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| CHAPERONES AND COMMUNICATION: KEYS TO AVOIDING TROUBLE |
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By Michael Sherman, Chief Investigator
and
Philip Parshley, MD, Medical Director
Recently the Oregon Medical Board has received and investigated an increasing number of complaints alleging improper examination or improper touching during an examination. These complaints typically allege sexual or voyeuristic behavior on the part of the practitioner. An analysis of these complaints shows that most of them are preventable. Complaints of improper examination tend to have the following elements in common:
- The practitioner is male, and the patient is female and typically an adult.
- The patient is not familiar with the practitioner.
- The examination is an intimate one such as a breast, rectal, or gynecological exam requiring the patient to disrobe.
- No chaperone is present.
- The patient is either surprised by the practitioner’s conduct in the examination, or is unaware of what the examination involves.
The last point is the key to many of these situations. Medical practitioners should keep in mind that what they see as a routine examination may be far from routine for the patient.
Apprehension a major factor
Patients facing intimate examinations can be apprehensive and embarrassed. This can be aggravated by an unfamiliar practitioner, unfamiliar surroundings, and uncertainty about the nature of and reason for the examination.
In turn, aggravated apprehension increases the risk that the person will experience an anomalous reaction to the examination. Investigation has shown that most of these complaints involved a patient's misinterpreting a practitioner’s actions during an examination, and overreacting because of heightened apprehension.
Chaperones strongly recommended
The American Medical Association Ethics Policy on the Use of Chaperones During Physical Exams1 (a careful reading of which shows that it is as much about communication and consideration as it is about chaperones) speaks to preventing this problem.
The policy states:
From the standpoint of ethics and prudence, the protocol of having chaperones available on a consistent basis for patient examinations is recommended. Physicians aim to respect the patient’s dignity and to make a positive effort to secure a comfortable and considerate atmosphere for the patient--such actions include the provision of appropriate gowns, private facilities for undressing, sensitive use of draping, and clear explanations on various components of the physical examination. A policy that patients are free to make a request for a chaperone should be established in each health care setting. This policy should be communicated to patients, either by means of a well displayed notice or preferably through a conversation initiated by the intake nurse or the physician. The request by a patient to have a chaperone should be honored.
The policy goes on to recommend that the chaperone be "an authorized health professional" whenever possible, and that the chaperone be trained for the role and understand the importance of confidentiality. A time for confidential physician-patient discussion without the presence of the chaperone should be arranged, especially for sensitive issues.1
The Oregon Medical Association's Guidelines for Physicians—Sexual Issues 2 states that chaperones "…are encouraged, but by no means required," but that a request for a chaperone should never be refused. The OMA further states that patients should be asked if they want a chaperone before being asked to disrobe, and recommends that physicians strongly consider using chaperones with the very young, the elderly, those belonging to certain cultural ethnic groups, and those new to the physician.
Under the "Safeguards for the Physician" section of its guidelines, the OMA recommends the use of “draping that would be considered appropriate by even the most modest patient.”
OMA also suggests training staff members to recognize and neutralize potentially compromising situations. The astute nurse or assistant can spot patients who should be provided a chaperone, either for their own comfort or the physician’s protection. If the physician feels that the patient is even the least bit uncomfortable, or if the physician feels uncomfortable, a chaperone should be arranged.
While the AMA and OMA policies mentioned above are directed primarily at doctors, not all sexual misconduct complaints coming to the OMB involve physicians. The Board cannot overemphasize the need for all licensees—physicians, podiatrists, acupuncturists, and physician assistants alike—to follow these guidelines.
Respecting the patient’s dignity and making an effort to provide a considerate atmosphere enhances the quality of any examination. Especially where the examination involves an intimate area of the body, adherence to this policy will go a long way toward reducing the patient’s apprehension and embarrassment.
Communication vital
Carefully explaining the nature of the procedure and how it relates to the complaint helps further reduce both the patient’s concerns and the likelihood of a negative reaction to the exam, especially if the patient may not expect it to be part of the evaluation. For instance, the patient being examined by a rheumatologist for bone and joint complaints would not expect a breast examination, and could experience a negative reaction unless the doctor explains that the breasts may contain a cancer leading to osseous metastases.
To summarize, good communication and careful respect for patient dignity will greatly reduce the likelihood that the patient will have an unexpected or anomalous reaction to something the practitioner does during the examination. The net result will be examinations that meet the expectations of both the patient and the practitioner, and that are ultimately more successful.
1 AMA Policy E-8.21 on Use of Chaperones During Physical Exams, adopted June 1998, www.ama-assn.org/ama/pub/category/2503.html under Code of Ethics.
2 Guidelines for Physicians—Sexual Issues, www.ormedassoc.org/pub/guidelines-sexual%20issues.pdf
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