Tuesday, 12 April 2016

Behaving badly

Usually when I have a stupid patient story, I like for it to be mine.  Though I have posted numerous submissions from readers, I prefer the stupid patients to be my own so that I have first-hand knowledge of the events and can elaborate on (read: embellish) them.  But oh do I have a good one today.  It's definitely a stupid patient story, but fortunately it isn't mine.

Wait, "fortunately"?  You just said that you prefer the stupid patients to be yours, but you're glad this one isn't?  What?  Be consistent, Doc!

I'll explain.

I've written before about doctors behaving badly, and boy did they ever.  In case you missed that little escapade, a man (identified only as "DB") undergoing a colonoscopy had used a small voice recorder in order to record the verbal instructions he was given before his procedure (in case he forgot them later).  He accidentally left it running and ended up recording the entire procedure.  While he was asleep his anaesthesiologist made several nasty and very personal remarks towards him, including insinuating that he was gay, saying she wanted to punch him in the face, and calling him a wimp and a retard.  She also falsified his medical record in the process (recording that he had haemorrhoids when he did not) just for good measure.

Despite the fact that his procedure went well and there was no real medical malpractice, DB sued her and was awarded $500,000, and rightfully so.  Her behaviour was atrocious, unprofessional, and has no business happening in a healthcare setting.  Ever.

Well, it happened again.  Sort of.  This time the patient is 44-year-old Ethel Easter (her real name) from Texas.  Her surgeon was recorded making disparaging remarks about her while she was asleep.  Sort of.  Only this time, Ethel is the bad guy.

Wait, what?  He said bad things about her, and SHE is the bad guy?

I'll explain.  Again.

First, a little background.  According to news reports (including dramatic news coverage with dramatic sound bites and dramatic interviews of dramatic Ethel), Ethel went to see the unnamed surgeon for a hiatal hernia, which she said made her "terminally ill" (no, it didn't).  She was told she would have to wait two months for the surgery (totally believable), but because she was having pain after eating, she didn't want to wait and apparently threatened to call a lawyer and lodge a complaint against the surgeon (100% believable, though she denied this - more on this later).  According to Ethel, the surgeon yelled at her, "Who do you think you are?  You're gonna wait like everybody else" (yeah, sure he did).

Ethel reportedly lost trust in the surgeon and was so shaken by the interaction that she did the right thing and chose another doctor to entrust with her life.  Right?  RIGHT?  HAHAHAHA no, of course she didn't.  No, instead she did what any reasonable person would do in this situation - she went ahead with the surgery and hid a voice recorder in her hair because, according to her, "I was afraid that if I didn't make it nobody would know why, and I wanted them to know it was because he didn't care about me as a person."

Wait wait wait.  Just . . . wait.  Let's pause here a moment so I can make my first completely unbiased (not really) evaluation of Ethel, shall we?
  • Hiatal hernias are common, often asymptomatic, and are always treated medically first unless there is a surgical emergency (which hers clearly was not).  I'm assuming that her GP treated her with the appropriate H-2 blocker and/or PPI, which failed.  They are not fatal unless they strangulate, which is rare.
  • She was so uncomfortable with and unnerved by the surgeon and was so worried that she would die under his care that she figured, Hey, I'll just record him.
  • The surgeon wrote in her permanent medical record (a legal document, mind), that their interaction raised "red flags" about her attitude.  Therefore he was obviously concerned about how she treated him from the start.
Oh, I like her already.  But just you wait, it gets worse.  Much worse.

On the recording just after Ethel went off to sleep, the surgeon mentioned their first consultation and said "She’s a handful.  She had some choice words for us in the clinic when we didn’t book her case in two weeks.   She said, ‘I’m going to call a lawyer and file a complaint'".  Ethel, of course, denies ever saying that.  The anaesthesiologist (presumably) replied, "That doesn’t seem like the thing to say to the person who’s going to do your surgery."  No, it certainly isn't.  Don't piss off the person who is responsible for your life.

