Are chaperones a hindrance to patient privacy?

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.

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. 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.   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 their presence 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.
  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.

Joel Sherman is a cardiologist who blogs at Patient Modesty & Privacy Concerns.

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  • Mark

    Ha, there is no way I am doing a gyn or little kid exam without a chaperone. Of course the majority of chaperones are used to protect the physician. What planet do you practice on?

    • Stephanie

      I completely understand the legal necessity for a chaperone during certain visits, but I am one such patient that will forego those exams, in part due to the number of people in the room. The doctor, chaperone and now a scribe is just too many people.

    • D

      I’ll bet you don’t use male chaperones for those gyn exams. Unfortunately women in healthcare think it’s perfectly alright to use female chaperones for male patients, especially teenagers. I’m afraid I would end up in jail if they tried to do that to me.

  • http://fertilityfile.com IVF-MD

    How would one “specially train” a chaperone? Is there a test they would have to pass also?

  • Joel Sherman

    Mark, of course the majority of chaperones are used to protect the physician, but you wouldn’t know that if you read the AMA guidelines. They make it sound like it’s a service to the patient. Also never said you should do gyne exams or whatever without chaperones. All I said was that you should give the patient a choice. The studies are clear that a substantial percentage of patients don’t want them including women getting pelvic exams. Not surprisingly hardly any men want them .
    IVF, ideally chaperones should be taught to actually help the patient, get them ready for the exam and explain it to them. Comfort them if need be. A totally untrained assistant will not be ready to do that.

    • D

      Excellent article Dr. Sherman. I have avoided female healthcare providers for intimate exams my entire life for that very reason. 2 female eyes are nearly impossible to accept. With 4 female eyes my health isn’t worth it.

      How could I ever trust a healthcare provider that doesn’t trust me enough to examine me without a witness?

  • stargirl65

    I have a solo office with one employee. She is managing phones, checking people in and out, and watching the cash box. I can’t have her come in the room every time I do an intimate exam. I can’t afford to hire another person either.

  • Mark

    Thanks, Joel, for the response. The point is I’m not going to ask because I’m not going to do one without the chaperone. The system dictates the way we act. Just look at the difference between the rate at which male and female MD use of them. Male and female doctors get the same training, do the same job, work side by side; but, there is much less risk for female MDs from an accusation, either stemming from malice or just a misunderstanding. Can you imagine what even a blatantly false molestation accusation could do to you? Change the system, you’ll change the behavior. BTW, I don’t think you can have someone sign a liability wavier that says, “You can’t sue me even if I molest you”, so I don’t understand how that would negate the need to have a chaperone in the room.

  • Dr. Dredd

    Sorry, I don’t think allowing people to opt out and sign a waiver is practical. A good attorney would be able to undermine or invalidate a waiver. Chaperone, or go somewhere else.

  • http://fertilityfile.com IVF-MD

    Dr. S, that doesn’t sound like it would be that hard. I think 12 structured 15-minutes training sessions with feedback and testing would be more than enough, especially with a time-tested training system in place. No?

  • Joel Sherman

    Of course 90% of male physicians use a chaperone when doing pelvic exams. But it’s not a sacred rite. My wife’s gynecologist asked her once if she wanted to wait until a nurse was available. She told him to go ahead, no problem. They have an established relation and trust each other. He didn’t consult a lawyer either.
    If you want a guarantee that you’ll never be sued, medicine is the wrong profession.
    But my major point is not with pelvic exams; most patients are understanding with them. When you always use chaperones in other situations you are paying more attention to lawyers than to your patients in my opinion.

  • Alan

    As a patient I understand the need for a physician to protect themselves, however when it is done without consideration for the patient, or even knowing it causes the patient more stress and emotional distress what does that say. I would feel better about it if several things would occur, first be perfectly honest, the chaperone is there mainly for your protection not patient comfort, you expect patients to be honest with you, being dishonest with them is not the way to accomplish that or create trust. Be considerate of patients modesty concerns and do everything you can such as positioning the chaperone where they will not be seen as just another set of eyes on the patients exposure. And most important, if you feel you need a chaperone for your protection, give the patient the choice of gender. I understand and respect your need for protection, should I not expect the same from you for my need for comfort. I understand most of these issues are male MD’s, female patients, and female chaperones. If the only consideration is for MD protection, without accomodating the patients side, the basic premisis of concern for the patient is just smoke and mirrors,

  • Female FP

    One interesting observation – I have several married couple patients in my practice who come as a couple at all times. When either the husband or wife requires a genital exam, they ask their spouse to leave. I agree that most patients prefer as few eyes as possible and chaperones are a great example of a vocal minority affecting the majority.

  • http://Www.twitter.com/alicearobertson Alice

    This recently happened during a biopsy on my daughter’s lymph nodes. I think it made the doctor nervous, but it was either sign a waiver (which was about more than a chaperone) or find a new facility. The doctor wanted to go over the waiver, and seemed to display body language of embarrassment that we were both under duress. The lymph was near the main artery so it was tricky, and I feel the waiver and chaperone added stress to both of us……and the medical assistant…who did not want to be there. She chatted nervously with me…I thanked her and she said, “For what?”.

    Why don’t the paranoid risk managers just make us sign and videotape the visit? Um…er..well….as long as the lighting and camera angle are set up right. Doctors could take some phot journalism classes in medical school….and maybe keep some touch up powder in their desk….paint a Carribean background on the walls…make the exam bed look like a surf board…..a Star is Born!:)

    Okay…all joking aside…..video conferencing is already a reality….works really well for the homebound. Obviously, a biopsy needs done in an exam room, it’s not a fun experience, and I didn’t like adding another set of eyes. None of us did.

  • Anonymous

    Eight years ago, when I was in the second year of seeing my current primary care doctor, I suggested when he was ready to go get the chaperone that I was perfectly comfortable without a chaperone. He, however, informed me that his malpractice insurance required a chaperone.

    Of course, I’m a piece of work anyway. I feel like if we are going to have one extra person, then why don’t we just send out an invitation to everyone in the building and have a pelvic exam party. Perhaps I’m a bit of an exhibitionist.

  • jsmith

    I always use one for gyn, rectal or breast exams on females, to protect myself, and i always ask male pts on whom I’m about to do a genital or rectal exam. i can’t remember the last time a male pt wanted a chaperone.

  • http://ethicalnag.org Carolyn Thomas

    Any woman who’s ever delivered a baby in hospital is used to having a small army of onlookers staring at her private parts in the delivery room. Modesty takes on a whole new meaning after that kind of experience!

    But every woman knows on some level the difference between clinical necessity and downright inappropriate behaviour.

    Long ago, as a young patient referred to a new (male) gynecologist, I didn’t feel too uncomfortable the first time he asked me to contract my pelvic muscles around his fingers during an internal exam, complimented me profusely on my “amazing” muscle tightness, and then asked me to contract again. But when he asked me to contract a third time, it hit me that there was something definitely creepy going on. I yelled: “OKAY!! I’m outta here!” and my visit was abruptly and awkwardly over.

    If I had known then what I know now, that guy would be reported to the police and charged appropriately. Better yet, he wouldn’t have even dreamed of pulling a stunt like that had there been a witness.

    Fast forward 30 years and this time, I’m in the E.R. in mid-heart attack, with textbook symptoms like crushing chest pain, nausea, sweating and pain radiating down my left arm. My friend Lynne is beside me in the curtained cubicle, correctly there to “protect, comfort and assist” me.

