, if you need to discuss this with your NP, you know what your talking about. Rather than a "This doesn't seem right..." you can say "The standard of care in most practices is..." If you find the way the exam is being conducted in your office needs to be updated, it won't be just this one practitioner who needs to update, they all will.

I think this is an excellent idea, as one step. However, it may be the case that the "standard" is either nonexistent, existent but inconsistent, or just based on past arbitrary practice. As I understand from the posts, when this person was asked why she did it this way she responded "I just always did it this way." Apparently, a "standard" was never really referenced, or perceived to be needed to be referenced (by this person).

As a male who has had numerous exams, visits and procedures I can tell you that any sort of consistent standardization I've ever encountered in terms of modesty consideration was purely arbitrary and random at best. I think that when it comes to modesty consideration and male patients, typically the "standard" is whatever the individual provider herself/himself happens brings to the procedure/experience.

It is typically different for female patients because of generalized heightened awareness, and sensitivity to complaints, lawsuits and advocacy. It is amazing what one or two lost lawsuits can do for procedural "standardization." It is amazing what the mere threat of lawsuit can do. Male nurses have to walk on the proverbial egg shells worrying about these things when treating female patients. That is not so for providers treating male patients -- even male child patients.

Then, maybe there is a pediatric standard. But, could it be one that justifies the routine stripping of all boys and not all girls. Could it be one that supports this particular person's rationalization -- "because I've always done it that way?"

Believe it or not, there was a "standard" at Abu Ghraib. The standard was that upon entry, all males were to be fully stripped. The standard policy was to implement "ego-down" stress, through forced nudity. They were paraded around in the nude like dogs in a kennel -- by standard policy. It was recognized by the military intelligence, the military psychologists and anybody with a half a brain that forced nudity was humiliating and degrading, as a tactic. Now, please, I'm not drawing a direct link between this post topic and the standard policy at Abu Ghraib, but it is worth noting that it is recognized as a universal "ego-down" experience.

When it is necessary -- as it certainly is in many medically related situations -- it needs to be done and handled professionally. When it is just done "because it was always done that way," ... more clarification is needed. What's the reason?

Questioning it is a sign of independent thought, courage and integrity. It certainly does not make a person "weird."

Shuck · Dec 17, 2010

Wow, been busy lately, haven't checked this in a while.

Thank you for your help people, I think I will post this in the pediatrics forum.

BabyLady, BSN, RN · Dec 17, 2010

I've been working at a private pediatric office for a couple months or so after I got my nursing degree. During spring/summer times, there are a lot of teens coming in for sports physical or just a general physical.
The practice consists of all women. I work with a nurse practitioner, and most of the time, the NP does the sports physical. What I didn't understand was, that when a female comes in for a physical exam, she just tells her to remove her shoes and socks, but when a male comes in, she tells him to undress down to underpants.
Of course, for a male, the examination includes a hernia exam, so she asks the patient to remove his underpants towards the end. She also does a brief visual check of the orifice. She also examines the testicles and retracts the foreskin if the patient is uncircumcised.
For a female, she keeps them covered except for the parts that are being examined, but she does not perform a breast exam or a genital exam.
I just couldn't understand why she differentiates how much a patient disrobes, and what parts of the body is examined based on their gender. Adolescent females are not immune to growth abnormalities either.
I would provide both patients, regardless of gender, a gown, and not omit any part of an exam, just because of gender, but apparently, the NP that I work with has a different view on things. She is in her 50s, so maybe she has an old way of thinking.
Is this practice standard?

The purpose of the exam is not a yearly physical for overall health but to see if the student is SAFE to play sports.

That does not include a breast or a pelvic exam/pap smear/etc.

I would never, ever use a sports physical in lieu of a regular yearly physical, with either one of my children.

Many offices do these exams for a signficantly reduced rate...one facility does these one morning a week FOR FREE.

zsbaby · Dec 17, 2010

Who cares? You are waaaaaaay overly hung up on this issue. Actually you sound really weird.

REALLY??? Hmm...

Shuck · Dec 18, 2010

The purpose of the exam is not a yearly physical for overall health but to see if the student is SAFE to play sports.
That does not include a breast or a pelvic exam/pap smear/etc.
I would never, ever use a sports physical in lieu of a regular yearly physical, with either one of my children.
Many offices do these exams for a signficantly reduced rate...one facility does these one morning a week FOR FREE.

Well, whether it is a sports physical or a standard physical, she pretty much goes through the same agenda in terms of examination guideline.

I've assisted in physicals for both genders. Boys always end up completely undressed towards the end of the physical for a genital and visual orifice exam (never a DRE), and females are mostly covered, expect for the parts that are examined. She normally lifts the shirt up for a scoliosis check for girls. I should mention that she only performs breast/genital exam on a female patient only if a parent raises a concern.

