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NYT Book Review.
Diagnosis: Female
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May have to read it, wish I’d written it.

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?