NUT UP

Let’s face it.  Doctors are used to having a lot of power.  So in spite of some very stringent ethical guidelines, some of them overstep their boundaries pretty consistently and thoughtlessly.  They fail to ask the patient what the patient herself wants, and what her values are.  They direct unsolicited advice both to patient and family members.  They use sarcasm, off-hand, and even off-color remarks.  In addition to being unethical, some of it is truly cringe-worthy.

Case in point, and as the saying goes, “You cannot make this shit up,” or at least in my case, I don’t have to, because so much of it actually happens, and yes, this really did.  Word for word.

While counseling her patient on whether to consider a tubal ligation during a cesarean section, out of the blue, the doctor turns to the very shy and traditional husband and says, “Or you could nut up and get a vasectomy!”

Now in my personal value system, a vasectomy is a good idea.  It is a very simple and straightforward office procedure.  Just think about where testicles hang out, compared to how deeply embedded our precious ovaries are.  I don’t think men even get a stitch, just a little steri-strip bandage.  A day or two of ice packs, and they are good to go, with a happy female partner who no longer needs birth control.

My personal belief system is that both genders should share responsibility for birth control, family planning, and all other aspects of family life, including whether or how to have children, and what gender to identify as.  If something such as permanent birth control is needed and comparatively much easier for one partner, the answer is clear.  But here is the thing: I am not the patient, or the patient’s family.  It is none of my business to direct them, and in this case, it is not the doctor’s either.  Informed consent means you give the patient the information, and the patient decides.  This is decidedly NOT the way to inform the patient about her options.  And this is not even a patient.  Let’s go over some of the ethical issues:

Number 1.  The husband is is not a patient of the gynecologist, for obvious reasons, or even of our hospital.  It is every kind of inappropriate to give him unsolicited advice on whether to undergo an elective surgery the purpose of which is to render him permanently sterile. Do we have any health history?  Do we know if he is a hemophiliac, or has a liver disease that prevents blood clotting? For that matter, do we know that he is our patient’s only sex partner, and will be for the rest of her life?  If not, sterilizing him is not going to solve her issue of not having more children.

Number 2.  Understanding patient culture includes understanding what may be uncomfortable for a patient (or a non-patient in this case).  In an ideal world, a man would be perfectly comfortable to talk about his testicles, his fertility, his future sex and reproductive plans, and much more with two random women and his wife, but this is not an ideal world, and doctors should at least make some attempt to meet patients where they are at.  And he is not a patient.

Number 3. Doctors need to talk grown-up talk, unless the patient (or again, non-patient in this case) is developmentally incapacitated or chronologically infantile.  It comes across as condescending at best, and once we turn to very crude terms, it can come across as shocking, insulting and disgusting to populations with a lot of taboos.  Grown-up talk includes not swearing or using street terms like balls, dick, twat, titties, and yes, nuts.

Number 4. I would like this on a t-shirt, bag, or my interpreter badge:  Sarcasm does not translate.  I have written about this before.  Sarcasm in the US is used with the intention of being inclusive, but it is in fact exclusive and very hurtful and even humiliating to the vast majority of patients who do not expect it, share it, or even want to mildly joke with their doctor (or non-doctor in this case) about their health and their illnesses.  Let alone their nuts.

Linguistically speaking, you take the phrases “grow up” and “be a man” (fraught with sexist peril already) and breed it into a child with congenital problems, at least as to socio-linguistic functioning: man up.  This supposedly makes a new and hip phrasal verb meaning to grow up and be “a man” and take responsibility.  Then you take out the man, which is fine, but instead of making it a nice gender-neutral phrase about being an adult, you make it even more forcefully and crudely gendered by bring the testicles into play.  Then to add insult to injury, you use the casual and crude term “nuts” instead of testicles.  And to add to the interpreter’s personal suffering, you make “nut” into a frikking verb.  Testicles can hang or dangle, and tend to do so unless safely cupped, but a verb they are not.  Neither are nuts.

The interpreter has to focus on the message.  There is no such thing as “word for word” interpreting.  We convey meaning, rendering as closely as possible the meaning, and the intent of the speaker.  Now I could argue that this speaker meant to be crude, insulting, and even humiliating.  She meant to put her license on the line by offering medical advice to a non-patient, joking sarcastically about a man’s balls and what he should do with them, and swearing at her vulnerable, high-risk patient’s beloved.

What I believe her linguistic intent was, though, was simply to make a casual, offhand suggestion that yes, Mrs. Patient, we could do additional surgery on you while we are in there anyway, but hey (friendly smile turned to the husband for a split second) “you could always be a gentleman and have the vasectomy surgery yourself!” (Friendly nod and glance, still smiling, giggle, then turn back to patient as if she didn’t just casually and thoughtlessly diddle her ethics the way you might your beloved’s balls).

Am I positing that no doctor should ever mention vasectomies to their patient or families?  Of course not.  But I think we can all imagine a scenario where the doctor – speaking seriously, using her grownup words, and directing her attention to her patient – mentions options for the patient and includes the fact that “if your husband is willing to consider taking on the family planning from here on out, you may want to consider the option of his getting a vasectomy, instead of you having further surgery.  I can certainly get you some written information on that today, you can look it over, and if you like, I can refer him on to a urologist for more information.”

This would be the way to provide professional, ethical, and responsible healthcare, directed and guided by the patient’s goals, needs, and preferences.  Based on the patient’s values, not the doctor’s.