Saturday, September 11, 2010

Do They Reassure or Disturb Patients?

By Joel Sherman MD

Chaperones are increasingly recommended for routine use in Western medicine.  There are semi official recommendations in both the UK and USA.   The AMA has long had this policy.   

The rationale for using chaperones is twofold.  In theory their primary purpose is to protect, comfort and assist the patient.  In reality though, the usual purpose is to protect the physician against claims of sexual assault or harassment.
Preferably chaperones should be real professionals, ideally nurses, female or male.  They should function as a patient advocate and their presence should reassure and comfort the patient.  Medical assistants are far less able to do this and should never be used without them being given special training.  Unfortunately, many offices use anyone who’s available at the moment.  This could be secretaries or clerks.  They could be experienced at their jobs or young girls just out of high school.  I have never seen data delineating just what type of personnel each office uses as chaperones and how they are trained.  This information is sorely needed to evaluate the topic.  It is also not clear what percentage of these chaperones are introduced as such.  It is probably more common to pass them off as ‘assistants.’

There is no doubt that male physicians feel that they need to offer chaperones when doing pelvic exams on women.  Over 80-90% use them in the US. (Ehrenthal et al, Chaperone Use By Residents J GEN INTERN MED 2000;15:573–576) and Rockwell, DO et al,  Chaperone Use by Family Physicians During the Collection of a Pap Smear Annals of Family Medicine 1:218-220 (2003).  For other intimate exams, ie breast, male genitalia and rectal, the percentage drops off.    Not surprisingly male physicians use chaperones at a much higher rate than women do for opposite gender patients.   Women physicians plan on using chaperones for male genital exams no more than 20% of the time.  The use of chaperones by male physicians is driven by legal concerns.  This is not as evident for women physicians (Ehrenthal, ibid).   They more often site patient comfort and their need for assistance with the exam.  In truth what is the real legal risk for women physicians?  Suits and complaints against male physicians are common enough.  State medical boards deal with them every year.  However complaints against female physicians are nearly unheard of.  Their risk is so low that the presence of chaperones cannot be justified to protect the physician in my opinion.  Some women may use them not to protect themselves against suits, but to ease their own discomfort with the patient.

It’s clear however that many patients aren’t comfortable with the presence of chaperones for a variety of reasons.  Surprisingly nearly 50% of women don’t want chaperones present even when male physicians do a pelvic exam.  For men, the figure is 80 to over 90% refuse chaperones when given a choice in most studies.  That is hardly surprising when you consider that almost all chaperones are women.  Men are almost never hired as medical assistants in an office setting.  In part, that’s because they won’t accept the low pay scale, but many offices won’t hire men because they can’t readily be used as chaperones for women patients whereas female assistants are generally used with both men and women.  Few men feel that the presence of extra female eyes is reassuring.  One statistic that is not readily available in the US is the percentage of physicians who actually ask their patients whether they want a chaperone present.  If the chaperone’s  presence is driven by legal concerns, many doctors don’t ask  as they plan on using them anyway.  Some women physicians may use them because they feel at risk of inappropriate behavior from their male patients.  Patients turn down chaperones for many reasons.  The presence of extra people watching intimate exams increases the embarrassment factor for many patients.  There is also a loss of privacy that patients may resent.  It is harder to discuss intimate problems when strangers are present. Factors such as the familiarity of the patient and physician come into play here.  New patients are less comfortable in these situations.   In short, it must not be assumed that patients want chaperones present.

Adolescents are a special case as they are more prone to embarrassment than adults.  Boys are particularly subject to embarrassment when the physician (male or female) brings in a women chaperone to watch.  And the chaperones are almost always women.  Doctors do this again for legal reasons as they are concerned about charges of assault.  At least one state, Delaware now mandates the presence of chaperones during intimate exams given by pediatricians.  This law was passed after an egregious case of a pedophile pediatrician who assaulted many children over the years.  The case is not unique; Connecticut had a similar case and I’m sure there are others.  Delaware’s law is unusual in that it does state that same gender chaperones should be used ‘when practicable.’  However in the average office, it is never practicable.  Pediatricians’ offices almost never have any male employees.   I believe the law is an overreaction to a rare problem; bad cases make for bad law.   This law forces the presence of women as observers to watch the exams of older adolescent boys, many of whom would be severely embarrassed.  Using a parent, usually a mother, would not be much better in many families.  In short this law substitutes inflexible provisions for common sense. 

In my opinion, sensible provisions for chaperone usage should include:

1.)     Chaperones should be offered to all patients for intimate exams.
2.)    They should always be voluntary.  The AMA regulations above make no mention of this allowing physicians to use them against the patients’ wishes.  This is wrong.  If the physician is worried about liability, he/she can have the patient sign a waiver or refer them elsewhere.
3.)    Chaperones should be professionals.  The use of secretaries and clerks is not acceptable.  Medical assistants, i.e. unlicensed ‘professionals’ need to be specially trained.
4.)    Chaperones should not be present during history taking segments of the visit, only during the intimate exam.
5.)    Chaperones should be introduced as such, not labeled as assistants when none are needed otherwise.
6.)    Chaperones should be same gender as the patient.   This always happens for female patients and almost never for men.  Any exceptions should be made clear ahead of time with the patient given the option to refuse.

In summary I believe that the large majority of chaperones are used solely to protect the physician without the patients’ wishes being taken into account.  They are a hindrance to patient privacy and betray an underlying lack of trust on either the physicians’ or the patients’ side.  I believe they are greatly over used in our litigious society.

Further references on chaperones can be found in the thread on my discussion blog.   They are embedded throughout the near 250 comments.

This article has been chosen for publication on KevinMD, a widely read medical blog. 

Addendum  4/26/11  I note with pleasure a just released set of chaperone guidelines from the American Academy of Pediatrics which does allow both  for patient choice and same gender chaperones.