Now is this inappropriate talk for an operating theatre?  No, not even one iota.  This is normal shop talk, and we talk like this all the time.  And the rest of the banter on the recording is just that - banter.  For example: a female in the room makes a comment about her belly button.  Someone calls her "Precious", which she believes (with no verification whatsoever) is a reference to the 2009 movie about an obese black girl but could just as easily be a reference to the One Ring from Lord of the Rings or just an ordinary term of endearment.  The surgeon says "I feel sorry for her husband," which I would too (this is really the only thing said that I would consider over the line, but only just).  Something is said about touching her, but based on the limited information available, it doesn't sound remotely sexual (which she claims it is, of course).

To top it all off with some nice cherry-flavoured bullshit, Ethel also claims that the doctor "jeopardized my life" by giving her a dose of Ancef.  "It’s just by the grace of God that I’m even alive right now.  It was an unnecessary risk that he took with me," she said.  Ancef is an antibiotic in the beta-lactam class, which includes penicillin (to which Ethel has a mild-moderate allergy, not a serious one).  More on that in a bit.

What Ethel happens not to mention in any of her interviews is that the surgery was uncomplicated and apparently a success, because I'm 100% certain that she would have screamed otherwise from the rooftops, and saying that her surgery went well would have definitively undermined her "Oh woe is me" credibility.

Now that we have more details about what was said, I'll give a few more thoughts.
  • Did the surgeon actually yell at her?  I highly doubt it.  I have no doubt he said something like, "You'll just have to wait like everyone else", but I'd bet my life savings he didn't yell.  Regardless, is that insensitive or unprofessional?  Absolutely not.  She was not critically ill and there was no surgical emergency, so the surgeon was simply telling her that she was no different than his other patients and her case would not be more or less important.  That's called being fair.
  • The surgeon did not put her life at risk by giving her Ancef.  There is only a 10% cross-reactivity between cephalosporins and penicillin (if that), and true penicillin allergies are rare.  She had a mild reaction to something after the surgery (which could have been any of the medications she was given) which was treated in an emergency room.
  • The mild disparaging remarks about her body are par for the course in the OR.  I've written about it before, and yes it's true - we absolutely do make comments about your body when you're asleep (most but not all of them innocuous).  You know who else does that?  EVERYONE.  Put microphones on people sitting at a caf√©, and I guarantee with 100% certainty that you will hear much harsher comments made about the people walking by.  I'm guilty of that too, as are you.  If you deny it, you're lying.  Is it unprofessional?  Maybe.  Are we going to stop?  Nope.  Are you?  Nope.
  • Ethel was (and is) looking for a payday.  It is perfectly clear that her first interaction with the surgeon didn't go her way, she was angry that she wasn't given priority over the doctor's other patients, and she wanted to catch him in a "Gotcha!" moment.  She failed at that but is publicising this episode anyway simply to gather support for a lawsuit.  She is dramatising this in a ridiculously histrionic fashion, saying that her hernia was "terminal" (NO IT WAS NOT) and that the mild allergic reaction put her life in jeopardy (NO IT DID NOT).  
  • She had a successful and uncomplicated surgery, but I'd also be willing to bet that she was hoping for some kind of complication.  I admit this is (obviously) pure supposition, but while I'm betting my life savings anyway, I may as well add this one in too.
  • If I hadn't already bet my life savings twice already, I would bet it again that she will sue the surgeon, the anaesthesiologist, the hospital system, and/or everyone else in the room.
Perhaps I'm looking at this from a biased point of view.  Maybe Ethel was truly scarred by what she heard.  I suppose it's within the real of possibility that she only had angelic, pure motive for hiding the recorder in her hair.

I doubt it.

44 comments:

  1. Ms. Ethel is definitely the drama queen. Another article on this subject, from the Washington Post article contains this statement:

    "Last summer, Ethel Easter wanted nothing more than to see a doctor. A hiatal hernia had caused her to suffer more than a hundred abdominal attacks within 24 hours, her stomach was bruised, and she found blood in her urine. The pain was excruciating, so Easter prayed that a surgery could be scheduled as soon as possible."

    Doc...a few medical questions, besides the ones you've already raised...

    1. What is an "abdominal attack" that could have happened more than a hundred times in 24 hours?

    2. What's up with the blood in the urine? Even if something happening in the uppermost part of the GI system *is* causing bleeding, the blood has to pass through the rest of the digestive system before being eliminated. I'm assuming that Ms. Esther wouldn't have the technology at home to test for occult blood, so she's probably referring to some visible red blood in her urine. But how would this be related to a hiatal hernia? It might happen with a really mean bladder or urinary tract infection, or maybe no infection at all, if it was some routine bleeding from a menstrual period that just got mingled in with urine. (Sorry if I grossed out the guys reading, but that's normal too!)

