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. The new exam 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.
History of patient modesty part 1: How bodily exposure went from unacceptable to required
The physical exam and society’s regard for physicians: A history
The doctor-patient relationship: What have we lost?
The esteem of the medical profession: Then and now
The physician as humanist
The art and science of medicine
Image: Midlife Bloggers
Amy L. Friedman, MD, Secret Shopper, The Journal of the American Medical Association, November 17, 2010, Vol. 304, No. 19, pp 2103-4 (subscription required)
Giovanni Battista Morgagni, The seats and causes of diseases investigated by anatomy
Malcolm Nicolson, The Art of Diagnosis: Medicine and the Five Senses, in Companion Encyclopedia of the History of Medicine, edited by W.F. Bynum and Roy Porter, pp 801-825
Roy Porter, The rise of physical examination, in Medicine and the Five Senses, edited by W.F. Bynum and Roy Porter, pp 179-197
Stanley J. Reiser, Technology and the use of the senses in twentieth-century medicine, in Medicine and the Five Senses, edited by W.F. Bynum and Roy Porter, pp 262-273
Stanley Joel Reiser, The Science of Diagnosis: Diagnostic Technology, in Companion Encyclopedia of the History of Medicine, edited by W.F. Bynum and Roy Porter, pp 826-851
Stanley Joel Reiser, Technological Medicine: The Changing World of Doctors and Patients