    When the E.R. doc returns to my bedside with my cardiac test results and his misdiagnosis of GERD, it is my companion Lynne (not me, the overwhelmed and frightened patient) who clearly insists to him: “But what about the pain down her left arm? That’s NOT a symptom of acid reflux!”

    It’s not only during “intimate examinations” that a companion can be both supportive and life-saving.

    • http://www.twitter.com/alicearobertson Alice

      It’s not only during “intimate examinations” that a companion can be both supportive and life-saving [end quote]

      I think this is a good story for patient advocacy….a companion like a doula who helps a laboring woman. But a chaperone helps hospital management. It would be rare for an employee of a hospital to risk their job afterwards (if something goes wrong) and side with a patient. They are the doctor’s companion (bought and paid for) …..no matter what type of nice PR job or label they put on it.

      • FR

        I agree completely Alice. Why wouldn’t an employee payed by the doctor in question side with the doctor, even if it is an exageration or an outright lie?

        If the comfort of the patient is truly what is important, why not let a friend or family member of the patient be present? It’s true that the friend of the patient might make it more difficult in court if they gang up on the doctor, but why is an employee of the doctor completely beyond reproach? When it comes to gaining or losing a lot of money and your reputation, nobody’s “assistant” can be beyond reproach.

  • Chaperone resenter

    I stopped going to the ob-gyn because I could never have a private exam. The nurses/assistants were a hindrance to ME . I particularly resented them when it became clear they and the doc were there to support each other, and not me.

    The “knowing” looks cast between them was enough to make me keep my history or any questions, to myself.

    I also resented the lack of physical privacy. I didn’t give permission for extra people who couldn’t give a hoot about my condition or problems or have any training to deal with them, and who would no doubt turn some patient dealings into water cooler chatter, which I would not care for even if it were with the physician himself.

    So I don’t go. That way I keep control.

  • http://www.twitter.com/alicearobertson Alice

    So I don’t go. That way I keep control.[end quote]

    I think anyone can appreciate your reaction…..and it’s something management will have to deal with on surveys. But, ultimately, we may want to actually find a doctor who doesn’t want a fly on the wall chaperone with a one-sided viewpoint. Yet, if we need medical care we may have to belly-up and throw all caution to the wind in order to live.

    Do states like Texas with caps have chaperones? Just a thought. I hope this is a wave that patients will smack down, or else it will….again….be regulated and the government will chase the chaperones outta there (or give patients a type of “out” option). The problem is as petulant as patients are…..doctors are so defensive they rarely listen…and sometimes they simply can’t….management pays their paycheck too.

  • ninguem

    Alice – Do states like Texas with caps have chaperones?

    The purpose of the chaperone is not to protect the patient. The chaperone protects the doctor. Here’s a story of how bad it can get. A true story.

    http://www.pulitzer.org/archives/6414

    I’m not practicing in Texas. If I were, the tort reforms would be irrelevant. I’d have the chaperone. The accusation will cause damage to the doctor, damage that goes far beyond any tort reform.

    Like jail…….when a woman lies about you. Ask Dr. Griffin.

    • http://www.twitter.com/alicearobertson Alice

      These stories are real tragedies…..but sometimes it seems like overkill. I don’t know the answer….I tend to think aloud here because I like being able to converse with doctors like you. My beloved doctor says that doctors like having a type of encoded secret language….as if they have a higher form of thinking than others…..(that’s a broad sweeping generalization….but it’s the way patient’s view many of their doctors). This is an aspect that definitely has a place in the conversation. Thinking………

      You know in truth…….I really don’t like the chaperone bit….. I would probably just sign away my rights to get rid of the chaperone. It’s getting pretty hard to sue a doctor anyways. Even if they kill you the settlements are less than 10% of the claims. But you can certainly make a doctor’s life miserable with a false claim. I have to admit if I were a doctor I would probably get chaperones to protect myself above the patient’s comfort. For that matter……I didn’t allow overnights at our home……I was too terrified some girl would grow up and get a shrink and have some repressed memory and sue us over an event that didn’t even happen (our friend’s daughter had repressed (i.e. false) memories, and it ruined their life for years because the memories seemed so real to the woman……who eventually realized the therapist planted thoughts in her mind.

      Thanks for enlightening me. I was thinking about my own observations…..and I really don’t like the chaperone thing at all. To be fair, I do take my daughters to all our visits and our doctors don’t mind one bit.

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    It’s interesting that this discussion is focusing on male doctors, female patients and pelvics. That makes sense. But there are many other examples, some mostly unspoke ones involving men. How about the tendency of some female doctors to use chaperones when doing intimate exams on men, for their own protection. There’s always a fear among some female doctors and nurses that men will act out inappropriately — which a few do. How about dermatologists who have all female staffs (mostly medical assistants) who take notes during exams and act more as chaperones than as note takers. (Of course, they don’t have male note takers when examining female patients.) How about urologists who have all female staffs for chaperone use. Female nurses, med assistants, and cnas can double as chaperones for these male doctors when they’re examining women, but male staff are not considered able to act as chaperones when male doctors are examining women. There are real chaperones, and then “chaperones,” staff who really don’t need to be there but are acting as chaperones without admitting it to the patient. And — who can be a chaperone? Do they to be licensed medical personnel? Can they be receptionists? Can they be “hired” or chosen by the patient, rather than be “hired” by the doctor? Are they required to have any training? Do they have to have any formal medical knowledge of the procedure being done? If they’re not seeing anything, or behind a curtain, how can they claim to really know what’s going on? Problem is, there are really no standards for what a chaperones. The written policies I’ve found in the US all make patient comfort the main purpose of chaperones — which we all know is not the case. That problem alone makes the rest of those written policies mostly disingenuous. They sound they’ve been written by lawyers, which is probably the case.

    • D

      “Can they be “hired” or chosen by the patient, rather than be “hired” by the doctor?”

      Very interesting concept Doug. It may cost patients a pretty penny but I can imagine in the future the ability to hire “chaperones” from a trusted outside agency to be present during intimate examinations or procedures. This may help patients protect themselves from doctors trying to protect themselves. Patients with ongoing medical problems could become very comfortable with their “chaperone”, and this chaperone could be in a sense the only kind of true “chaperone”.

      Let’s be honest, a patients friend or a doctor’s employee can never be completely trusted as a valid chaperone. Only someone who has nothing to lose or gain can truly be trusted. Someone who has no personal loyalty to either the doctor or the patient and gets paid for their honesty and devotion to justice. Someone who BOTH the patient and the doctor can be comfortable with. And of course the patient will be able to choose the gender of the chaperone.

      I can see this happening in the future, and maybe our legal system may come to favor this type of chaperone system.

  • PT

    The concept of chaperone takes on a whole new meaning
    when it involves male patients.From military induction
    physicals for male patients with leering female clerks
    to female cna’s in urology. We haven’t even touched
    on leering female unit clerks in hospitals as well as
    female nurses who think it takes 3 of them to insert
    a foley in a male patient.

  • http://ethicalnag.org Carolyn Thomas

    Why can’t chaperones be simply family members or friends? The guy with three female nurses inserting a foley definitely needs to call his wife….

  • Alice

    Family members are not paid by those in charge, and have a mind of their own…they will protect and defend the patient. That would defeat the purpose….but the good patient is supposed to be thankful for the supposed support. I wonder what the doctor would say if I said, “Sure I don’t mind an extra set of eyes…but let me get my cellphone out to videotape this procedure”.