    No way am I trying to minimize another fellow human being's distress and fear about being in pain. But this story does sound very "embellished."

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    1. I have no idea what an abdominal attack is. Perhaps she means symptoms from her hiatal hernia.

      There is no mechanism by which blood could get in her urine from a hiatal hernia. I should have mentioned that in the post, but I must've forgotten.

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  2. Oops. Forgot to include link to the story I quoted.

    https://www.washingtonpost.com/news/morning-mix/wp/2016/04/07/patient-hid-recorder-in-her-hair-as-surgeons-operated-on-her-their-words-left-her-deeply-distressed/

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  3. "My daddy once told me, 'son, if a man comes up to you and offers to make a bed he can make the jack of spades jump out of the deck and spit cider in your ear, do not take that bet, because sure as you do, you'll wind up with an ear full of cider."

    Guys and Dolls.

    the bet you are offering is more like betting there is a jack of spades IN the deck.

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  4. I agree 100% that Ethel sounds like she is only in this for the money. Nobody in their right mind undergoes and operation conducted by a surgeon they think might kill them in anything but the most dire emergency. If she was that worried then she should have taken her custom elsewhere.

    The one thing that I would contest somewhat is the analogy between sitting in a cafe discussing passers-by and operating theatre banter. When someone is out in public, they are in control of their body, what is concealed and revealed, how they dress, how they hold themselves and all that jazz.

    In the theatre the patient is totally vulnerable and totally exposed. The surgeon has the control and can see, touch and do whatever they consider fit without any consent, or even knowledge, of the patient. That exposure and vulnerability puts the medic in a position of responsibility which does not apply to a casual passer-by who sees what you have chosen to reveal. It doesn't even apply to a masseur, who can be told to back-off if they make a client uncomfortable because the client remains alert and in control.

    I do think it not unreasonable for theatre discussion to be limited to what would be said if the patient was awake. This is a professional environment and the fact that the patient is unconscious and thus completely vulnerable makes professional decorum more important rather than less. If you walked through an (imaginary) airport scanner that allowed the security guards to see you completely naked, would you be happy for them to make comments about your body?

    Having said all that, and assuming no sexual meaning or intent (I can perceive none from what was said), I see little to criticise in this case. Comments about her belly-button, if not relevant to the procedure, are the sort of thing that one typically cannot make of a person who has dressed themselves for exposure to the world and so do illustrate what I mean, although really that's so mild that it is hard to see how it could cause real offense.

    Pretty sure she had her eye in that half-mil'!
    Ugi

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    1. Sorry to burst your bubble Ugi, but ORs are not sanctuaries, though I understand your point about vulnerability. I should say however that comments about people's bodies only happen in perhaps 5% of my cases, if that. And most of the time it is along the lines of "Her belly button is dirty" or "Did you see his tattoo?" Comments that I have overheard other people make in restaurants etc are much harsher and more personal.

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    2. I'm sure they are not, but they are also not children's playgrounds and if one expects to be respected as a professional then one should behave as one even when nobody is recording the conversation. You are on "company time", so to speak, and you have access to very personal and private information. I think a fair test would be that you would be prepared to say the same if the subject was awake. A dirty belly-button or an interesting tattoo probably makes that cut.

      The fact that one may be harsher in a public place is not a fair comparison. Firstly because the respect I give to and expect of a stranger in a restaurant is not equivalent to that of a doctor and secondly because the stranger only has the information which I choose to reveal. A stranger in a restaurant would not be commenting on my "Reverse Prince Albert" (Google it if you dare) and I would not expect my surgeon to either if it wasn't relevant to the procedure.

      And before you ask: No, I don't.

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    3. If you honestly expect folks not to comment on a reverse Prince Albert, then you expect too much. We are human, and that is human nature.

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    4. OK, maybe that's asking a little much!
      Ugi

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    5. Why on earth would anyone want to impale their urethra on purpose? I don't know about men but as a female the one time I had to be catheterized was the most painful thing, outside of labor and childbirth, I ever experienced. No thank you!

