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Wednesday, February 3, 2010

Chaperones Part 2

Part 1 is full. Please continue posting here.  A summary article on chaperones can be found on the companion blog.

74 comments:

Joel Sherman said...

Here's a summary of a Canadian study which again shows that the use of chaperones is seen as an intrusion by a large percentage of women. The major points are that a majority of women trusted their own physician to do a pelvic exam whether or not their physician was male or female. Results are not broken down by age. I believe the results would be similar in the US though liability issues make an American physician much more likely to use a chaperone despite patient preferences.

Joel Sherman said...

Here's a nice summary of chaperones uses from the student BMJ. It gives some statistics from the UK which sheds some light on accusations of physician violations. 77 complaints were filed in the UK accusing them of sexual abuse or rape from 2006-08. Chaperones were not used in these incidents. Of these only 12 were referred for a hearing with penalties assessed against 4 with 4 still pending. I assume all the other complaints were dismissed without action taken. Doesn't say what the reasons were for dismissal.

Anonymous said...

That summary was interesting, Joel. It makes it quite clear that today, the purpose of offering a chaperone is to protect the doctor. Now, if that's the case, then that's the case. Let's at least admit it. Let's not make a list of reasons for chaperones and put at the top, patient comfort. Any reasonable person can understand why a male doctor may want a chaperone when examining a female patient intimately. Let's just make sure everyone's honest about why.
I loved the comment: " Dr Estreich, however, says that it’s “very unusual” for men to take up the offer of having a chaperone. “And if they did, it’s unclear how we’d resource it.”
How we'd "resource it." Now what exactly does that mean? What a way to say that there probably are not any male nurses or cna's on duty and thus we can't guarantee respecting the dignity of the man. Why not just say it? Why use this obnoxious double speak.
Sorry if I sound cynical -- but I just can't stand the misuse of language -- using language not to communicate but to prevent communication.
Good sources you found, though.
MER

Joel Sherman said...

MER, I noted Dr Estreich's comment with some amusement. The English have studied the question of opposite gender chaperones in several studies which I have referenced in Part 1. The results were clear, men don't want chaperones present. In American literature it is indeed rare to find any consideration of the chaperone's gender whatsoever. It's the same game; male modesty officially doesn't exist when it comes to chaperones, only female modesty. It's also uncommon in American medicine to ask permission of the patient to bring in a chaperone. Why? Same reason as you also quoted, the chaperone is there to protect the physician not the patient. Chaperones can be used to protect the patient but probably over 90% of the time, that's not why they're present.

Anonymous said...

Below is the URL for an excellent British chaperone policy. It's quite comprehensive, and even states this:

"It is recognised that where a male chaperone is requested by the patient and it would be inappropriate to delay the examination, this may cause some
departments difficulty. In these rare circumstances agreement has been sought that Theatres may be contacted and will attempt to provide a male member of staff..."

So...it recognizes that male chaperones may not be readily available -- but it provides a special procedure to get one. I'm not sure what "Theatres" refers to -- a special department? Does anyone know.

Not that they say "In these rare circumstances..." This probably acknowledges that most males don't want and don't request chaperones of any gender -- so few request same gender chaperones.

I've never seen anything like this on any chaperone policy statement. This document is worth reading, and worth sharing with your local hospital or clinic.
MER

http://www.southtees.nhs.uk/UserFiles/pages/3287.pdf

Anonymous said...

Joel -- Here's an unusual study about use of chaperones by ENT's. Interestingly, the study shows that more men than women requested chaperones. This is not what most studies show. Maybe you could look at this study to see what's going on.
MER

http://journals.cambridge.org/action/displayAbstract;jsessionid=EB5D26F29F67FF6F35CF53F1B899531F.tomcat1?fromPage=online&aid=1115844

Anonymous said...

Just a guess but it could have some merit with this study. This study was on an ENT and not something more personal like urology or proctology. That could have swayed the patients in favor of a chaperon. They might not have cared as much about having someone else present as the genitals and rectum wouldn't be involved.

Dr. Lisa

Anonymous said...

They are referring to the OR, MER.

Dr. Lisa

Joel Sherman said...

MER, as always, UK papers are the only ones to routinely mention that same gender chaperones should be the norm for both male and female patients.
I will look at that article if possible. Dr Lisa's suggestion may well be correct. Since the men didn't care if a chaperone was present, some may have said yes just to make the physician happy. I think there is a prior reference on this thread to ENT chaperones. Apparently some patients do feel uncomfortable when a physician is directly in their face. It's not a modesty encroachment, but it is a privacy violation. You can ask why all dentists don't offer chaperones for the same reason. Of course for any procedure, a dental assistant is usually present anyway.

Joel Sherman said...

