ethics&modesty

Excellent observations. The system of incentives is different for the medical profession. One indigent drug addict or one gang-banger with multiple gun shot wounds brought into the ER can cost a small fortune to treat. They won't be paying those bills. So what to do? Leave them to die? Ask their family and friends to pay their bills for their bad behavior? Who should be responsible for those who are not responsible?

Economics is the study of scarcity. There is never enough of anything to satisfy everyone. Labor like any other commodity is a matter of supply and demand. It is also a matter of what the market can bear. No matter how good a deal you are offering on a Rolls Royce there are people who cannot afford it at any price. That being said you are worth whatever you are willing to work for. If you are being paid $80,000 a year and you continue to work for that then that is what you are worth by your own determination. Nobody is twisting your arm. You could go be a movie actress and be paid $5 million a movie if you like so long as somebody is willing to pay you that amount. If hospital;s decided to pay only $20,000 a year what would happen? Nurses would quit and do other jobs. There would be a shortage and they would offer higher salaries. Simple free market concepts. Unfortunately there is a monkey wrench fouling up the works. Government and insurance companies. Since they are actually paying the bills (the patient never sees the real bill nor rarely pays it) they have a lot to say that influences wage levels for everyone in medicine. They limit competition through requiring a Certificate of Need supposedly to lower costs yet paradoxically raise costs. They also limit how many doctors graduate each year. If you think wages are low in your field now, wait until we get to a single payer system where a layer of government bureaucrats are added to the mix.

Ruby - your post brought ne to tears i was laughing so hard. Bobby T.

Dear Rocknurse, Curious as to which medical facility hosted your nursing students. I assume that you and the others were going for physician's assistant or nurse practitioner. Yes, we get a stipend for the day but it is not a full time job even if you work at several facilities. I do this because I have lost too many friends to cancer and the one common element of survival is early detection. I know that doctors are reluctant to giving men, especially teens and young adults, full and thorough exams because their patients dread it. So if I can educate medical students and nursing students that the exam does not need to be embarrassing if the examiner adopts the right interpersonal skills then maybe they will go from being a good medical provider to being a great medical provider. The difference is the ability to connect with the patient and communicate respect and care for their well-being. When the students come into a session with that look of dread on their faces not knowing where to look or what to do it is my job to normalize the exam and model good communication skills for them to follow. I acknowledge their discomfort. I reassure them that I am not embarrassed. I reassure them that they will not hurt me. I reassure them that while some nudity will occur and some touching has to happen that it will not be sexual at all for either of us. The more they relax the easier it is for them to learn how to find the landmarks on my body and palpate various areas. As for the DRE I know that it is falling out of favor because there are better diagnostic tools available but those tools are more expensive and are used on even fewer men than a DRE. At least there is a chance that a DRE might uncover a problem before there is pain. A DRE is a bit awkward, yes, I always feel a bit vulnerable each time I lean over, but the students all have been gentle and all do well and are thrilled when they can feel my prostate. The students have all been respectful, even when they are nervous, but feel elated once they finish because it is never as "bad" as they thought AND they have learned something interesting. Ultimately I would hope that doctors doing their residency or nurse practitioners would one day be visiting high school health classes teaching the girls about breast self exams and the boys about testicular self exams with proper parental authorization and proper supervision. Teach the kids that their health matters, their bodies are not shameful, and maybe save a few lives in the bargain.