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    6. If I can imagine one thing that would be terrifyingly, unbearably painful it's having a sharp object put in through the urethra and out through the glans, which is where the "reverse" bit comes in. I don't have too many secrets but you would only have to hint at that as a plan and I would tell you absolutely anything. Oh, and you end up pissing like a watering-can.

      Agreed: Not a good plan.

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  5. It's such a shame that people get so immature and/or greedy that they attack the people who save the lives of others.

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  6. I was hoping Doc would comment on this story.

    She lost all credibility the moment she said the surgeon made her feel so uncomfortable that she feared she wouldn't make it out of her operation alive. Of course that was also her justification for hiding a recorder in her weave.

    Like Doc said, kind of, "Who does that!" Any rational person would choose another surgeon.

    I immediately got the impression she was a drama queen as did the surgeon, thus his remark about her being a handful.

    Texas happens to be a "one party consent" state that only requires one of the parties to agree to being surreptitiously recorded. The same was true in the case of colonoscopy guy.

    I found this information online:

    38 out of 50 states, including the District of Columbia, have a "one-party" rule that requires the consent of at least one person in a conversation before it can be surreptitiously recorded. This means that as long as one person (for instance, the recorder) consents to the recording, she can record the conversation without informing the other parties she is doing so. 38 out of 50 states are single consent.

    12 states forbid the recording of private conversations without the consent of all parties: California, Connecticut, Florida, Illinois, Maryland, Massachusetts, Michigan, Montana, Nevada, New Hampshire, Pennsylvania and Washington.

    Federal law is a little more complicated. The federal wiretap law permits the unauthorized interception of most forms of electronic communications when one party consents unless the interception is made for the purpose of committing a crime or tort.

    The definition of tort:

    A tort, in common law jurisdictions, is a civil wrong[1] that unfairly causes someone else to suffer loss or harm resulting in legal liability for the person who commits the tortious act, called a tortfeasor.

    Correct me if I'm wrong but isn't Ethel attempting to commit a tort by exposing her surgeon to legal liability by surreptitiously recording him? She admitted that she did so because she anticipated him causing her harm and wanted to give her family some legal ammunition. Of course she didn't actually say the latter but what other reason would there be?





    Most states have copied the federal law. Some go further and impose additional penalties for using or divulging the unlawfully acquired information and trespassing to acquire it.

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    1. It seems to me that she illegally recorded a conversation that she was not in.

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    2. good point. none of the parties INVOLVED in the conversation were aware of the recording device - therefore none of them could consent.

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    3. Certainly, she does not seem to have been a "party" to that conversation if she was asleep.

      As far as the tort question is concerned, unfairly damaging the reputation of a surgeon is no-doubt a tort, as would be attempting to extort money by threatening to do so. It might be difficult in the circumstances to prove the intention, however and I can't see it ever being in a hospital's interest to sue one of their patients, however obviously they are trying to make a quick buck.

      Doc': I'd be interested to know how you would feel if surgery was routinely recorded in video and/or audio. Would it change how the people involved behaved? For better or worse? I'm pretty sure it would result in a new full-time occupation of scouring such tapes for perceived malpractice so it's probably not a practical solution, but I would be interested to know your reaction.

      Ugi

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    4. Ugi - that has been suggested numerous times. Doctors generally will fight that recommendation as they believe it is an invasion of privacy. While I am not completely opposed to the idea, I think it could potentially have several repercussions, mainly that surgeons would be much more careful not only about what they say but also what they do. While this seems like it would be a good idea, it would also dramatically increase operative times which is not good for patients. It would also make surgeons (in general) much more nervous about making a mistake on video, and one thing you don't want is a nervous surgeon. Some also argue that it would infringe on their autonomy, though I don't necessarily buy into that.

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    5. I did not expect that it was an original idea. I was just interested in why it was not routine. The arguments against mostly sound like a question of trust that the person reviewing the tapes will understand all of the factors (for example the need to trade-off caution against speed).

      I don't understand the privacy argument at all, unless you are referring to the privacy of the patient, in which case the video would evidently fall under the same types of rules as other medical notes and tests.

      Nervousness is simply a case of familiarity. I'll bet my savings (such as they are) that a first-time surgeon is much more nervous about the prospect of making a life-altering mistake than the idea of being videoed. If you have always been videoed then you always expect it. That's cultural rather than absolute. The same applies to caution. You use the degree of caution you expect to require and that's only different on camera if you are unaccustomed to being filmed.