This article of Dr Margaret McCartney was first referenced on the women's thread because of her disagreement with allowing patients to have gender choice of their physicians. But she also has a section on the use of chaperones which is of interest. Apparently the UK is now beginning to approach the US in its formal recommendations for using chaperones in many circumstances no matter the respective genders of patient and physician. Interestingly she cites a UK case where their ruling boards said that the use of a receptionist as a chaperone wasn't acceptable, apparently implying that chaperones must be specially trained. That's the first formal mention I've heard of that, usually recommendations only say that medically trained personnel are preferable. The doctor doesn't make her own position on chaperones clear, but implies that they're overused.

Anonymous said...

One very easy way to cut down the need for chaperones is for everyone to just go to a same-gender doctor. I'm sure some doctors and patients will want a chaperone anyway but not nearly as many.

On the other hand nurses and aides will still be a big problem, for men at least.

Joel Sherman said...

Here's an article from the UK of course about chaperone use.
I found it interesting for the statistics it gave.
As always over 90% of male physicians use chaperones when examining women, but over 30% of women physicians used chaperones when examining men, a fairly high number. But surprisingly 74% of the lady docs used male chaperones. I doubt that in the US the number would be 5%.

Anonymous said...

I would like to hear your thoughts on what happened to me today. I went to my Doctor apprx 2 months ago for a lump on my scrotum. I was told when I made my appt. that I would be seeing a different Dr. that was a female. When the Dr. came in we spoke for a moment and she asked if " I wanted one of the girls to come in while we do the exam ?" That was the last thing I wanted but all I said was no thanks.She did the exam and I kept my penis covered with my hand while she was feeling the lump in my scrotum. She said she wanted me to see a urologist. I had to make a follow up with her for 8 weeks later. Today she comes in the exam room and we talk for a moment about what the urologist had said.She was then ready to do the exam when she couldnt find the exam gloves. She leaves the exam room with the door wide open. I was stripped from waist down but covered with a drape. She comes back with the young girl who had taken my blood pressure etc.This girl stood 2 feet away from me while the Dr. did the exam. Now I have to go back in 6 weeks. I'm not even sure why.

Joel Sherman said...

I think the doctor was out of line, especially for leaving the door open. She may well have forgotten that you previously declined a chaperone.
But if you objected to her presence you need to speak up right away and challenge it. You should also have mentioned the open door. Some physicians need to be reminded to respect their patients. Also don't hesitate to ask why she wants you to come back if you don't understand it. A physician patient relationship is a 2 way street.

Anonymous said...

The point is, the Doctor should not have assumed that a chaperone was OK, even if she forgot the previous request.

Frankly, I would call the clinic and say I don't want to see this Doctor again and tell them why. Even send them a letter or email explaining how you felt. (I can understand how you felt at the time, feeling unable to express your views; its not uncommon with us males)
But I am suggesting that you should not let this rest.
Chris

Anonymous said...

I'm in perfect agreement with Chris. I shudder when I think of my own modesty violations--and sweat cold when I dream of them--and can't forgive myself for the times I didn't protest. Never, and I do mean never, again.
--rsl

Anonymous said...

Surgeon Atul Gawande writes quite a bit about chaperones in his 2007 book "Better: A Surgeon's Notes on Performance." He doesn't look at it from a male patient's point of view, but the insights he notes are important.

He's the doctor who wrote the article "Naked" in the New England Journal of Medicine back in, I think 2003 or 4. That article becomes the basis of one of his chapters in this book.
MER

Joel Sherman said...

Here's an unusual attempt by a hospital/healthcare system to explain the use of chaperones. It perhaps asks more questions than it answers but it at least recognizes the pertinent problems.

Anonymous said...

This is an interesting article, Joel. I don't want to diminish the fact that these people are at least asking some important questions. And they do considered embarrassment and modesty. But, to me, the most important aspect of this article is how ambivalent it is. The fact that it is produced by Risk Management demonstrates the position from which everything comes. Bottom line -- it's about reducing inappropriate behavior allegations, lawsuits, and settlement payments. Now, that's important. I'm not diminishing this. And the fact that the articles places such importance upon communication is important. But the piece goes back and forth as to the real purpose of a chaperone.
The article says: "When an offer is made, it should be clearly understood that the chaperone is for the patient’s benefit, not an unwanted spectator for an already potentially sensitive experience." Well, that would be nice if it were completely true. But's not the whole truth. Of course, if the whole truth be told, that the chaperone is for the protection of the doctor or both patient and doctor or to avoid miscommunication -- then the whole trust issue comes up -- who will be the one misunderstanding things.
Yet with all the focus on documentation and legalities, it's clear the real issue here. The fact that the chaperone, unless it's a friend or relative of the patient, is working for the institution or medical professional -- makes neutrality a big issue.

It still fascinates me that there's absolutely no mention of gender. Gender neutrality is so embedded within the system, that it's probably not left out on purpose. The writer is blind to the issue.