  • Joel Sherman

    Carolyn, family members can be used as chaperones. That is especially common in pediatrics. But in adult medicine, family members offer less protection to the doctor so are less often used.
    Ninguem’s post is certainly of concern. Miscarriages of justice happen in all facets of life. I don’t understand why a physician doing a colonoscopy didn’t have an assistant present. Obviously some patients and procedures require assistants or chaperones being present. But judgment is needed so that the doctor patient relationship doesn’t degrade into a purely adversarial relationship. That’s not how I want to practice medicine.

  • swf

    As the system stands, chaperones are little more than paid witnesses on behalf of their employer. They are certainly not unbiased, and this leads to questionable motives. I would imagine the court system sees this obvious favoritism as well.
    Just as family members may protect the family, employees will protect employers.
    If some malpractice insurance companies mandate chaperones, then it should become a hired,trained, and paid position by an unbiased third party who protects the interests of both doctor and patient. Insurance companies could then reduce rates by the amount of the cost of the hired position because of the malpractice liabilty reduction.

    For the record,,,if a doctor tried to force a chaperone on me, I would leave and find a doctor more suited to my trust and ethical expectations. If someone is so focused on possible liabilty then their attention is not on your wellbeing anyway.

    swf

  • ninguem

    Again, read the Dorothy Rabinowitz article about a doctor who got jailed because the woman lied about her experience with the colonoscopy. She claimed he performed oral sex on her with the colonoscope in place. If you’ve ever seen a colonoscopy done…….

    And that doc didn’t have a “chaperone” but had a nurse, working, floating in and out of that room, prepping new patients, helping the post-procedure patients. She would pop in and out of the room at random times, or if called.

    Yeah, in five seconds, he could get his face out of the woman’s perineum, wipe off the lubricant and mucous……..I don’t even want to think about it.

    In my area, we had a doc doing colposcopies. He had a video colposcope. He was taking pathology images of the cervix.

    He got accused of taking porno pictures of the women’s genitalia.

    Yeah a 10-X enlargement of a cervix smeared with Lugol’s iodine just turns me on. Almost as much as a perineum smeared with lubricant and mucous.

    That made the newspapers and ruined his career before “justice” was done. At least they had the sense to realize the stupidity of the charge, they didn’t go as far as jail, like with Dr. Griffin.

    I’ve had accusations of NOT doing a pelvic exam. Woman comes in with pelvic pain, I did a pelvic and the usual investigations. She then went to a local ER and told everyone she came in with an acute abdomen and I blew her off, didn’t even do a pelvic exam.

    You think she’d have noticed lying down on a table with her pants off, feet in stirrups, and a doctor standing between her legs. She, literally, walked into an ER four hours later, claiming I didn’t examine her.

    That turned into a hospital quality assurance matter and a medical board complaint that I had to deal with.

    And that’s just what I’ve seen, my corner of the world, and my practice is actually a relatively nice one. I can only imagine what they see in the public aid clinics.

    • http://www.twitter.com/alicearobertson Alice

      This certainly puts a whole different perspective on chaperones. Good grief! These would be situations that would be quite hard to defend yourself from. Don’t these people who make these type of accusations get a psychological exam? If not, maybe they should? Hmm…..thinking about who has more rights….the patient or the doctor….and who would ultimately be hurt by such an action…um……

      In truth, they couldn’t pay me enough to sit and watch some of these exams (I would feel like a voyeur). I once had two doctors and nurse walk in to a hospital test room, and I kept looking to see if they would yell, “Surprise!” I had never seen any of them before, but it was the onlookers who got the surprise (and, in this case, it was helpful to have them there). It happened so quickly, and you are vulnerable with only your gown on. It involved a new procedure at that time (it measured your uterine lining),. The doctor messed it up and it was like torture. So much so the nurse asked three times (each time becoming more animated, to the point on the third try she got the other doctor involved….I nearly bit my finger off trying not to scream) , “Please STOP!” and the other doctor looked sick, and said it was time to stop (I had a pre cancerous growth removed and was told this test was vital, or I would have drop kicked him). As embarrassing as it was the doctor who was present was upset at the doctor for doing a procedure he didn’t really know how to do. He still billed though, and had no diagnosis. The nurse and the other doctor apologized all over the place.

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    As swf and others have noted, if there is a need for chaperones (and I don’t for a moment suggest that there are not cases where chaperones are in the best interest of the doctor and necessary) — then there are ways to handle this while still respecting patient dignity and autonomy. The profession needs to be proactive with this, rather than reactive. A good part of this involves honest, open communication between doctor and patient. I find it no accident that a recent post on this blog
    (http://www.kevinmd.com/blog/2010/12/pay-close-attention-doctors-patients.html)
    pointing out a fascinating article in the Archives of Internal Medicine (http://archinte.amaassn.org/cgi/content/short/170/15/1302)
    called “Communication Discrepancies Between Physicians and Hospitalized Patients>
    What doctors think patients are hearing — well, that’s not what patients are hearing to a significant degree. Doctors need to communicate better; and patients need to focus on listening and asking questions..

  • Mel

    When doing intimate exams most doctors aren’t going to ask if you want a chaperone because they want one present. If they don’t have one and an accusation is made even if completely false the doctor is still in for a world of trouble. Most aren’t going to take that kind of risk.Some malpractice companies also have wrriten policy regarding chaperones so if you don’t have one they won’t even cover you. They just can’t and won’t open themselves up to that kind of liability.

    Call and check the policy in your practice. Often the patient can bring in someone as well. It makes for a lot of people but it might be comforting to some that they have a friend or spouse with them.

    Very rarely do you see an accusation made where a chaperone is in place. It cuts down dramatically on the accusations. In the example above the doctor left himself vulnerable by having the nurse in and and out of the room versus there the whole time. Big mistakle when intimates part are involved.

  • alan

    First off I could not agree more on tort reform, agree or disagree with “Obamacare” to not include tort reform was political payback for trial lawyers at the expense of our Dr’s who are saving lives and at the expense of the patients. That said I completely understand the need for chaperones to protect the Dr’s.. I imagine they wish they could do without as well BUT, if you are going to have chaperones for your benefit, you should do everything possible to minimize the discomfort for patients. Female patients have the luxury of same gender chaperones, I as a male would appreciate the same. A certain amount of exposure is required, no getting around it, but when it is magnified by having additional people in the room to protect the provider it should be incumbant on the provider to accomodate the patient as much as possible. I understand the argument that there are not many males in nursing or assisting, but until Dr’s start trying to accomodate their male paitents…there is no reason for that to change. Dr’s actually support that by hiring only females for thier practice since it is easier to use them for both genders. That is the problem I as a male patient have for the whole subject.

  • CherylTay

    Isn’t there a possibility that a patient might actually be telling the truth about being molested by a doctor? Or is it inherently impossible for a doctor to be a perv. The defensive comments here seem to suggest that any accusation by a patient is automatically a lie.

    • http://www.twitter.com/alicearobertson Alice

      Cheryl in this case I think it’s a good counterpoint. It is thought-provoking, but your question is valid……we have only heard one side……and doctors are defensive…….rightfully so……but as I have shared here before a doctor definitely hurt my child……proven…….but other doctors fluff it off. One specialist said to me, “Oh that stuff happens all the time” while waiving his arms about like he was erasing an imaginary whiteboard. They do tend to blame the patient. In this case though……whoa……..if this patient is wrong wouldn’t this be defamation of character? This isn’t just saying a mess up happened……this is life ruining.

