The Medical Paper Gown

I recently got an email from a reader that included this bit:

I just left the hospital last night after a small cut needed 7 stitches. Nothing big, just obviously a self inflicted wound. The nurse tried to force me to put on a gown in the middle of the ER while no other patients were wearing one. I realize now it was to see how many other cuts I had. She yelled at me when I refused.

Which led me to realize that a good topic for a post would be “What’s up with those hospital gowns?”

About gowns in general, I assume the reader is in North America.  The whole gowns thing is an American thing. Sometime in the 1950s, some efficiency expert decided that doctors could work faster if patients were all naked when they came in the room. But naked seemed too awkward, so the NOT-awkward paper gown was invented. And they tell you to get in it before the doc comes in, presumably to save time! There’s no real medical reason. Most doctors today probably don’t know this. Incidentally, there’s tons of discussion online between medical professionals about what is more sanitary/cheaper/classier – paper or cloth gowns, but no one seems to question much the whole necessity of the things. Check out this article, and don’t miss the comments! They go over and over when to gown, what kind, how to put it on, but NEVER ask why to do it at all.

Nakedness/gowning never caught on in the rest of the world. I suspect this might have to do with cost of either disposable gowns or laundry. I’ve never worked anywhere where those gowns even exist. Our ER has pajamas for people who come in covered in blood or whatever – but they’re just pajama pants and button-up shirts with a hospital logo. There are robe-type tops for people who are having heart attacks or something and might need very quick access to their chests…but nothing like the American hospital gown (except in labor and delivery, and those are also cloth nightgown type things and everyone brings their own clothes anyway).

So, when the reader asks, “Is this normal protocol for a forearm wound?” I have no idea. For someone who finds him/herself in that situation, what I’d recommend doing is just saying Ok to the nurse, and not changing. I seriously doubt anyone would notice.

I personally don’t think that any time saved by undressing a patient beforehand is worth causing discomfort/awkwardness. Every country I’ve worked in other than the US seems to agree. In most of the world, the standard practice is for a patient to come in the room and sit down and talk first, and then move to the exam table.

If we are on the subject of medical culture, I’ve also found that medical office rooms look weird in the US – most other places, the room is divided into the office part and the exam part, with a curtain or screen around the exam part and a locking door. The doctor sits at a desk, and the patient on the other side of the desk at first, moving to the exam table only later. It’s like walking into basically any other kind of office in the world. I have no idea what’s up with the weird rolly chairs and patients sitting on exam tables there.

To examine a patient, AFTER we’ve discussed what’s going on, we ask him or her to move to the table if necessary; if I only need to check their throat or something, I’ll just do it in the chair. No getting naked. They go to the table, and I either put my hand under the shirt or pull it up to listen to heart and lungs, pull pants/skirts down to the hip and shirts up to the ribcage to examine a stomach, whatever. It is NOT the world standard to do the whole gown thing or ask a patient to strip down to begin with. I guess sometimes, if I need to check feet or something, I wait a little for someone to take off their shoes…but I doubt it’s a significant amount of time. Not worth having every patient come in with shoes off.

I don’t do a lot of gynecological exams, but usually the standard is to just undress from the waist down, or pull a skirt up, and use a regular sheet to drape over the patient. I don’t give instructions, so some women wrap themselves with the sheet more like a towel after a shower, which is fine with me. If I know that the complaint is not likely to require a full internal exam (likely a yeast infection or something), I usually don’t even do this, I just have her lie on her back and slip her pants down to her knees and look like that while I stand at the side of the table. I think it’s less invasive if I stand there than between the legs, and it feels better to have pants around your knees than totally off. I do not use stirrups at all, just have them put their knees on the table and spread. I’m not even sure if most of my exam tables even have extendable stirrups. I think that the ass-hanging-off-table and feet floating in the air in stirrups is a much worse feeling than just lying down on the table.

Of course, I’d probably fail a medical school exam if I were seen doing this. And I don’t often do a really comprehensive gynecological exam where I need “full access.”