Anyway, nice find -- and still, it's good to see these issues coming up.
MER

Hexanchus said...

Good points MER!

The other thing I noticed is that it made no mention of the patient's absolute right to refuse the presence of a chaperon.

Joel Sherman said...

Here's another UK summary of guidelines for the use of chaperones:

www.wsh.nhs.uk/AboutUs/FOI/FOIRequestsAndResponses/Attachments/694.doc

It is brief but contains all important elements in my estimation. It emphasizes that the use of chaperones is voluntary though adds that physicians have the right to refuse to do the exam if a chaperone is refused.
Beyond that it also states that chaperones should be same gender whenever possible.

Joel Sherman said...

The Delaware senate has passed a bill mandating that doctors have chaperones present when doing intimate exams on children 15 and under. This is in response to a well publicized case of multiple assaults brought against a pediatrician.
This bill sounds like it is overkill to me as there does not appear to be any protection for patient privacy. A 15 year old along with his/her parents should be able to decide on their own whether or not they want a chaperone. Many studies show that many do not. An old legal adage is that one bad case makes for bad law.
The bill also mandates fingerprinting of all doctors for whatever difference that makes.

Anonymous said...

I'll bet you money that the bill makes no reference to the gender of the chaperone. I'll also bet you money that it will always be assumed that females will chaperone young girls and that females will chaperone young boys.
MER

Joel Sherman said...

I'm sure you're right MER. No bet; you'll have to settle for a beer.
The bill doesn't mention gender of the physician either which means it would also apply to a women physician doing a breast exam.
Hopefully the bill won't pass the Delaware House and be signed by the governor.

Hexanchus said...

I wonder what happens if the parents/patient refuse the chaperone?

Regardless of any law requiring one be present, the patient/guardian still has the absolute right to refuse if they are not comfortable with it. My assumption would be that the examination would not take place. Sends a wonderful message doesn't it? If you want medical care, you have to give up your privacy and allow yourself to be exposed to unnecessary strangers in the room.

Anonymous said...

This Delaware chaperone law brings up an interesting issue. If a law requires chaperones for children through age 15, then there needs to be a standard chaperone police that applies across the board to all clinics and hospitals. This police needs to include gender selection, and rules about who can and cannot be chaperones. As I've pointed out, I can't find any American hospitals who have clearly written, detailed chaperone polices. We've posted several on these blogs, most from Canada, UK and Australia that are very clear about these issues.
The danger of the Delaware law is that, if it passes, it may become a model for other states. That's why I contacted one of my US Senators about this bill and asked for help to get this message about chaperone polices to the Delaware legislature. We should all do that.
MER

Joel Sherman said...

The bill has passed MER. Here is House bill 456. Not sure if you lose the bet, but is does mention gender, but adds the huge qualifier when practicable:

"§ 1769B. Treatment or Examination of Minors.
A parent, guardian or other caretaker, or an adult staff member, shall be present when a person licensed under this chapter provides treatment to a minor patient who is disrobed or partially disrobed or during a physical examination involving the breasts, genitalia or rectum, regardless of sex of the licensed person and patient, except when rendering care during an emergency. When using an adult staff member to observe the treatment or examination, the adult staff member shall be of the same gender as the patient when practicable. For the purposes of this section, "minor" is defined as a person fifteen years of age or younger, and the term "adult staff member" is defined as a person eighteen years of age or older who is acting under the direction of the licensed person or the employer of the licensed person or who is otherwise licensed under this chapter.".

SYNOPSIS
This act would require a physician or physician's assistant treating a person 15 years of age or younger to have another adult in the room when that child is disrobed, partially disrobed or otherwise undergoing certain physical examinations. That additional adult may be either a family member or other caretaker, or an adult staff member or colleague of the licensee.



It is better than I would have thought to mention same gender at all. I'll consider that a minor victory. I'd guess it was added to prevent a male physician from bringing in another male to witness a girls exam, something that almost never happens.

Joel Sherman said...

Hexanchus just posted this, but it will make little sense because I deleted my post which it refers to after I found a copy of the actual bill.

Joel,

My take is that the first provision applies to specific situations, while the second gives the parent the right to have an adult present for any examination.

The actual bill could differ, but from the summary, there is nothing that would prevent a parent, sibling 18 yrs of age or older, or other adult that the minor patient trusts being the "other adult present". Better that than some stranger.....

Anonymous said...

I lose by bet de jure. I win the bet de facto. The health care lobbies always make sure they get the words "when practicable" into legislation like this. Notice that it isn't even "when possible." What do we mean by practicable? Practicable based upon what? Practicable based upon whose standards? See what I mean?
Also, will patients be asked about gender? I'll be you beer they won't be. What will happen in practice is that young girls will always get a female chaperone, and young boys will almost always get a female chaperone -- all without asking.
Will 13 to 15 year old boys protest? We all know the answer to that.
No -- these laws need to say that (1) patients will be asked about gender; and (2) if they want same gender chaperones they will get it.
The mention of gender in this bill means little. Imagine the average clinic. How many male medical assistants will be hanging around?
Lip service to gender choice makes me angry, because in practice, the way staffing is gendered, we all know what this really means.
MER

Joel Sherman said...