      From a position of absolute ignorance on surgical procedure, the argument that seems most persuasive to me is the autonomy one. If you are conducting a surgery then the last thing I imagine you need is someone else watching and giving you instructions from a position of less information than you have yourself; a sort-of surgical back-seat driver. Presumably you avoid that by just not having such a person.

      On the plus side, as well as possibly making surgeons respect the privacy of the Prince Albert that I don't have, it would give the opportunity for surgeons and their trainers (teachers? I don't know - I don't mean to make you sound like a performing monkey) to review and improve their technique in the same way that elite sportsmen do. There must be an element of continuing training in surgery and it might be a helpful aspect of that.

      I would be surprised if this was not routine within a professional generation and I can only see that as a good thing, so long as everyone can keep the lawyers well away from it all.

      Ugi

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    6. Sorry, I did not make it clear that those were not necessarily my concerns, but concerns that I have heard from others. The autonomy issue is my only real concern. However, in your last sentence you hit on the one major issue I didn't address - lawyers. I don't see any way that any surgical surveillance videos would not be used by lawyers for malpractice claims. I am no legal expert, but would a hospital and/or doctor be able to prevent patients and their lawyers from obtaining a copy of their own recorded procedure even if they had them sign some kind of statement saying they wouldn't? I have no idea, but the idea doesn't appeal to me one bit.

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    7. On the flip-side, I did not mean to imply that I thought they were specifically your personal concerns. I didn't intend that.

      I am sure you are right - there would be no way to withhold the tape in legal proceedings and in some cases it would clearly be warranted. Surgical malpractice must exist and in such cases it would be reasonable for the tape to be reviewed. Indeed in cases of suspected malpractice the tape would probably vindicate the surgeon more often than it would condemn him(/her) and would probably be useless in more cases than either.

      What would really need to be avoided is that an action could be brought on the basis of the video where no significant actual harm was caused. My area of law is nothing like close enough to that to know whether that could be prevented. Maybe not.

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    8. That, I believe, is the salient point.

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    9. Intrusive surveillance or security only sounds good in theory.

      In practice, people abuse the shit out of it. There's TSA agents that thought it was good sport to tag team and grope people they found attractive or save naked scan images of people.

      Let's not even start on Snowden.

      The security company manning those cameras hire idiots at minimum wage. It will be abused, videos will be leaked to the internet. We already have murder videos from court cases leaked online.

      But that said, if you really think your doctor is going to screw it up, get a different doctor. I've switched dentists because one was clearly being an idiot.

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    10. Good point, Shark. Technology has given us (society) the ability to put cameras and recording devices just about everywhere. But we *haven't* done an equally good job of making sure the recordings themselves are kept secure, in terms of not being abused and misused.

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    11. Sorry - slow to get back on this one.

      It cannot be beyond the wit of man to develop a protocol that avoids this being abused. For example, the video does not need to be watched in real-time. It could be recorded and sealed and at follow-up all parties could be asked to confirm no complications, at which point the tape is destroyed. The tape would only be un-sealed in the event of a genuine case of apparent malpractice, when the court would accept it only if it had remained sealed until called for.

      That would avoid the "trawling" issue and in most cases the perceived malpractice would no-doubt be revealed to be bad luck. It's clearly not the ideal solution, however, because many of the benefits, such as allowing the surgeon to review his procedure and that of others, would be lost.

      Somehow, I reckon it could be done, although I willingly accept that it would be difficult and convincing all parties that it was "safe" would be harder. I would still bet it will be routine in a professional generation, however.

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  7. Ugi, she may not have been a party to the conversation but she placed the recording device in her hair for the express purpose of recording what was said about her while she was under anesthesia.

    This was also my impression when I first read the story about colonoscopy guy. His assertion that he did it merely to record instructions he may not remember afterward did not hold water. First of all, I didn't receive any verbal instructions prior to my colonoscopy. Upon discharge they give you a page of written instructions and you can always ask questions afterward too if you are that dense or illiterate.

    It didn't excuse the personal nature of some of the comments made about him but I just don't buy his expressed reason for recording anything. I have a feeling he was also a pre-procedure drama queen and quite possibly was trying to provoke the response he got. It certainly paid off for him.