Thank you. Yes, most are 2nd year med students who are usually totally inexperienced. They all look like they are going to their doom when they enter the exam room for the first time. My job is to first address their feelings of embarrassment, fear of injuring me, getting over the idea that this is somehow sexual, breaking normal social taboos, etc. After all for the past 20 years or so they have been taught that nice people do not look at or touch other people's "private parts". Unfortunately in the USA our culture teaches body shame and that nudity always equals sexuality. If you are an experienced nurse you know that this is definitely not true, but try to explain that to a non-medical person. I can not think of anything less sexy that sitting in an exam room wearing a hospital gown with my bare legs and black socks sticking out and having my genitals examined by a group of 20-something med students. Also med students tend to be far more academic and tend to lack social confidence. They were all good kids and got top grades in elementary and high school and when they went to college they hit the books, not the party circuit. So there was a lot less sex, drugs, Rock & Roll in their lives. They also tend to put off personal relationships so as a group are a bit more on the introverted side and far less likely to be sexually experienced then many of their peers. A few have volunteered that they have intentionally delayed getting into any relationships and I assure them that there is nothing wrong with that at all. I was a science nerd myself, but a math and computer geek as opposed to a biology / chemistry geek so I understand completely. I think it is hardest on the male students in that they have never touched another male's body much less in any intimate way so are a bit creeped out by the image of homosexuality. I have to keep reassuring them that 1. I am heterosexual, 2. even if I were a homosexual I am still a patient and this is about learning how to treat patients and how to sensitively teach males self-examination. I have yet to meet a male med student who has ever been taught how to do a self-exam for testicular cancer. All of the females have been taught about breast self-exam but the guys are neglected. Also males are always fearful of being accused as sexual predators in some manner especially when examining female patients. The female students are less fearful but no matter what personal experience they may have had with males, I doubt they ever tried to find the epididymus or palpated the vas deferens on their partners. Their fear in most about hurting me and bashfully asking what to do if a patient becomes erect. Once they get past the embarrassment the nerdy scientist comes out from within and they get a kick when they can find the landmarks inside my body just by touch. The session usually ends with big grins and grateful thanks. One young woman thanked me because I was more like a favorite uncle and not a creepy pervert. I took that as a compliment. The nursing students are the easiest as they usually have had a good deal of patient experience and most have placed catheters, drawn blood, started IV, etc. and are therefore much less squeamish. Their only problem is that they do not take their time examining carefully. It is more of a quick touch and go to get it over with. I understand this. They normally try to spare patients extended pain or embarrassment so try to get whatever procedure they are doing over with as quickly as possible. Not good during an examination, especially while palpating for tumors. One nurse palpated the lymph nodes in my leg so fast that it felt like a 100 rpm Swedish massage. No way she would have felt a tumor at that speed. Even when I have been a patient in the hospital or at the blood donation center (I go 4 times a year) I tell them to "SLOW DOWN, don't rush, take your time, do a good and careful job, you are not really hurting me, I do not have any modesty issues" and I always make sure I tell them how grateful I am for their care. As for making a patient who is conscious feel more comfortable, communication as a human is the key. Look them in the eye. Tell the patient what you need to do and why. Ask if this is the first time the patient has had this procedure, even if it is simple like drawing blood or starting an IV. If they have then tell them that they are a pro just like you. If not assure them how long it will take (10 seconds), it may pinch or they may feel a bit of discomfort (never say pain) but it will be only for a few seconds. Explain that taking a deep breath and exhaling slowly for a ten count will help a great deal, then ask "OKAY?" They will always say yes but will feel like they have control and you will have permission and a more cooperative patient. Well, usually. Then "congratulate" them with "good job" or "well done", anything positive. In the end they will feel better. Even with my knowledge and experience, when I was going into surgery last year I was feeling anxious even though I did not expect to be and the O.R. nurses were terrific. They let me get in position and comfortable on the OR table and allowed me to get my legs into the lithotomy supports, protected my sense of modesty with drapes, asked if I needed warmed blankets as the room was cool, explained everything they were doing, what machines they were hooking up, were willing to answer my questions and asked me what else I would like to know, and the CRNA even waited and asked me if I was ready before she administered the propofol. She gave me a sense of control, respect and showed a great deal of empathy. I woke up on the table and they waited about 3 minutes before they asked me to slide over onto the gurney. While waiting for me to get my bearings and gather myself they asked me how I felt, what I last remembered, any discomfort, introduced me to the recovery nurse who explained how I would be taken to recovery and what would happen there, answered whatever questions I had. I never felt that I was a piece of meat in a processing plant. Never once did they ignore me as a human even though they do a dozen patients each week.

Interesting perspective especially on real life and real patients. You then advocate the sink or swim method of learning. But if I were teaching music I would not start with Beethoven's fifth. I would teach the student the scales. Real patients can present real difficulties in physiology and demeanor. Nursing is hard. A nurse can have just finished tending to a woman who has had a miscarriage with all of the emotional upheaval to go to the next patient who is whining about being served cold soup. Every patient is selfish and is constantly demanding attention for their own needs. That is part of the job. When I have been a patient I always try to make a double effort to be grateful for any kindness the nurses have shown to me, but sometimes, especially when I have been in pain, I forget. So you would make the student's first experience doing an intimate exam as emotionally uncomfortable as possible with inappropriate comments from the patient? Not sure they would learn how to do a proper exam under that additional stress. Yes, they will face those situations in clinical rotation eventually, but on day one in school? I am not sure about that. Would like to hear from others on this point. Hmmmm ... I am a pretty big fellow, I suppose I could pretend to be a combative homicidal patient just brought in by the police and be handcuffed to the table so they can forcibly insert a catheter to draw urine for evidence but I am not sure that would be a good first experience. Certainly would not be for me as a standardized patient!!!