I don't feel as strongly as you do MER. If I were writing a bill I'd make sure only that the use of chaperones was voluntary, that is the child and parent would have to be asked if they wanted one and could refuse.
When you consider that the AMA doesn't even mention same gender when talking about chaperones (at least up to 1-2 years ago), I believe that raising the issue is an improvement.
When you consider that I'd bet that not one pediatrician's office in a hundred has a male nurse or assistant working for them, it's really not practicable to mandate male chaperones. The emphasis should be on voluntary, not same gender.

Hexanchus said...

Joel & MER,

One positive I see is that this measure is clearly designed to protect the patient, while the AMA's recommendation is primarily to protect the provider. The "parent, guardian or other caregiver" provision is also crystal clear - the only way I can see a staff person being used is if one of those were not available and the parent agreed to it - no way they could force them to accept a staff member being present. With the exception of a life threatening emergency, they can't examine or treat a minor without the parent's permission.

The mention of gender is also encouraging, though as MER stated, the actual odds of having a male staff member available are remote at best. At least it recognizes the issue, and more importantly establishes it in law. It's a start and establishes a precedent in law - from this, other things may grow.....

Anonymous said...

Perhaps it's this: "the adult staff member shall be of the same gender as the patient when practicable."
PRACTICABLE rather than possible. This implies that, even if it's possible -- that is, if there is male available nearby -- but the hospital considers it isn't PRACTICABLE -- the the patient won't be accommodated. That kind of nullifies any accommodation and makes the entire intent questionable. We all know it will rarely if ever be PRACTICABLE for clinics or hospitals. This is a case of using words dishonestly, not an uncommon tactic in legislation.
And this isn't voluntary. Its law. But you're both right, in many cases parents will act as chaperones. But let's be realistic. In our society, how many kids 10 to 15 go to the doctor themselves -- take a cab or a bus, or are taken there by a family friend.
I suppose it's a start. I shouldn't be so negative. What bothers me is what I consider this to be lip service to gender choice. To suggest that these boys will have a choice when we all know they won't, is, at best, disingenuous. And, it's an example of a bill really written and/or extremely influenced by the industry that it's meant to protect the victim from. This is all too common when legislation
MER

Joel Sherman said...

MER: And, it's an example of a bill really written and/or extremely influenced by the industry that it's meant to protect the victim from. This is all too common when legislation.

MER, this bill wasn't written by doctors. You think the mandate for fingerprinting was the physician's idea? No, this was a knee jerk response by the legislature to do something to prevent a recurrence. Most doctors won't be happy about the mandate for chaperones either which increases their cost. Undoubtedly though the state medical society did have a chance to comment on the bill at some point.
Hexanchus is right though that parents will be the usual chaperone.

Anonymous said...

Joel:

I disagree. When the medical profession saw the writing on the wall, that is, when they realized that this bill was going to be written and passed -- I'm convinced they sent their lawyers into the fray as advisors to lobby. I say this because the word PRACTICABLE doesn't strike me as a word the legislature would use. It's a legal tactic to protect the medical gender status quo. The difference between "possible" and "practicable" is great, and as written gives the entire judgment of gender choice to the medical community and, in essence, eliminates any choice for young boys. Practicable could mean that, yes, there's a male available but it's just not practicable for us to use him for whatever reason we decide is valid. It could also mean that it's just not practicable to have any male nurses or med assistants on staff. Frankly, it could mean anything the clinic or hospital wants it to mean.
Yes, parents will probably be the main chaperones, for children who have involved, caring parents. But we also know which parents tends to take kids to the doctor -- the mother. Even a 15-year-old boys deserve some modesty protection at that age, even from their mothers -- if they don't want their mother as a chaperone. But, as we know, if they don't use their mothers, they'll get a female nurse, cna, med assist, or "adult." And what does "adult" mean? Could it be the female receptionist? Why not, as long as she's an "adult staff member." Note, also, the kind of medical rights a 15-year-old girl has over her body in some states when it comes to her "reproductive health" and abortion. Compare to that of the gender selection rights of a 15 year old boy.
No, this is a bad bill with good intentions. It forces chaperones upon people and, in essence, doesn't give gender choice, except to young girls. The bill needs to require same gender chaperones when requested. And medical staff needs to ask the question, not just assume that if nobody says anything, everythingis just fine. If a young boy doesn't mind his or her mother in the room, fine. If the boy doesn't mind a female staff member, fine. But to put the bodily modesty of a 15 year old boy on the same plain as that of a 3 or 5 year old boy, is nonsense. The same rules shouldn't apply. It's the same double standard principle we've been talking about regarding hernia exams -- drop'em and cough regardless of who is there to watch.
MER

Joel Sherman said...