As for one poster who asked if the supervisors or parents know about this, yes. Sometimes a parent sits in during the exam, whether it may be boys or girls, so they know.

I don't see any standard protocols for this subject, so I guess I can't argue with the NP. She did give me the "I've been doing this for 25 years" speech once.... :yawn:

Cul2 · Dec 18, 2010

The OP asks: "Is this practice standard?"

tbrd450 answers this question concisely: "As a male who has had numerous exams, visits and procedures I can tell you that any sort of consistent standardization I've ever encountered in terms of modesty consideration was purely arbitrary and random at best. I think that when it comes to modesty consideration and male patients, typically the "standard" is whatever the individual provider herself/himself happens brings to the procedure/experience. It is typically different for female patients..."

I would go a step further. Although I do concede that there is a double standard toward male patients, I would say that the typical modesty standard, for both male and female patients, is whatever the individual provider her/himself happens to bring to the procedure/experience. It may be typically different for female patients. I don't doubt it. But female patients suffer significant modesty violations, too.

The problem is, as suggested -- there are no standards, no protocols. How much is taught officially, academically regarding patient modesty also varies from institution to institution, depending upon the instructor and the textbooks used. American texts for doctors and nurses contain very little about this subject as compared with texts from UK, Australia and Canada. The countries mentioned also have specific written policies regarding modesty and patient gender preferences. Another important factor is what gets learned on the job, that hidden curriculum, pretty much takes over regardless of what was taught in school. The details of that hidden curriculum vary from institution to institution, depending upon the health of its culture. Where working conditions are poor (not enough staff or supervision) the hidden curriculum emphasizes simply what's in the best interest of the institution and the individual caregivers. Where the culture is healthy and the staffing and supervision is adequate or excellent, the care is more patient-centered.

JS343 · Dec 18, 2010

Almost certainly the American Academy of Pediatrics has guidelines for sports physicals and they are probably similar to what the NP was doing here. That doesn't mean though that there is any rationale for the guidelines. You can be positively certain that there is no study demonstrating why boys should receive a visual inspection of their orifice whereas girls should not. What does anal inspection have to do with playing sports in an asymptomatic patient?

You have to be clear whether these physicals are really sports physicals or substitutes for regular exams. It is hard to see how any genital exam has much relevance to ones ability to play sports. Significant hernias are rarely asymptomatic if they would be a problem with sports. Many boys get these physicals every year or even twice a year which makes little sense for genital exams. The most important part of sports physicals is to determine cardiovascular and musculoskeletal fitness, not genital health or hygiene.

There is no doubt that an irrational double standard is at play here. Why?? Only because it has always been done that way.

middleager · Dec 28, 2010

First I have to compliment Shuck for caring about these young men's comfort. I commend you for caring so much. There are two issues, the exam itself and the apparent double standard in addressing modesty. While I feel the exam itself is a double standard including exams that really have nothing to do with fitness to play sports, and I recognize there could be residual benefit for them in having the exams, the same would apply to the females. The fact that these young men's modesty seems to be completly discounted is even more telling. It sounds like these young men end up naked infront of the female NP and nurse. Would we ever find it acceptable for a male NP and male nurse to have a young person 12-18 yrs old standing naked while they examined her lady parts and orifice for any reason. The fact that the young men are not even given a gown is very telling. I feel for Shuck, the OP was sometime ago, I would love to hear what if anything has happened. Shuck is in a bad situation, the disreguard seems to really bother her yet she is faced with possible retaliation if she challenges it. I would hope she does one so a couple things, at a minimum provide the young men a gown, challenges the practice, or if she leaves and goes to work elsewhere challenges the practice with the administration of the practice. Justifying a current wrong with the mantra its always been done this way sounds an awful lot like the justification of civil rights violations and womens sufferage challenges. Wrong is wrong regardless of when it occurs, God Bless Shuck and those who question and challenge the wrongs they see. If Shuck picks this up I would love to hear what has transpired since.

allnurses Guide · Dec 28, 2010

Not to discount the modesty issue for young males, but I think it is very important to teach the boys about testicular self exam, etc. I've seen a fair number of boys brought in after a football tackle or something similar for testicular torsion; making them aware that problems can occur and its okay to talk about it is important.

I think it is the girls who are getting the short end of the stick; they need to be taught self breast exam at an early age as well. This is well within a nursing scope. I would suggest the OP offer to teach SBE herself to the girls, since the NP isn't. That would be offering a solution to a problem with seeming to attack the NP.

Pelvic exams come later for older teens, and aren't necessarily needed at the younger age.