Thank you. That was very helpful. I find that most nursing students going for a certification already have practical patient experience so are less intimidated with the sight and touch of a patient. One of the best questions from a bolder student is "What can I do to lessen the patient's embarrassment?" and "What can I do to lessen the likelihood of causing an erection?" In my sessions I am already in a gown with my pants and underwear removed and I remain seated on the exam table with the back at 45 degrees with a drape over my legs. I can keep eye contact at all times with the students and encourage them to do so even during the exam. We talk for about 1/2 hour before I uncover anything and I first teach how to fold the gown just enough to uncover the part of the patient to do that portion of the exam. So when they palpate for lymph nodes on my thighs or suprapubic region for instance my genitals remain covered. After I demonstrate upon myself and I have the first student begin an exam, the others typically hang back so I stop and ask the others to gather around the table to watch more closely so they can see what is being done and hear any advise I may give I find that they all step up eagerly which seems to make the student doing the exam a bit less "alone". My first piece of advice is to use a firmer touch when palpating anything as it is much more effective at finding tumors or swollen nodes and much less likely to cause any arousal. And yes, the male organ is very flexible when flaccid so it can be twisted and stretched without any pain. The most difficult thing to impart is that I feel no embarrassment and that they are not going to hurt me. Even when trying to find the epididymus or palpating the testes. I teach them to teach men how to do a self exam and the reasons why it is important if we are going to catch testicular cancer early enough. Something that helps my students is that I am in my 60's so I usually look more like a father or uncle figure than a peer in age Again thank you

"Voluntold", eh? I like that He should be commendedHow many faces did he light up when the It is sad that we do not fund our nursing students and even our medical students better. However there are many nursing schools that do, specifically for nurse practitioners. NP's and PA's need to be expanded otherwise we will not have enough medical personnel to cover our aging population, especially in rural areas. Sometimes the nursing students are transported to a medical college but some schools are large enough to have the proper clinical skills facilities available. The problem for the schools is the cost of floor space and equipment that is not in constant use. I can see a day when there will be more clinical skills centers, separate from a medical college, designed to teach specific technical skills on high end mannequins and well trained standardized patients. Who should be the first person that you stick a needle into to draw blood? Or have you place a Foley? Or administer an IM injection for the first time? An unsuspecting patient who may be in pain or fear or somebody who has been trained to guide the student and accept the risks? BTW, I have also participated as a test subject (human lab rat) in a clinical trial of a minimally invasive surgical implant device. I endured repeated examinations, sedation, surgery, bleeding, risk of infection, pain and discomfort, and about a week's worth of recuperation. As part of the process I agreed to multiple immodest exams by a fair number of people from the manufacturer as well as the medical staff conducting the study and greed to be photographed and witnessed by medical students or residents so that they can learn a new technique. I may have received the implant device or may have been in the sham control arm. I do not know and may never know. I did this to advance medicine without a guarantee of benefit to myself It is the only way to get new technology approved by the FDA. Think of the fireman who enters a burning building, the police officer who chases the bad guys or the soldiers who advance toward the sound of guns. They all are trained and are willing to accept the risks for a greater cause. This is no different for me.

I know what you mean. Years ago when I was in my 20's I was taken to the ER for difficulty breathing and was diagnosed with pneumonia. The Doc said he would order a shot of antibiotics to "kickstart" the fight with the infection followed by oral meds for a week or so. He walked over to the nurse who was in charge to give the orders. She looked at me, turned away with a slight smile and looked around for a nurse to give me the shot. She selected the youngest nurse who looked about 16. Had to be her first week working in the ER. When she came over the expression on her face was priceless - deer in the headlights look, and fumbled a bit filling the hypodermic right in front of me. Nothing was prepackaged back then. She then turned toward me and with a sheepish stammer asked me for my, ... um, ... er, .... um hip. I saw her boss looking at us over the young nurses shoulder so I thought I would help her out. I asked if she was new. Of course she was. So I suggested these things to talk her through it: 1. Never show the patient the needle. Prepare it out of sight. 2. Tell the patient that the doctor ordered you to give them an injection of whatever it is. This confirms to the patient that you have the right orders and sort of blames the doctor. 3. Be sure to close the curtain. It gives the patient his privacy and avoids being watched by your boss. 4. Ask the patient to turn around, lower their trousers and underwear, and lean over the exam table a bit. He won't see the needle or have to watch you seeing him undress. 5. Then tell your patient you will be touching his right hip, find your landmarks in the upper outer quadrant, tell him you are swabbing the site, ask him to take a deep breath and exhale, and then insert the needle firmly just as you learned in school and you will be fine. She was so relieved and asked if I was a nurse. I told her no. Everything I learned was from a corpsman, often near a rice paddy.