  • http://www.myheartsisters.org Carolyn Thomas

    I agree, Cheryl – it is of course entirely possible that patients are actually telling the truth about inappropriate behavior from their docs, despite the collective outrage – along with some downright offensive and misogynistic sarcasm from ninguem – being expressed here, that it’s the doctors who need protecting! In fact, I know very few women my age who have not experienced nappropriate actions like the ones I described from my gynecologist’s office – actions that doctors got away with precisely because of the doctor/patient power imbalance.

    There really ARE two important reasons for having a companion/chaperone, doctors.

    • D

      I usually tend to side with the patient in a discussion about medical chaperones, but I think it’s very possible that patients can misinterpret something that’s done during a necessary medical procedure as being unnecessary and sexually abusive. It’s possible that touching or squeezing or focusing on something is pertinent to figuring out the problem. But if the patient thinks it’s excessive or unnecessary, both the patient and the doctor honestly believe they are right. In that case a trained chaperone that cares about both the doctor and the patient can be there to back up the doctor’s motives and reassure the patient. But a giggly, 18 year old receptionist would just make everything worse for both the doctor and the patient.

  • PT

    Reading these comments only affirms the fact that many
    posters here are in denial.Many it seems have a hard time
    realizing that yes, many physicians,male and female behave
    unprofessionally. One only has to look at state medicals
    boards under recent actions to see this.
    Many need to realize though that many patients falsely
    accuse physicians of sexual impropriety.Many need to
    realize that its not just physicians that are guilty of
    sexual misconduct with patients.
    Those patients most susceptible to abuse are those who
    are unconscious and ventilated in various intensive care
    units. For these patients there are no chaperones and
    often no advocates to insure they recieve round the clock
    respectful care.

    PT

  • ninguem

    That “downright offensive and misogynistic sarcasm” is called the truth. Those stories really happened.

    Did you actually read the Rabinowitz article I cited?

    The. doctor. got. put. in. JAIL. over a patently false accusation. Laughably false in fact. Well, I’d have laughed if the result wasn’t so tragic. The biggest thing that hurt the doctor in the beginning?

    “Why didn’t he have a chaperone?” That was said, over and over. It was sad how little defense came from the medical community.

    Not good enough that the float nurse pops in at random times to help. In the minds of many docs and medical “leaders”, there has to be someone just standing there for the whole procedure. Which means someone else standing outside the procedure room to take care of everyone else. And you see the cost of medical care go up that much more.

    Now here’s something really offensive and misogynistic.

    Doctors are human beings who sometimes lie and do bad things.

    Patients are human beings who sometimes lie and do bad things.

    The patient sees a handful of doctors in a lifetime. Dozens if sick enough.

    The doctor sees thousands of patients, year in and year out.

    The odds favor the doctor getting a false accusation far more than a patient encountering a bad doctor. And I know……I’ve had mine.

    I stick to my assertion. The chaperone (who is my employee) protects the doctor from false accusations more often than the chaperone protects the patient from a bad doctor.

    Having had my false accusations, more than one really, I was glad to have someone in the room with me.

    If that’s mysogynistic, so be it.

    • FR

      ninguem, do you use chaperones for intimate exams on male patients? If so, what gender are the chaperones?

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    “The chaperone (who is my employee) protects the doctor from false accusations more often than the chaperone protects the patient from a bad doctor.”

    Both sides have good arguments, and I’m not claiming that doctors don’t need chaperones. But I question, first, the use of he word chaperone. These people are witnesses. Secondly, they are witnesses hired by, being paid by, one one party. I don’t know the history of these kinds of cases in court (maybe some here could enlighten us), but it seems to me that a witness paid by the doctor could be easily crucified during cross-examination in any court case. How does this work in court? I know paid experts are used all the time. How do juries react to paid chaperones/witnesses?

  • ninguem

    Here’s ol’ Wikipedia. I quote:

    http://en.wikipedia.org/wiki/Chaperone_(clinical)

    In clinical medicine a chaperone is a person whose has a role to witness both a patient and a medical practitioner and to be a safeguard for both parties during a medical examination or precedure. The exact role of a chaperone will vary according to the clinical situation.

    Chaperones are widely used for gynecological and other intimate examinations. A chaperone may support the patient with reassurance and emotional support during a procedure or examination that the patient may find embarrassing or uncomfortable.

    As a witness, the chaperone can help the doctor disprove unfounded allegations having been present during a procedure and witnessed continuing consent. A chaperone can also help the doctor with practical help during an examination or procedure, or protect the doctor from physical attack.

    I use “chaperone” because everyone else uses it for this clinical setting. As best as I can tell, in this context, it’s used everywhere in the English-speaking world. See BMJ articles on the sublect.

    You have a better word, I’d like to hear it.

    And yes, in my practice, the chaperone supports the patient, mostly. The chaperone occasionally hands me an instrument or something. Use as a witness, fortunately it’s never gone that far with me.

    Where don’t we have chaperones? In the nursing homes, where abuse of elders by staff with poorly-researched backgrounds, can happen from time to time. They just caught one across town from me, an aide caught with his pants around his ankles in an elderly woman’s room. Made the papers, and local TV. Dr. Shipman in England wasn’t doing intimate exams, he made house calls on elderly patients. He killed them, by all accounts with their clothes on. He’s one of the biggest mass murderers in recorded history.

  • CherylTay

    ninguem,
    Since you cite an anecdotal article how one doctor was abused, I’ll turn the tables with this article about pedophile pediatricians who have freely abused and raped their young patients for years, aided and abetted by their colleagues and hospitals who turned a blind eye to their crimes. Will you admit that an equally valid reason for chaperones is to keep doctors on the straight and narrow?

    http://www.cbsnews.com/stories/2010/02/24/eveningnews/main6239943.shtml

  • Mel

    Doctors who have chaperones in place during intimate exams more often than not don’t have acusations made against them. It deters the false allegations because there was someone else in the room. In the case above had the doctor had a chaperone the whole time chances are the patient wouldn’t have even made the claim. The doctor left himself vulnerable.

    The response to him as stated above was where was the chaperone and it’s a valid question in this case. The doctor didn’t behave inappropriately but it left the question of impropiety in play. Chaperones are so widely used with intimate exams and procedures that failure to use one will be questioned.

    A waiver also won’t hold up in court so I would never suggest going down that road either. It offers no legal protection in a court of law.

  • Alice

    I understand the role of the chaperone…which makes the Wikipedia citation invalid. Did a doctor write that?:)

    Why wouldn’t a waiver hold up court? I had to sign one twice this summer and it was not patient friendly. I sign away our right to sue all the time. When we play Junior Olympic Volleyball the waiver the parents sign does hold up in court. So do the bungee jumping waivers, etc.

  • PT

    Well I’ll be darned!

    Its looks as if men have done much better in the chaperone department than women. It seems that
    when women don’t want a chaperone they get one
    and when they want one its not offered.

    Men never have that problem,we have every woman
    in the facility wanting to watch our procedures even when
    the provider is a male. Are they there to make sure we
    are safe?

    • http://www.twitter.com/alicearobertson Alice

      Men never have that problem,we have every woman
      in the facility wanting to watch our procedures even when the provider is a male. Are they there to make sure we are safe? [end quote]

      No, they are there to sexually harass you because we all know all male doctors are eye candy. What hospital do you work at? Did you say, General Hospital? I’m tellin’ ya’ what management will do to keep you doctors happy! I think they should just go back to cash bonuses.