Friday, September 3, 2010

Not Just Bodies


By Doug Capra © 2010

A few years ago, I came across an interesting article while surfing the web. It’s title immediately attracted my attention -- “NOT JUST BODIES: Strategies for Desexualizing the Physical Examination of Patients” It can be found in by Patty A. Giuffre and Christine L. Williams. Both authors are sociologists, not medical professionals. I noticed the study wasn’t published in a medical journal, but in Gender and Society put out by Sociologists for Women in Society.

Since doctors and nurses routinely deal with naked bodies, the study asks how these professionals avoid or deny their personal sexual feelings. How do they deal with patients who show sexual feelings toward them? Polices and professional ethics standards guide them in many ways. In medical and nursing school they are taught to desexualize the human body, to hide their feelings, avoid emotional involvement and to use scientific, technical language, But these are often strategies taught in the “academic” curriculum. Students then go on to learn and develop many other strategies in the “hidden” curriculum as they enter the profession. Most of us have experience this “hidden” curriculum. You’re given training, then you get on the job training, then you start working, perhaps with a mentor. “This is what you learned in school,” they tell you. “But this is how we really do it.” Or, the message isn’t even verbal. It’s taught silently. You just watch and learn.

In medicine, the “hidden” curriculum can be extremely powerful since it gathers its strength from medical history, tradition and culture.

In discussing “patient” modesty, we are sometimes missing the other half of the equation -- that is, doctor and nurse modesty. As human beings, these medical professionals bring with them into the examination room just as much emotional baggage as do patients. Doctors and nurses have certain feelings and values associated with bodies and nudity. They don’t leave these issues at home.

But -- the big difference between these medical professionals and most patients is the years of experience they have had dealing with naked bodies. Nudity becomes routine to them. They may still have the feelings and attitudes they began their professional experience with, but the report “Not Just Bodies” found that “With few exceptions, the men and women in this study reported that they were uncomfortable performing examinations in the early part of their training but that they became more comfortable as they progressed through their careers.” The report goes on: “Several physicians and nurses noted that they ‘see 20 patients a day and everybody looks the same’ and that they ‘have been doing this for so long’ that they never get uncomfortable.”

Why? Because they have developed strategies to deal with this. At the very least, these strategies make them feel comfortable.” That’s the key, and it makes sense. To do a any job competently, one has to feel comfortably competent.

The more empathetic, experienced and talented doctors and nurses have developed a variety of strategies that work different patients with a focus on making the patient more comfortable, too. But some medical professionals, depending up the personal baggage they bring with them, and their communication skills, are more focused on their own comfort, or perhaps on just getting the task done.

This study deals with physician and nurse comfort. But the theory seems to be that if they feel comfortable and go about the exam demonstrating that comfort, then the patient will be comfortable. And that theory as much merit to it. No one wants medical professionals working on them who seem uncomfortable and uncertain of what they are doing.

But this is a tricky and sensitive subject. And, as far as I can determine, it’s rare to find any studies that look at this from the patient perspective. How do patients see this? What strategies work for what patients? What role does the gender of the doctor or nurse play when matched with male or female patients? How do patients react to strategies used by same gender care or opposite gender care?

This study focuses on gender and the caregiver as it tries to answer questions like “How does the gender of the doctor or nurse, and the gender of their patients, figure into their choices of which strategies to use? The authors aren’t so much interested in how successful or effective these strategies are, but rather the logic behind the strategies used and how they may differ for male and female patients.

These strategies, the authors contend, are mostly “unreflective habits bolstered by an organizational context that frames their workplace interactions.” We can call this the hospital or clinic “culture,” the underground values and mores that are mostly hidden, not discussed, rarely challenged, considered “just the way we do things around here.” The authors write: “…it is likely that most health care professionals follow hospital rules and conventions without considering their disparate impact on men and women. Many may not even be aware that they use different strategies for men and women.”

The researchers conducted lengthy interviews with doctors and nurse, asking questions like: “How do you make yourself and your patients comfortable when you are physically examining them when they are unclothed? (Note here that the interviewers don't appear to ask how the doctor or nurse really knows if the patient is comfortable. Do they ask?) Do you think you treat your male and female patients differently? Are you concerned about allegations of sexual impropriety? If so, how do you protect yourself from false allegations?

I believe this study is extremely important. I’m not claiming it is definitive. The authors didn’t interview thousands of medical professionals -- but they did conduct in depth discussions with the ones they did contact. This study does represent, I believe, important indicators regarding patient and caregiver modesty and how this subject intersects between and among them. I would like to see a team of sociologists and doctors continue studies in this area, perhaps using this study to help them get started.

In a series of articles, I will cover these various strategies from the patient perspective, how to recognized and analyze, and more importantly, how to communicate your feelings to caregivers based upon how comfortable you feel.

These strategies discussed in this study are:

-- Using a Chaperone
-- Objectifying the Patient
-- Empathizing with the Patient and Protecting Privacy
-- Joking about Sex (I would broaden this to read -- Using humor, perhaps body humor.)
-- Threatening the Patient (I would rather put this as -- Using power to control and/or intimidate patients to do what they’re told.)
-- Looking Professional

These are the strategies we’ll explore in upcoming articles --
but more specifically, how patients can recognize these at work and learn to express their personal comfort level. If a strategy makes you feel uncomfortable, more embarrassed, or humiliated -- don’t hesitate to speak up and let the doctor or nurse know. They may or may not even be aware of how what they are doing affects you as the patient. And if you find a caregiver who is particularly good at making you feel respected, valued, dignified and comfortable in any intimate situation -- be sure to compliment them. They don't often get feedback in this area and, like all of us, I'm sure they would appreciate knowing they did an excellent job.