Other times I can think of where I need more exposure is during an orthopedic exam if I think legs might be different lengths or I want to check for scoliosis (both can be done in underwear or even with pants pulled down a little and shirt off, bra for the ladies), a full skin exam (which can be done in parts), rectal exam (which I do by just lowering the pants as little as possible while the patient lies on his side with knees bent, which I think is better than bending over, but if you’ve been through it, let me know if I’m wrong). Believe me, it feels better to have your underwear half pulled off or lifted than to sit around naked in a gown.

While we are on the topic, another practice that seems uniquely American in my experience is for the doctor to be running between multiple exam rooms at once. I’ve not seen another country where patients are briefly seen, asked to undress while the doctor leaves and sees another patient, and then returns. Most doctors have their own office where they sit all day, and patients enter, finish everything, and leave. Offices are therefore more personal as well, because they belong to a specific doctor and all of her shit is in there (well, especially if you are like me), not a clinic where doctors are bouncing all around looking for open rooms. I can’t wait to finally be settled in my own permanent office, where I can paint in warm friendly colors, and put in nice furniture and curtains and normal lighting rather than overhead.

One more thing: chaperoning! I personally hate this. My family doc is a man (I used to have only women doctors until I went to medical school and then realized that 1. it didn’t matter, and 2. I would be pretty pissed off if someone didn’t come to me just because I was a woman) and despite knowing me for years, he lately has started calling the secretary in for even simple exams.

I do understand why and all that, but on the other hand I find it kind of offensive – like, does he really think I’m going to sue him? It bugs me every time, messes up the basic trust of the relationship. And of course, it makes me wonder that if I weren’t a psych patient too, would he do it?

Thoughts? Do you want the chaperone or not?

11 Comments

  1. Interesting post…I agree the running between rooms to see different patients at once is annoying/weird. Perhaps your Dr has a chaperone because someone made a complaint about him? I know if that happened to me I would want to protect myself. Glad to see you posting.
    …aqua

  2. Thanks for sharing your thoughts on this. Very interesting!

  3. Wow, how interesting! I never questioned the gown issue for ob/gyn or mammography or dermatological visits, but I’d rather bleed to death than have to put on a gown for a forearm cut. When my kids were little I happened to always take them to women doctors. Once we saw a doctor who was a man and my son said, “Men can be doctors too?”

  4. Fascinating. I never knew the gown was such a uniquely North American thing, although I agree that there’s no good reason for it – and lots of good reasons to avoid it. Medicare billing requires us to do more exam than we really need to do, which doesn’t help.

    For the record, you can tell your questioner that no, that is *not* common protocol for a wound on the forearm in the ED.

    My father used to have a consult room – complete with desk and chairs and journals and family pictures – between his two exam rooms, and his visits went much as you described. Patient starts at the desk, moves into exam room, comes back to the desk. I would have loved to do it that way but never had the set-up.

  5. Hahaha I remembered something really funny about the rolly stools. In a New York clinic I worked at, the rolly chairs had these HUGE Xs on them with writing FOR DOCTOR ONLY DO NOT SIT.

    Now, obviously this was because some patient had once sat on one and fallen and maybe even broken a hip. But it seemed so ridiculous – THE DOCTOR IS THE ONLY ONE QUALIFIED TO SIT ON A ROLLY CHAIR. Or THIS IS THE THRONE OF THE DOCTOR, MORTALS AWAY!

    Seriously, all it was missing was a skull and crossbones. I thought, what must a patient coming in for the first time think of that?

  6. Being that I was dancer, and I have no problem stripping totally nude in front of tens of people, I don’t see the gowns issue as a major problem, but I see your point. It’s kind of a cattle in the chute situation, streamlining approach, instead of treating patients like people, dehumanizing medicine. Sadly, I’ve come to expect this, especially in an ER situation for psychiatric reasons.

  7. Gee, what i’d love to know is how she got released without a trip to the Psych Ward…just days outta my last…i a l w a y s end up there. Fuck.