    If anything, the publicity he generated surely gave people who are so inclined ideas.

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    1. I am not a drama queen but did need to record some information given to my mom & I about my mom. I can see the need for it. My first endoscopy I was so out of it that I didn't even remember seeing the dr after! Thankfully my husband was there to take notes. My second one I was cracking jokes after.

      Anyway, my point being, I can totally see colonoscopy guy recording for instructions. And some drs like to give you written instructions as well as verbal.

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    2. It's hard to be certain about the motives for the first guy, but certainly the recording was much more abusive and I can't see it as justifiable even if provoked.

      I'm happy to say I have never yet needed a colonoscopy but when I picked up my mother after one a year or so ago, she was so high and spaced-out that she could barely remember her own name so oral instructions at that stage would have been utterly useless! It's not, to my mind, unreasonable to expect that you might receive pre-op instructions and very much reasonable to expect that with the stress of it all you might forget what you were told. Beyond that it's all a question of the circumstance and difficult to know without being there.

      I'm with you 100% on it giving others ideas, however. There will always be people looking for a quick buck and we are yet to find any depths they will not plumb in search of it. Another of the Doc's favourite topics is a case-in-point.

      Ugi

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  8. Can anyone tell me, what even IS an iota?

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    1. https://en.wikipedia.org/wiki/Iota

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    2. https://en.wikipedia.org/wiki/Iota

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  9. Dr. Marion Sims (surgeon) experimented on black slave women in the 1800s for his research. The Tuskegee syphilis study. There is more to that problem than meets the eye and the mistrust of the healthcare system by African Americans is nothing new. Humanities - "The Immortal Life of Henrietta Lacks."

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    1. Really? That's the excuse you're going with?

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    2. I'm sorry but that's how it is in the US. Medical students are required to take courses in humanities to understand these things. I meant no disrespect.

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    3. if you have a race card, you play it. that's what you do.

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    4. I'm not black so I don't have a race card. You might want to read this: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924632/

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    5. you still managed to play one.

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    6. from the article you cited: "Many scholars have written about the historical underpinnings and likely consequences of African Americans distrust in health care, yet little research has been done to understand if and how this distrust affects African Americans' current views of the trustworthiness of physicians."

      paraphrased: "this sounds really great, but we haven't checked if it is true"

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    7. You've read bits and pieces. Please read the discussion and conclusions.

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    8. I did. Here's one.

      "Surprisingly, the majority of respondents indicated that physician race did not influence their trust. What did matter was whether physicians could communicate across language and cultural barriers."

      IMHO, in these days when *most* of the larger health care systems in major urban centers include a large number of physicians who were born in, and often educated in, countries outside the USA, communication is a challenge for *everyone* ...on *both* sides of the doctor/patient relationship. This is true for both doctors and patients of *any* race or ethnicity.

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    9. Discussion and Conclusions: "What caused the African-American participants in our sample to distrust health care providers was different, and disturbing. Discrimination by physicians were reported in all focus groups. The Institute of Medicine Report recently identified discrimination by physicians and health care systems as an important factor in contributing to health care disparities. Our findings suggest that an expectation of discrimination may also contribute to disparities. As participants in the groups indicated an expectation of discrimination can lead to distrust and distrust and, in turn, can lead to avoidance of care."

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    10. Ken Brown i don't think that's accurate paraphrasing of the quoted text. I have not read the article.. but i think the text means: a longstanding perceived prejudice is confirmed among the american black population... but the current effect of this historical belief has not been properly studied.

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  10. I really loved reading your blog. It was very well authored and easy to understand.http://www.easily-business.net |

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  11. while I agree that we all comment on folks' looks, we do not do so in the context of our jobs. It is bad practice, although apparently common, to have medical staff comment on patients' bodies. This is likely uncomfortable for the women in the surgical suite, or maybe at least a few of the women. or the men. Even if it is not, it is unacceptable in that it objectifies the patient. I hope you will rethink this. Do I think it is the basis of a lawsuit? No, but it is horrible practice.

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    1. A fair point. However, it comes with the job. Expecting people who regularly see other people nude to not make comments would take inhuman restraint.

      Similar things happen in other occupations. Wait staff comment on how people eat, IT people comment on their colleagues' ineptitude, etc. It's human nature.

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