We won't agree on this one MER. You make too much of one word. The truth is that no matter what the bill said, male chaperones aren't likely to be available for boys. I note that there don't seem to be any penalties for not obeying the law which may mean that in practice people can refuse the offer of chaperones.
Whether a mother wants to chaperone her 15 year old son is a personal decision. Some parents and kids would have no problems with it. A mother always has the option to look away or a doctor to have the patient turn away or even use a privacy screen.
The law also mandates a women physician to use a chaperone for a 15 year old girl which many girls would not like as well.
In practice my guess is that pediatricians will do less intimate exams.

Anonymous said...

Well -- I could be wrong. But specific words in legislation are usually put there for a reason. If the bill prevents abuse, then that's good. But as you say, bills like this that come between doctors and patients could have other results. I can see why some doctors would begin to feel less and less comfortable doing intimate exams on children.
MER

Anonymous said...

Sorry, I could not let this stand unchallenged. Joel wrote:

Whether a mother wants to chaperone her 15 year old son is a personal decision. Some parents and kids would have no problems with it. A mother always has the option to look away or a doctor to have the patient turn away or even use a privacy screen.

The sniff test for gender double standards is simply to reverse the genders. A father takes his 15-yr-old daughter to the pediatrician. The doctor performs a pelvic exam. The father chooses not to look away. (He doubtlessly finds the procedure "fascinating," indifferent to the embarrassment of his daughter.)

Does this scenario provoke the same gut reaction?

Of course, the above scenario, while merely the flipside of the gender coin, has a snowball's chance in hell of actually happening.

Should a father attempt the same insensitivity toward the his daughter as is exhibited by some mothers toward their sons, the script would run a little differently:

First, it would not be an issue since the doctor would run the father out of the exam at that point, regardless of what that parent thought his options were. The doctor him/herself would insist on substituting a female staff member—privacy screen be damned—even in the unlikely event of the daughter wanting daddy around. But a father merely suggesting to attend such an exam would probably start a whole new chain of events, the very least of which would be extensive questioning of the patient as to whether or not she'd been sexually abused. And that's probably just the tip of the iceberg.

------------

Regarding this terrible law, I agree with MER. The substitution of the word "practicable" for "possible" has the AMA's fingerprints all over it. I'm sure they were consulted about a law that adds further restrictions on their practice. I'm equally sure that they did what they could to mitigate a law sure to pass, protecting the status quo as best they could.

The unintended upshot of this law is that while under the old rules an older boy might have avoided female eyes (other than the doctor's), now he has no choice. Unless his father can take him, he must endure either his mother or the 19-yr-old MA invading his modesty. In essence, now he must pick his poison.

--------------

Joel, please do not dismiss this as "gender warfare." For over 55 years I've been sensitive to gender double standards. Nowadays I have zero tolerance for it.
—rsl

Joel Sherman said...

rsl, yes there is a double standard, though it is not unheard of for a father to stay with his daughter during an exam. Some fathers are the only parent. But a double standard was not my point. Most frequently only the mother is present and her son may prefer her presence to a stranger. As long as 80-90% of child rearing is done by mothers, it won't change.

Hexanchus said...

rsl,

I think maybe you're confusing "practicable" with "practical".

These two adjectives have overlapping meanings. Both indicate that something can be done, but practical also implies that it is appropriate, sensible, or useful and is therefore less restrictive.

If you look at the difference between impracticable and impractical is becomes a little more clear-cut: impracticable means "impossible" and impractical means "not workable when put into practice."

To paraphrase, practicable equates to possible, while practical equates more towards convenient.

While I'm not necessarily pleased with the qualification in the bill, I'd be far more concerned if it had been "practical".

IMHO this bill has some real positives:
1. It is clearly written to protect the patient, not the provider.
2. It recognizes that a parent or other adult caregiver the patient is comfortable with are preferable to a stranger.
3. It recognizes gender preference as a real issue.

No it's not perfect, but it's a whole lot better than the chaperone recommendations the AMA & other organizations have come up with.

It also doesn't force chaperones on anyone - they can still refuse if they're not comfortable with the situation. Nothing in the law requires a patient to accept a chaperone, only that the provider can't do an intimate exam without one present. On the plus side, maybe this will help reduce the number of intimate and potentially embarrassing exams that aren't really medically necessary.

Anonymous said...

Hexanchus: You make some good points. But I also see some problems with your position. Note that the bill also says that if a parent or guardian isn't used as a chaperone, then an adult staff member may be used:

"...the term "adult staff member" is defined as a person eighteen years of age or older who is acting under the direction of the licensed person or the employer of the licensed person or who is otherwise licensed under this chapter."