Acting like you have been there before when you have not presents students with a dilemma of sorts. How much to tell a patient? Do you intentionally hide the fact that you are new to medicine in order to keep your patient calm or are you honest to develop trust with the patient? As a patient I prefer the later. As a patient I personally have had doctors and nurses outright lie to me because they assumed I knew nothing about medicine. I gently called them out on it because I knew they, being only human, were a bit insecure and thought they were shielding me. The problem is that the patient very likely realizes that they were "shielded" and learns to mistrust the medical profession. Not good. That being said, there is also something to be said for being able to put a little starch in your demeanor. Experienced nurses I know all have that stone face that they can put on when having to do an unpleasant procedure. It is a fine line that has to be walked and it is always a judgement call.

Nobody can do this for a living. We are paid a small stipend but most of us, male and female, do this to improve the medical profession. Similar to donating blood several times a year. Yes, we are trained by gynecologists and urologists just like every standardized patient is trained. Google GTA MUTA gynecological teaching associate and male urogenital teaching associate. Also ask your director of clinical skills at your school for more information.

No, I am a standardized patient who specializes in teaching intimate exams. I have my female counterparts called GTA's who teach students how to give a breast exam and gynecological exam including how to take a PAP smear. Years ago they would take medical students into asylums and use patients there to teach and practice mostly gynecological exams but male exams to a lesser degree. They reasoned that since the state was caring for them they could use them as they wished. When that caused an ethical upset in the press they then used anesthetized patients who were in the OR at teaching hospitals prior to an unrelated operation without specific consent or knowledge. They got away with it by burying a clause in the 20 page informed consent form everyone has to routinely sign, often while they are on a gurney headed toward an OR. They reasoned that patients at a teaching hospital should expect such treatment and what a patient does not remember can't hurt her. That still goes on today at some hospitals but is fast fading away. Then they tried hiring prostitutes and indigent men, often winos. But that made many students feel uncomfortable and the "patients" could not give guided feedback. It was no better than using mannequins. Some medical schools then used peer physical exams asking students to practice on each other. The reasoning is that students should know what it feels like to be the patient. But students felt used and coerced and resented paying big tuition bills while being subjected to unwanted treatment. Plus with more and more women attending medical school there were huge issues with this. Since this happened mostly to women, women's rights groups alerted by nurses, began complaining. So about 30 years ago GTA and MUTA programs were begun out of the standardized patient programs. It was lead by women who wanted better treatment by their doctors, mostly men, who often paid little attention toward patient modesty or sensibilities. The idea was to train people to train med students and nurse practitioners how to approach patients with the greatest level of comfort and dignity while preforming an effective exam. Also we can give excellent feedback on where to find landmarks, how hard to press when palpating, and what words to use to avoid patient discomfort. These are things that pictures can not achieve because palpating is a tactile skill not a visual skill. Although we are paid a fee, nobody can make a living doing this. Just like I donate blood several times a year I do this to help the medical community to improve itself. Otherwise the first exam a new doctor does is on a patient who is in pain. may be fearful, is vulnerable and is not likely to tell the doctor that he is being too rough or doing it wrong. If you Google GTA MUTA Gynecological teaching associate you will read more about these programs in medical and nursing schools.

I work as a male urological teaching associate. I use my body to teach students to find all of the physical landmarks to do a complete exam including inguinal lymph nodes, hernia, testicular cancer, STD's, locate the epididymus, vas deferns, femoral pulse and a DRE. The sessions usually have 4 students at a time. What can I do to make a student's first intimate exam of a male to be less stressful? What information would be most helpful to have prior to the exam? Should there be a lecture or a video demonstration prior to the actual exam? Would it be helpful to have the urogenital teaching associate meet with the class prior to the session to discuss crossing social and religious taboos, ethics and modesty? Does being in a session with students of the same gender or mixed gender matter? What questions you would like answered that you might feel embarrassed to ask in public?