      Any other little tips you can share to help the patients enjoy the experience better? :)

  • Joel Sherman

    Surprised at the amount of heat this topic has generated. In the lawyer laden US, no male physician would consider routinely doing pelvic exams without a chaperone. Certainly there are exceptions as I gave with my wife’s experience and the patient’s wishes should be taken into account, but chaperones in this situation are the standard of practice.
    But chaperone usage should not be extended to all other situations. I’ve seen legal websites that recommend having a witness present for all patient encounters, no matter what is involved. This is not only unnecessary, but is indeed a gross violation of privacy.
    Despite the recommendations you sometimes see, women physicians just don’t need chaperones for legal protection. Complaints are rare and criminal actions are unheard of. The use of female chaperones for male patients is always a violation of privacy rights unless the patient requests it, which is rare.

    • http://www.twitter.com/alicearobertson Alice

      Despite the recommendations you sometimes see, women physicians just don’t need chaperones for legal protection [end quote]

      My female gynecologist has a medical assistant in the room. It’s procedure. I wish they would find some way to let us do the freakin’ pap test at home, and send it away via Fed Ex yourself. But I am not double-jointed! :) Honestly, I don’t like the doctor doing it, but it’s necessary….anyone else is just a pest….but it’s obvious they don’t like it anymore than you do.

  • ninguem

    Mel: “It [the presence of a chaperone] deters the false allegations because there was someone else in the room……In the [Griffin] case….the doctor left himself vulnerable…..”

    Exactly my point. The chaperone protects the doctor.

    And I was wondering when someone would bring up the Earl Bradley case. I visited Beebee Hopsital once, nice little seacoast town. I decided not to go there. Just as well, it seems.

    Actually, at one point, Beebee did require him to use a chaperone, after receiving complaints. There were complaints about the number of female catherizations and technique of female catherizations. i don’t know if you call it a “chaperone”, but it was nurses present for the procedures, making complaints.

    Again, not a “chaperone” but the office manager (and adopted sister) made multiple complaints to local doctors, to the police, and to the medical board, about that doctor’s behavior in the office.

    http://www.capegazette.com/storiescurrent/201005/12000-bradley-report.html

    http://www.beebemed.org/html/patient_report_recommendations.cfm

    http://www.capegazette.com/storiescurrent/201002/beebe-chaperone19.html

    It’s not just the human being in the room, but what you do what that human being reports something is wrong. The hospital took a lot of grief, facing bankruptcy I heard, but there is plenty of blame to go around. Clear up to the Medical Board.

    For what it’s worth. Beebee now has a mandatory chaperone policy. Anything between the armpits and the groin. Every time I put a stethoscope on a clothed chest, I get a lightning bolt in my butt from the ghost of a stern professor long ago.

    Spinal manipulation. You’re putting your body all over the patient, shoulder to groin.

    And given the nature of this particular scandal, all pediatric patients get a chaperone, period, regardless of the nature of the encounter. It applies to all patients, all doctors, regardless of gender. Oh, and it’s a chaperone of the same sex as the patient. So you need two chaperones available at any one time.

    Last week, I saw all my patients by myself, with a receptionist in front. No one else in the office. My assistant had a vacation. My receptionist can pitch in when there’s a real-live pelvic exam, she likes helping out.

    But if I’d accepted that job offer, I guess I’d need a male and a female chaperone.

    I see a growing need for transsexual hermaphrodite medical office staff.

  • Joel Sherman

    As I mentioned in my article, my impression of the Delaware law was that chaperones were mandatory in pediatric exams when intimate exposure was involved. The third reference that ninguem gives from Beebe Medical Center likely applies to adult settings not covered by the Delaware law: “Patients will have the option of refusing a chaperone, and the doctor’s office will document that the patient objected.” That’s exactly my point. Offer a chaperone, but give the patient the option to refuse.

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    Though not common, there are cases of female doctors violating men.
    http://www.scsun-news.com/ci_13887704
    Note that she’s required to have a chaperone during all surgeries and exams — according to this article, a chaperone is defined as anyone over the age of 18.

    • http://Www.twitter.com/alicearobertson Alice

      I could not get the link to work, so I hunted it down.

      It would be wise for a doctor to get chaperone…and this time it is the men complaining. So….patients, basically, have to suck it up, because of false accusations of patients, and doctors behaving badly. Not to worry…it is bound to happen…a chaperone will become demented by all they have witnessed ….egads….nightmarish tattoos, mutilations…..stories from nervous patients with a past jabbering away……and sue (of course….their lips will be sealed until after they are fired). Maybe we can add a new malady to the annals of medicine……oh I am not even going to post some of the funny phrases running through my brain right now……yep……I have chaperphobia!

      • http://Www.twitter.com/alicearobertson Alice

        Sorry..forgot the link…it is about a woman doctor accused.

        http://www.scsun-news.com/ci_13887704?IADID=Search-www.scsun-news.com-www.scsun-news.com

        • http://Www.twitter.com/alicearobertson Alice

          Could someone interpret this? It is from the article Doug sent. I am surprised they didn’t recommend art lessons in their list of requirements, or to stop watching LA Ink……sigh….

          Quote….B) For many years while she was performing Ear, Nose and Throat surgeries at the Gila Regional Medical Center, Respondent wrote messages and created artistic images on the bodies of many of her patients while they were under anesthesia without obtaining the patients’ prior written informed consent.”

  • Frank

    The best way to avoid this chaperone problem would be for everyone to just do their best to stick to their own gender for “intimate” medical problems? That obviously won’t solve every problem or do away with chaperones, but in the most part it should take the accusation of sexual deviance out of the discussion.

    With so many female gynocologists presently established or entering the field, I imagine now or in the near future any woman should have the option to go to a female. For any woman that doesn’t want to be seen or touched by a man, or doesn’t trust men in general, this seems like an obvious choice. If an assistant is needed I imagine all will be female.

    Unfortunately, as PT has mentioned men are hardly ever given this choice. Any man can choose a male doctor, specialist or surgeon, but very few have all-male support staff. Most don’t have any men. That goes for Urologists and others that specialize in humiliating medical exams and treatments.

    Instead of complaining, women should be counting their blessings. With the right choices, even if it involves some homework, women in the most part shouldn’t have to worry about being mistreated by male healthcare providers. It might be a little more difficult to go through major surgery without being seen exposed by men, but they have a much better chance than men do.

  • CherylTay

    D said:

    ….”I think it’s very possible that patients can misinterpret something that’s done during a necessary medical procedure as being unnecessary and sexually abusive. ”

    A thoughtful doctor will verbally talk through what he is doing while examining the patient, especially during a pelvic exam where the patient can’t observe anything.

  • CherylTay

    re: http://www.scsun-news.com/ci_13887704?IADID=Search-www.scsun-news.com-www.scsun-news.com

    ….” For many years while she was performing Ear, Nose and Throat surgeries, Respondent wrote messages and created artistic images on the bodies of many of her patients while they were under anesthesia without obtaining the patients’ prior written informed consent.”

    What is shocking is that it happened “for many years”. I don’t understand. There has to be at least 5-6 people in the OR witnessing these transgressions. And it didn’t bother them? Would this have been prevented if a designated chaparone were in the room? A person cut from the same hospital cloth as the operating team?

    And it’s a joke that the only problem the hospital had with this doctor drawing cartoons and messages on patients’ bodies was that prior consent wasn’t obtained. Can you imagine asking the patient in pre-op if it’s OK for the doctor to doodle on their naked body while unconscious.