Do we all realize the implications of this? So...the doctor's "adult" receptionist, who is an 18-year-old girl, under this law, is an acceptable chaperone for a 15-year-old boy. Could also be an 19-year-old female med asst.
Now, we know that it's always possible, but rarely probable, that there might be a male med asst or receptionist. But let's get real. That just won't happen.
And, Joel. More and more fathers are raising daughters alone these days. No one questions that. More and more fathers are stay at home Dads. That's considered a good thing by our culture. But our culture wants it both ways, e.g. men by nature are not really nurturers and are all potential abusers, but we want them to stay at home more with their children, be nurturers at home, etc.
Joel writes: "Most frequently only the mother is present and her son may prefer her presence to a stranger." We don't know what the boy prefers unless we ask. And even if asked, as Hexanchus said, the boy just gets to pick his poison.
And Hexanchus says that no one is "forced" to have a chaperone. Well, of course not in the sense that the doctor isn't going to drag the patient into the exam room kicking and screaming. But no chaperone, no exam under this law. So..if the 15 year old doesn't want a chaperone, he'll have to go out of state or provide his own male chaperone. These are self-conscious children we're talking about. We know most won't have the self-confidence to stand up for themselves and their dignity. I call that being forced to have a chaperone.
MER

Joel Sherman said...

Here's a blog thread relating one woman's experience having a male ultrasound technician do a vaginal exam on her. This would be a rarity in the US; the blog appears to be British.
Surprising to me was the ladies concern that a young receptionist was called in as a chaperone. Neither she nor the commentators seemed very concerned that the ultrasound tech was a male.

Joel Sherman said...

Here's an abstract of an article in the Journal of Medical Ethics. A UK study looked at patient awareness of the availability of chaperones and the increased use of chaperones following a campaign to increase awareness. Striking to me was that only 1% of patients initially asked for chaperones to be present. After the campaign this increased only to 4%.
In short, at least in a UK general practice, almost no patients wanted chaperones to be present.

Anonymous said...

Interesting study abstract, Joel. Notice the conclusion: "There is a need to improve the understanding of the general population about chaperones if we are to see greater use of chaperones in GP."

Here's the essence of what's going on, as I see it: Their needs to be greater use of chaperones. We, as doctors, need chaperones for our own protection. We're going to continue to use chaperones. Doesn't really matter whether patients want chaperones. Patients need to be educated so they'll at least accept if not choose to have chaperones.

It's one of those studies that seems to have been done to just ascertain the necessity of educating patients for the need of chaperones whether they want them or not.
Am I being too cynical?
MER

Joel Sherman said...

Here's a brief article on chaperones giving one physician's common sense approach to their use. Unlike some recommendations you see, not every patient needs or wants a chaperone.
I fullu agree with his stance on this issue.

Anonymous said...

That's a good article, Joe. It's remarkable to read such good common sense. Unfortunately, I feel it will fall on deaf legal ears, since the trend seems to be moving toward more use of chaperones and, thus, because many if not most patients don't want them -- figuring out a way to convince, coerce, intimidate or otherwise slip a chaperone in, even if in the guise as, for example, someone taking notes.
MER

Joel Sherman said...

MER, referring to your post of August 1, 2010 2:15 AM, you asked if: It's one of those studies that seems to have been done to just ascertain the necessity of educating patients for the need of chaperones whether they want them or not.
Am I being too cynical?

I agree fully. The author just assumes that chaperones are necessary, never asking if anyone wants them.

qrazy_8 said...

Hi all, as an adult male I wanted to comment on chaperones since in my experience they have been used extensively both when I was an adolescent and an adult. I played sports in middle and high school, and the pediatricians that did them were usually female for some reason and always used a chaperone usually one of the school nurses. The chaperone back then made it seem she was necessary because she held a clipboard and wrote things down, but they always watched even during the hernia exams. It seemed like there was a different chaperon every year and the rare male pediatricain also used one. After high school I worked several different jobs, and almost always had a pre employment physical that was evenly split among male and female doctors. It seemed the females did somtimes ambush me by stating her "assistant" would need to accompany her, and at times was a female younger than myself. I even had to take a pre employment drug test once that included urinating in front of the company nurse, of course a female, and of course "required" for employment there. I never thought of protesting or that I had a choice until I started reading your site despite the fact that it didnt seem right. I always turned red in the face and sometimes it drew comments that made me feel even more embarrassed. Some said I need to get used to it or other similar comments, but now I understand why as it kept me passive and permitted the exam to continue. I hope more men read this site and become educated that they do have a choice. Thanks for bringing this to light.

Sue said...