  8. I’m surprised to learn gowns are a US product. Or maybe not surprised, but I did not know it before. What is surprising is that other countries don’t have doctors on such a tight schedule that the only way to function is to jump from room to room and save time by combining the office with the exam suite. It’s an assembly line mentality. It’s a way of maximizing ‘profit.’ It sure does little for patient trust or doctor sanity. When I still worked in the business I resisted the multiple room thing, and fortunately the clinic did not have enough space anyway. But the HMO was building a new facility where we’d have had plenty of little exam rooms so we could hop from place to place and not have to waste time getting basic information (which actually is a good way to work slowly into the clinical relationship.) It’s reassuring to know that the ‘American way’ is just that: American, and that other countries still value physicians as human healers rather than just body-repair technicians.

    I also wonder if that surgeon who refused to operate on the suicide victim faced any consequences. Like I said in my response, in the US I believe (or hope?) there would have been repercussions.

  9. I’m a sonographer now, was a radiographer way back when, in Australia. Gowns are obviously (to me) not just an American thing as we antipodeans all learned to do it the British way. Colonials and all that, what!

    Because of the x-ray background I was stuck in the “off with the clothes, on with the (cloth, no starch) gown” rut, because a) they hadn’t invented paper yet and b) I was taught that in *good* radiology assessment the slightest extra shadow can mask something important,. Not only were gowns necessary because it’s part of the dehumanizing process inherent in the medical hegemony into patient/customers deeply personal secret lives, but also because people’s butts look funny as they waddle up the corridor. For historical reasons this gown thing carried over to our U/S rooms – Darwin only knows how much we wasted on laundry expenses, to say nothing of the environmental contamination from unnecessary detergent .

    Now I work in Asia, and it’s up with the shirt, doon wee da troosers (or skirt), a paper towel here, a paper towel there, splash on the gel – cleaning up is your problem Mr/Mrs Patient. Amazing epiphany! And environmentally close to neutral.

    p.s. I am on Lamictal for peripheral neuropathy. No side effects at all. Other than a frightening compulsion to post on stranger’s blogs. Must delve further into this blog to determine *your* problems. (Speaking of medical hegemony and invasion of privacy…)

  10. Ah, bi-polar.

  11. There are many things about the American system that are disturbing…the annual well-girl and well-woman exams for a start. Horrifying!
    Of course, they are completely unnecessary and harmful – they can lead to more unnecessary procedures even surgery. (and psychological issues)
    Our doctors do not recommend routine bimanual exams, breast exams, rectal exams or visual inspections in asymptomatic women – they’re of low to poor clinical value and expose you to risk. (biopsies hysterscope, scans etc)
    My Dr does not recommend any of these exams; I’d refuse anyway, they are not evidence based exams.
    Pap tests are an optional screening test that requires your informed consent.
    All screening carries risk to your healthy body, so assess your risk profile before agreeing to any screening.
    As a low risk woman, I made an informed decision to decline them over 20 years ago. American women are horribly over-screened and that leads straight to over-treatment. This cancer is rare and the test is unreliable – 95% of American women will be referred for colposcopy/biopsies after an “abnormal” smear in their lifetime – almost all are false positives.
    A high risk woman has a 1% risk from cancer (un-screened)
    Low risk – less than 1%….
    99.35% derive no benefit from smears (including the 0.35% who get false negatives) #R DeMay article at Dr Sherman’s site)
    The excess in the States shocks me – it’s no doubt why 1 in 3 women will have a hysterectomy by age 60.
    Finland has the lowest rates of cc in the world and sends the fewest women for colposcopy/biopsies – fewer false positives – they offer women 5 to 7 tests over their lifetime – 5 yearly from 30. Even this program still sends 35% to 55% of women for biopsies – the best you’ll do with this test.
    Less is more with pap tests. (if you want them at all)
    To the writer, YOU may not feel the gender of a Dr matters, but many men and women care very much – everyone should be free to see the Dr of their choice. I prefer females even though I don’t have any routine invasive exams. It is a personal choice.
    If you don’t like chaperones, a female Dr might be the answer.
    Anyone interested in the real value of these exams and screening tests should go to Dr Joel Sherman’s medical privacy blog and under women’s privacy issues you’ll find the holy grail of informative medical journal articles.
    PS The only exam needed for the Pill is a blood pressure test.
    Be careful with mammograms as well – go to the Nordic Cochrane Institute and read, “The risks and benefits of mammograms” – a rare, unbiased summary


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