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    Frank writes: “The best way to avoid this chaperone problem would be for everyone to just do their best to stick to their own gender for “intimate” medical problems?”

    Unfortunately, as you point out, Frank, choice isn’t available to both genders a significant amount of the time. Part of the answer is as you suggest above. Patients need to speak up about their values and what they require.
    But the medical establishment also needs to drag this patient modesty elephant out of their closet. Some providers don’t think it an issue — probably because no one complains, especially men. They’re confusing patient compliance with patient satisfaction. Experienced doctors know, and new doctors are often surprised, to learn how obedient patients are when they’re naked and embarrassed. Obedience is not necessarily informed consent nor approval. I challenge anyone on this blog, to find the website of an American doctor or hospital that directly discusses modesty and gender issues up front and at least makes an attempt to communicate with patients and try to ease their concerns. Find me one. Find me a pamphlet or patient education booklet that addresses this issue, esp. for the kind of exams and procedures that require maximum exposure with both genders present.
    Yes, I know the theory — by bringing up the topic we’ll create a problem that may not exist — we’ll make matters worse. Find me the research that supports that theory. I contend that most patients want to discuss this issue, want to know that providers are considering it and are sensitive.
    As Dr. David H. Newman writes in his book, “Hippocrates’ Shadow, “…there is a phenomenon within the culture of modern medicine that guarantees the widening of the distance between patient and doctor.”
    What is this phenomenon? “Secrecy,” Newman claims. “Doctors have secrets, and we have lots of them.”
    Let;s get these gender and modesty issue out in the open and discuss them — not merely on blogs like this — but between doctors, nurses and patients.

    • http://Www.twitter.com/alicearobertson Alice

      Doug…this was a good post….how revealing…not just that doctors have secrets…but a doctor honest enough to admit it. Because of the very nature of their job..and the risk of the loss of that very job they keep their own mess ups a secret and their colleagues. The patients view this as deceptive…often feel it is futile to complain. And it usually is…fear of any consequences means closed ears and minds…yet, the patient becomes distraught because they are usually met with a wall of resistance.

      The reality is few doctors will take the time to chat or explain. I was given no options, no explanations. And, yet, if they had explained I am unsure if I would have felt better about it. I may have become more frustrated or nervous. One doctor offered to go over the waiver with me (it was about a whole lot more than chaperone….I believe I signed away rights). The bottom-line…no signature…no biopsy…no surgery (the surgeon pulled the same waiver out the next week in the pre surgery consultation….neither doctor liked doing it….I was so distraught that my daughter’s cancer spread I could not remember the date…forgot to put the time down…the surgeon had to give me back the form and apologized saying management is very specific and I would have had to go back…I had no idea what time it was…..I signed….I just wanted the cancerous lymphs removed. Patients under duress are usually pretty pliable…maybe desperate).

  • http://bioethicsdiscussion.blogspot.com Maurice Bernstein, M.D.

    Of course I agree with Doug. Prior to running a 5 1/2 year series of threads on patient modesty on my bioethics blog, as a physician and med school teacher, thought I recognized, practiced and taught the general concepts of patient modesty during a physical examination, I was never told by patients and thus never aware of the intense fears some patient have about their modesty being violated by the physician and other healthcare providers to the extent of avoiding clinically important examinations or procedures,
    After reading what my blog visitors wrote, I can say that now I know. What was missing in my practice was apparently my failure to communicate to the patient completely during an exam and encourage the patient to express their concerns about the exam itself. I thought that simply behaving professionally during the exam and following the general rules to preserve patient modesty that I learned and taught would be sufficient. Well, I learned I was wrong. The first
    answer to this issue is communication in the doctor-patient relationship.. both ways! ..Maurice.

    • http://www.myheartsisters.org Carolyn Thomas

      Dr. Maurice – excellent example of how listening to one’s patients can be the second best form of medical education!

      The very best form, however, is for docs to become patients themselves, although I would not wish this on anybody specifically. There’s nothing like being the one in the drafty hospital gown, powerless and frightened on the gurney while suffering severely distressing symptoms, to give a health care professional instant insight into what it’s like to be on the other end of the stethoscope.

      I wrote about this after a particularly bizarre experience having a stress echocardiogram, in which I mused:

      “By the way, the next time a strange man orders me to strip to the waist, he’d better buy me dinner first!”

      More on my “Top 10 Tips On How To Treat Your Patients” at: http://myheartsisters.org/2009/07/10/open-letter/

      • http://www.twitter.com/alicearobertson Alice

        Carolyn: “By the way, the next time a strange man orders me to strip to the waist, he’d better buy me dinner first!” [end quote]

        LOL! What a great comeback! I don’t have time to read your article, but I love a wicked sense of humor.

        I really think some doctors could have a great comeback for that response……no I am not going there!:)

        There is another thread at Kevin’s about medical assistants asking people to put on the gown. Fed up patients often say really funny things under stress. The author had relayed that patients who dress really well get better treatment. One lady was a bit outraged that she was expected to put on a business suit while dragging her flu ridden body out of the bed. Well….it made me laugh…..but that is pretty easily accomplished.

        A few of our doctors have a wonderful sense of humor and we have some great laughs…..and teasing. It is so helpful to laugh together. By-the-way the interns and residents laugh much easier than the specialists. Hmmm…..:)

  • http://drpauldorio.com Paul Dorio

    Maurice, et al,
    I think chaperones are a matter of good sense, appropriately placed. I don’t need a chaperone for a biopsy, but my ultrasound tech and the patient certainly benefit from having a chaperone in the room during the transvaginal ultrasound exam.

    Yes, it’s a protection – for patient AND provider.

    No, it’s not a problem as far as I can see it. Just good common sense and good medical practice sense.

    And, Dr Sherman, I’d be interested to know whether your wife or daughter (if you have one or both) would feel comfortable with the male sonographer performing the exam without a chaperone.

    In my experience, chaperones vastly improve/diminish the tension in the exam and ease patient fears/concerns quite adequately.

  • Ken MD

    Seems to me that Ninguem, Mel, and, of course, Joel Sherman, have it about right.

    Notwithstanding the few exceptions to the rules, the fact is that it is women who bring the overwhelming majority of /false/ claims against male physicians, and these false claims usually come out of the blue so far as any one male physician is concerned. He has most likely never seen that particular patient before, and therefore cannot anticipate the potential problem. As the Rabinowitz article shows, a single, false, unsubstantiated claim of violation can have devastating, even permanent effects on a physician’s personal and professional.

    Malpractice insurance in many cases specifically excludes responsibility or even defense coverage for alleged sexual or personal violations–these are criminal and/or civil law matters, just as if your neighbor accused you of an assault or a battery, and have nothing to do with malpractice, per se.

    Everything in life and business is a matter of playing the odds and avoiding the high stakes risks. There is negligible statistical risk of false accusation for a male physician examining a male patient, or for a female physician examining an /adult/ patient of either sex, regardless of the combination of gender orientations that may be involved. So, if a male physician who wants to avoid extra personnel costs only uses a chaperone for female patients during the physical exam, it can be a reasonably cost effective risk avoidance practice. With minors, there should /always/ be a chaperone present during the examination, regardless of the combination of physician and patient genders.

    Yes, there is some sacrifice of privacy and of the intimacy of the doctor-patient relationship, but this is outweighed by the fact that our legal system does not have adequate safeguards for the falsely accused. The false accuser has less to lose.