Hi,

My wife recently had an appointment with a new doctor to renew her birth control pill prescription. She is 30 has been on the same pill for the last 10 years, all that usually happens is her blood pressure is checked and she is given a 6 month supply.

We have recently moved here and have no established relationship with any doctors or health care providers; I accompanied her to this appointment at her request as she did not know the doctor and my company medical insurance would be paying any costs.

At the appointment in his consulting room he confirmed that he could renew my wife’s birth control prescription but that first he needed to conduct a physical examination, he then asked me to leave the room. I started to get up to leave but my wife said she was happy to have an examination but wished me to stay, the doctor said that this was not “allowed”.

My wife insisted that I stay, she did not know the doctor, who was an older man and my staying would she said help her relax and make the examination, if it was really necessary, as stress free as possible.

Let me say at this point that I was happy to stay or go and wait outside as she wished I had no preference other than her wishes.

The doctor however refused to allow me to stay, my wife argued a little with him and repeatedly said that surly it was her choice if she wished to have her husband present for the examination, we both left with out her having the examination or getting the prescription for her Birth control pills.

My wife went straight to the reception/administrator to complain about the way she had been treated, to our amazement instead of getting an apology we were told that is entirely up to the doctor who he “ allows” to be present during any examination.

The administrator then did offer to arrange another appointment the following week for my wife with a female doctor, my wife agreed but said that she still whished me to be present for any examination if one was required ( I think by this stage it had become a pint of principle) to our surprise my wife was told again that this would be completely up to the doctor but the administrator though that is would not be allowed and was against the “rules”..

At this point we left, angry, frustrated and upset, my wife had still not been able to refill her birth control pill prescription which had been the whole point of the visit in the first place.

My wife has subsequently contacted a couple of other doctors, explained that she wants top refill her Birth control prescription to protect against an unwanted pregnancy, they both said she has to come in for a consultation, which she is happy to do but both have refused to confirm to her that she will be “allowed” to have her husband present if any examination is required. Apparently is depends on the “policy” of Dr X or the “Rules” of Dr Y.

We have had very little dealing with the medical profession as we are both fit, health and active in our early 30’s but I have to admit my wife’s recent experience has been frightening.

Surely she is correct that it is HER choice who she does or does not want to have present for any physical or personal examination. It is not up to what the Dr “allows” or not or what his “ policy” is ?

If my wife or any patient wants to have their husband present during an examination, surely that is the patients right and doctors should respect that, not completely ignore it.?

As I said I have no strong person view with this other than wanting to respect the wishes and preference of my wife, I would be happy to accompany her or not, to wait inside or out as she wishes but surely it is her right to make that decision.

I would welcome any medical / legal comments or opinions on this.

Thanks

James

Joel Sherman said...

James,
I doubt that there are any legal venues to approach this. And laws vary in every state. I will also copy this to the women's thread where some ladies might be able to suggest further advice.
I don't know why the physicians refuse to do a test with you in the room. It is not common, but certainly not unheard of. A family's presence in an examining room is certainly acceptable. They may think the two of you have a sexual fetish about this and don't want anything to do with it.
You may be able to avoid the issue entirely by going to Planned Parenthood where some clinics are willing to prescribe without exams.

Anonymous said...

I see this very differently, Joel. Once the woman said she would be more comfortable with her husband present, that, at the very least, should have opened up a discussion. Instead, it closed the discussion. When the administrator/receptionist told the wife that it was up to the doctor who was "allowed" in the exam room -- that should have been a warning to the patient as to the primitive culture of that particular clinic. At the very least, it's a matter of a compromise between the patient and the doctor as to who is in the exam room. If there are safety issues, the doctor should explain this with his/her reasoning.
This is an example of a non-patient centered clinic. If patients want patient-centered treatment, they must demand it. They must also recognized Medieval cultures like this one (by the way, that's an insult to the high culture of much of the middle ages)-- and file complaints.
What's "allowed" and not "allowed" in the exam room, as far as access goes, is up to both the doctor and the patient. Anything less should be considered unacceptable to patients.
MER/Doug

Joel Sherman said...

This comment was posted to Part 1 and I am copying it to here:

Anonymous has left a new comment on your post "Chaperones, A Violation of Privacy":

I was about to undergo a prostate biopsy. The nurse told me that my doctor was a male and the nurse asked me if I minded if a female "student" who was an "intern" assissted the doctor in the exam. I normally have a female doctor and since she was a medical professional, I agreed. After the procedure I was sitting up with just a sheet covering me and blood coming out everywhere and I decided to start a conversation with this "intern." I asked her how her school was going. She told me that she was not in school. I then looked at her badge and i saw the word, "office manager." I was shocked to say the least.


I think at the very least that warrants a complaint to the doctor. If you feel strongly I would take it further.

Anonymous said...

"If you feel strongly I would take it further."