    I have always followed these practices, making sure that I leave some time alone with the patient for discussion of matters that the patient doesn’t wish to share with anyone else. If a patient objects, I tell him or her to find another doctor–that is probably the patient who is going to be trouble, anyway.

  • Joel Sherman

    Paul, if you’ve read thru all this you will know that my wife has permitted her male gynecologist to do a pelvic on her without a chaperone. She might well allow a male ultrasound tech to do a vaginal u/s unchaperoned on her but it would depend on the circumstances. A chaperone should always be offered especially if the physician was not in the room. I can’t answer for my grown daughters.
    Ken, pediatricians do need to protect themselves doing intimate exams on minors. However it can be a major embarrassment for adolescent boys when women are brought into observe. The chaperone should be same gender, but that almost never happens for boys. I don’t think that chaperones are always necessary for older adolescents except with male pediatrician and adolescent girl, but there is room for disagreement. Every possible way of preserving the kids’ privacy should be used including screens in my opinion.

    • Ken MD

      Joel,

      I agree completely about protecting privacy to the fullest extent possible and using screens in any setting. The chaperone doesn’t have to “see” anything–only has to be in eye or ear contact with both the examiner and examinee during the procedure or physical exam.

      Sometimes I’ll just leave the door open a crack, with an assistant right outside who can hear everything that is going on. That may not be sufficient in peds, but in adult medicine presumably there would be audible complaints from the patient if he or she suspected something unprofessional was going on during the exam.

      • ninguem

        Ken, thanks for pointing out the malpractice insurance thing, I forgot about that. The doctor may well have no resources to hire the defense he needs. Malpractice insurance may not cover this sort of a complaint.

        Leaving the door open a crack with an assistant within earshot……..that’s what Dr. Griffin did in that Rabinowitz article. Popping in and out of the room to help out, and when not in the room the door is open…..completely…..with a drawn curtain for privacy. So the doc can call for her if needed, she’s never out of earshot.

        As far as I’m concerned, what you do is good enough for me or anyone in my family. It wasn’t good enough for the initial Griffin trial in the Rabinowitz article, and the doctor got jail.

  • Mel

    A chaperone can be present and a patient can still be afforded privacy. You can use screens or examine behind a drape. You can have the chaperone at the head of the table or to the side so they aren’t in view of private areas. You can even ask the chaperone to turn away. All are acceptable whether dealing with teens or adults.

    In the case of older children and teens the parents should speak to their children before their exam. Let them know what will happen and find out what they are comfortable with. Express that to the doctor. If the patient doesn’t wish someone looking on during say a hernia exam certainly the chaperone even if the parent is acting as one can turn away. It’s not an unreasonable request. There are ways where the doctor can have protection and the patient privacy.
    .

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    ‘but in adult medicine presumably there would be audible complaints from the patient if he or she suspected something unprofessional was going on during the exam.’

    In some cases (maybe many), it’s not uncommon for patients who suspect something to say nothing, unless it’s extremely obvious. Only later do they realize that something may have happened. Or, they read about the doctor being accused and their suspicions seems confirmed.
    I still don’t understand the use of a witness (chaperone) who can’t see anything — unless the mere presence of a chaperone lessens considerably the possibility of abuse. That makes sense. But, I wouldn’t want to be that chaperone on a witness stand, being asked what i saw and having to say “Nothing. I was in the other room,” (or behind a screen.).

    ‘In the case of older children and teens the parents should speak to their children before their exam. Let them know what will happen and find out what they are comfortable with.’
    Let’s face it. Most parents aren’t going to do that. Why? Half of them don’t know what’s going to happen, exactly. Why? Because it can be so different from doctor to doctor. Will there or won’t there be a chaperone? Will be be an opposite gender chaperone? (for a boy. Rarely or ever would there be a male for a girl). Will the patient wear a gown? Will the patient wear his/her underwear? It would be ideal if parents did that, but I don’t see it happening. We see ourselves as liberated sexually in our culture, but i contend we’re much more prudish that we’d like to admit. We still don’t talk about these things among ourselves (except on talk radio and cable). The media makes it appear that we’re really open about sexuality and our bodies. I don’t think we are.
    I do agree with Mel — “There are ways where the doctor can have protection and the patient privacy.’ But what we’ve learned on our modesty blogs is that patient modesty is very contextual and very personal. The definition of what modesty and privacy means should be discussed — a negotiation between the doctor and the patient — not an assumed definition that the clinic or hospital creates and hands down.

  • gme

    My GYN is female and she does not use chaperones. I had a male GYN over 20 years ago who did not use a chaperone and I had a very bad vibe with him. I just never used him again. My female GYN is very reassuring and says exactly what she is doing as the exam is progressing. I felt totally at ease with her explaining the exam as she was performing it. I think chaperones are a good idea if patients feel more comfortable with it. Physicians who explain what they are doing and what you may feel (ex; you will feel a pinching sensation at your cervix) also helps you feel at ease. Bottom line for me is, go to a doctor who you feel comfortable with.

  • Ken MD

    Doug’s point is well taken:

    “In some cases (maybe many), it’s not uncommon for patients who suspect something to say nothing, unless it’s extremely obvious. Only later do they realize that something may have happened. Or, they read about the doctor being accused and their suspicions seems confirmed.
    I still don’t understand the use of a witness (chaperone) who can’t see anything — unless the mere presence of a chaperone lessens considerably the possibility of abuse.”

    That is what makes all this so difficult. You can’t have it all at the same time–complete protection of the physician and maximum privacy for the patient, especially in the legal climate in which we practice.

    At the end of the day, I have to come down on the side of minimizing both physician and patient risk, at the expense of some privacy, if that’s what it takes.

  • http://bioethicsdiscussion.blogspot.com Maurice Bernstein, M.D.

    I am going to teach a workshop tomorrow for two groups of 6 second year medical students. The workshop will be to teach on plastic models how to perform a pelvic exam on a woman and a genitalia exam on a man along with a rectal exam on both genders. The students will have an opportunity later this month on performing these examinations on real teacher-subjects. In preparation for tomorrow, I have looked at our physical exam textbook “Bates Guide to the Physical Examination” (Lippincott) currently the 10th Edition. I wanted to see exactly what is written about chaperones, the current topic here, and when and how they are used. Here are the instructions as written in Bates.

    For examination of the male genitalia: “Request an assistant to accompany you”. It is not clear whether this is directed to a nervous student or general advice but no gender of the examiner is indicated.
    For the pelvic exam of a female:”Note that male examiners should be accompanied by female chaperones. Female examiners should also be assisted if the patient is physically or emotionally disturbed and to facilitate the examination.”

    What am I going to teach the two groups? Well, based on the discussion here it seems a bit up in the air. I think that the consensus of physicians here performing a pelvic exam should be to continue with the tradition of a female chaperone with a male physician most often within the exam room. However, if the patient objects to a chaperone, the objection should at least be documented in the chart. For a pelvic exam by a female doctor, it is up to concerns of the doctor and the desires of the patient.

    With regard to the male genitalia exam, it is up to the patient to decide if the female physician should call in a male chaperone. One issue in this regard which has not been described here but which might motivate a female doctor requesting a chaperone would be that of the “spontaneous” penile erection which occasionally can occur and whether the doctor has confidence that she can deal with the situation without being ruffled or concerned about uneducated accusations by the patient. Any further suggestions for me for tomorrow? ..Maurice.

  • Joel Sherman

    Dr Bernstein said: With regard to the male genitalia exam, it is up to the patient to decide if the female physician should call in a male chaperone.
    Dr B, that begs the real question. Though most men don’t want any chaperone, a male chaperone would be acceptable to some. But in the world outside hospitals and medical schools, male chaperones are never used. It’s not a realistic option in most doctors’ offices. Almost no medical offices hire male assistants. Men should have the right to refuse chaperones. Although an occasional male might get an erection, it is the patient who is embarrassed, especially true with adolescents. A female chaperone would embarrass the patient further. A physician should be able to handle the situation without adding to the patient’s embarrassment.

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    Re; Dr. Bernstein’s question —

    If the doctor doesn’t think she can deal with this kind of “situation” perhaps she is not yet ready to do these kinds of exams and should request another doctor do the exam who feels comfortable abiding by the patient’s request for no chaperone. What should not happen is for the female doctor to force or intimidate a reluctant male patient to have a chaperone solely for the doctor’s comfort. I agree with Dr. Sherman’s comments above.

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    This quote from the British Journal of General Practice dated January 2008 (58)546 from an article titled: “Chaperones: are we protecting patients?”

    “Many of the high profile cases concerning alleged sexual misconduct are characterised by the fact that the accused doctor’s colleagues had low grade concerns about the doctor’s behaviour often for a considerable length of time before the problem came to light. It is important that practices have effective ways of letting practitioners know when their behaviour, whether simply naïve or as a result of more reprehensible reasons, may be placing them and their patients at risk…The risk of doctors being the subject of false allegations of sexual misconduct remains low. A thoughtful approach to clinical risk management may be more appropriate than the blanket use of chaperones in clinical settings.’

    This is an essential issue in medicine — the willingness or lack thereof of colleagues and especially other staff with less status to caution, warn, and/or report doctors and nurses who demonstrated unwise or unethical behaviors over a period of time. Note the case of the female doctors, the ENT doctor, who abused male patients by exposing and toying with their genitals in the OR. How many staff observed that over a number of years and just laughed it off? Some facilities don’t have a culture that accepts and encourages this kind of reporting, or at least an intervention to warn or caution the doctor.

  • http://www.twitter.com/alicearobertson Alice

    I can’t keep up on the whole thread, but does anyone know how many doctors a year are actually charged with a sexual crime?

    I skimmed yesterday and a doctor said they keep the door cracked during an exam. Not sure if I would like that either…..a real curmudgeon I am when it comes to exposing parts that are usually under cover! In my naivety it would seem the doctors doing the crimes aren’t the ones usually working continually on our privates. I remember watching a show long ago and it was the guys working on our teeth that had the fetishes for knocking patients out and ……well…… No wonder insurance companies quit paying for patients to be knocked out. Ugh! But again it is really rare for this stuff to happen (I think the footage of a dentist caught in the act are online…….a video in the purse of a reporter caught him fondling her……next thing they will be not allow purses in the exam room).

    On the flip side…….it seems odd things happen in medicine that I know can be explained. I went to see a new doctor for a sinus infection and the nurse said my daughter or husband were not allowed in by this particular doctor (patient only is allowed in). He came in and seemed fearful to touch me (no……I don’t have warts or leprosy…..just incase you’re thinkin’:). I felt sorry for him. He refused me antibiotic which was fine…..but he started to chit chat with me and I meant to ask him why he doesn’t allow anyone else in the room. I am still curious. He seemed really nice….but he must be paranoid…so why patient only from this particular doctor (his choice)?

  • http://www.twitter.com/alicearobertson Alice

    I am contorted about the story of Dr. Twila Sparks…..and found an extremely interesting article that answers my question about the artwork (which journalism has turned into as it paints unrealistic pictures in our minds and condemns people with labels of guilty….we must be skeptical). Snippets that I found revealing are at the end.

    It seems an insurance company dropped her, and more may do so. I still can’t see that she was actually guilty of a sex crime. Apparently, all she did was do an exam she isn’t licensed to do? If so, if I were a doctor that is a huge concern that the community can go ballistic and call the Governor and have newspapers with reporters who like a scandal.

    Now that said I see a double-standard in another area. A male doctor would probably have lost his license for these accusation, and yet no sex happened. I think it was an ethics violation?

    I did find a post from an actual patient who defended her. But, truthfully, just because people have been hurt in the past we must tread carefully with this stuff. False accusations are just as hurtful as a real event. Lives are ruined. A man nearby was accused and found guilty of sexually assaulting a 17 year old student. He used his house for collateral to obtain a lawyer. The young girl turned 25 years old, and I think became a Christian, and confessed she made the whole thing up as revenge (he gave her a failing grade). The teacher had moved away from the scorn, but his daughter said his life was over.

    Not all accusations are true, and not all of the guilty get punished on this earth. But in our effort to do our best to get at the truth we can’t put an issue over the truth.

    I went and read about the CRNA who made the accusations. She is pretty colorful herself. Here is the description of what took place. Egads! Then a joke from the OR staff I don’t want rebuked for (i.e. quit reading now if you don’t have a sense of humor. This was printed in a newspaper):

    *****snip****According to Ms. Garner, who administered the anesthetic for this case, and another witness, Dr. Sparks, then chief of staff at the hospital, had just finished performing a tympanoplasty with mastoidectomy on a Hispanic male in his mid-30s. After applying the dressing, Dr. Sparks threw back the covers on the patient, reached into the fly of his boxer shorts, pulled out his penis and held it in her ungloved hand toward the ceiling. Dr. Sparks noticed fluid-filled vesicles indicative of a sexually transmitted disease on the right side of the shaft and yelled, “Oh, gross!” She then slapped the head of the penis 3 times to shouts of, “Bad boy, bad boy, bad boy.” The all-female OR team laughed. All except Ms. Garner. ******snip*******
    Dr. Sparks had another peculiar post-op practice: She’d write messages and draw images on the bodies of some of her anesthetized patients. Dr. Sparks “grossly negligent care” following the death of a patient with a full stomach and bowel obstruction on whom she allegedly failed to perform a rapid sequence induction. Ms. Garner vehemently denies this charge and views her dismissal as a clear case of retaliation for blowing the whistle on Dr. Sparks, the only ENT in a town where the next hospital is 100 miles away. wrote PROPERTY OF ______ (patient’s wife’s name) in surgical site marker on the left side of a man’s chest. “She said [the patient’s] wife would get a kick out of it,” says the OR staff member. Ms. Garner says she saw her write, WE LOVE YOU, KATHY on the breast of a nursing supervisor who’d just undergone surgery. ***************snip**************************

    “Umm, doctor, that’s a long way from the throat,” was one of the running jokes amongst OR staffers. “Now I realize that ENT stands for Ears, Nuts and Testicles,” was another.

    http://e-ditionsbyfry.com/Olive/ODE/OSM/default.aspx?href=OSM%2F2010%2F01%2F01&pageno=35&entity=Ar03500&view=entity

  • http://bioethicsdiscussion.blogspot.com Maurice Bernstein, M.D.

    I agree with Joel and Doug. But Joel, if the male patient was to receive a genital exam from a female physician and agreed to a chaperone, I can’t conceive, based on my readings of comments, that the man would want a female chaperone. I think it is important to consider really to whose benefit is the presence of a chaperone. I don’t think that the patient believes that he or she is going to be “raped” by the physician. I think it is for the doctor’s comfort or just a “standard of practice” that has been present for years. For me, a chaperone for a pelvic exam has been simply a recognized standard of practice. ..Maurice.

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