I'm not a lawyer. But from what I've read, case law in this area goes back quite far. A crime was committed here. Falsely identifying someone as a medical student in order to get them to view a private procedure is a serious offense. Why not just bring in a friend who's curious? Why not charge people to view interesting procedures like this? I would strongly suggest this individual see a lawyer.
MER/Doug

Hexanchus said...

Doug,

It's called fraud. Consent was obtained based on fraudulent or untrue statements. It also probably violates the principle of informed consent - which does have case law supporting it all the way back to the early 1900's.

The conduct of the staff as described was unethical, as the patient was deliberately lied to. A formal complaint to the BOM & BON would also probably be warranted.

Joel Sherman said...

I partially disagree with the above 2 comments. Anon, consult a lawyer only if you are so mad you want to make a real issue of it. You will have a hard time collecting any damages and it will cost you money. All the doctor has to do is claim he inadvertently misspoke.
Complaining to the state medical board is worthwhile if you want to follow up on this and if you don't need to see this physician again.

Anonymous said...

Joel et. al.
I don't necessarily support a court case -- but sometimes a letter form a lawyer will make a big difference. But I do agree there are other steps this individual can take before going the lawyer route. If fact, a detailed letter to the doctor might be a good place to start to see how he responds. But you're correct, if it comes down to a he said she said situation, the patient will probably have no case.
My point was how serious this situation is. Assuming this event happened as reported here, it goes to show how careful a patient has to be when asked to allow students to participate or observe. If really a student, a student where and for what? One almost has to get this in writing, with the name of the student and his/her situation. It's really too bad that these events, though no doubt relatively rare, when publicized, cause so much distrust among patients.
MER/Doug

Hexanchus said...

Doug,

I wasn't suggesting a court case either, although the actions as described were clearly nebulous.

My thought was that an official ethics complaint with the state board against the nurse that made the false statement, and/or the physician if he had complicit knowledge thereof would be the better approach.

From the OP's post it sounds like the doc doing the biopsy was a consultant, as he refers to his regular doc being female. If that were the case, I would also let my PCP know what happened and how extremely displeased I was with the treatment of the specialist they referred me to - might keep it from happening to someone else.

Anonymous said...

If the doctors that James and his wife went to are on the up and up, what possible reasons could there be to not allow James to be present? I could see the slight possibility that the male doctor might be afraid of the husband and what he might do when he sees the doctor stick his fingers into places he shouldn't, but what is the female doctor afraid of?

James, before you guys begin to discuss a vasectomy (though you probably already have) know that you more than likely will receive the same unethical treatment. All but one of the doctors and clinics I've communicated with on the east coast insist on having a female nurse present.

Joel, do you think the "need" for a nurse during a vasectomy is a chaperone situation? I've read many experiences and have talked to a few other guys that have told me that their doctors performed the vasectomy alone. A piece of tape took the place of a nurse. Do male doctors sometimes worry about being alone with a male patient?

As for inviting an office manager in to observe a prostate biopsy, we should all just refuse to let ANYBODY observe intimate procedures like that. Obviously it's true that med students have to learn sometime, but anybody that would somehow find his way to this blog should think twice about allowing it since there are so many true exhibitionists out there that get turned on by watching med students stare at their genitals. Anyone that hesitates giving permission to med students but relents because they feel the responsibility to train new doctors should remember that. Particularly when the med student is a woman because women shouldn't be performing that type of procedure in the first place. Don't let them intimidate you. The possibility of allowing yourself to be humiliated just to quench the curiosity of a nonessential audience/pervert is beyond unethical. That patient's experience sounds like an episode of The Twilight Zone.

Anonymous said...

If we as patients are allowed to have a chaperone during routine or preliminary visits, why aren't we allowed to have a chaperone, or some type of patient advocate present during procedures such as surgery? If I don't trust the medical staff enough to be alone with them while I'm conscious I certainly won't trust them when I'm unconscious. If having a chaperone is truly for the patient's sake why can't we have someone we really trust to chaperone us during surgery, pre-op or post-op? Any "chaperone" they claim to have for us during those times would be someone THEY trust but not necessarily someone that WE trust. Why are we not allowed to have someone that we trust watch over us when we're unconscious?

Joel Sherman said...

Anon 1, I think most urologists would want help to be available while doing a procedure in case they have need for assistance. Anything could happen; they might drop something and need a replacement that's not on their procedure tray. If the office is set up right, the assistant would not have to be in the room. If I was the patient, I'd feel safe in the sole presence of an experienced urologist.
Anon 2, most hospitals would balk at allowing a patient's family member into a procedure room. OR's are not an easy place for the uninitiated; their behavior could be unpredictable. You might be able to find a professional patient advocate who had real experience that they might let in, but you'd have to clear it ahead of time.

Bill said...

Everyone, with regard to the Office Manager who was being "trained" while watching a prostate biopsy, I think you have overlooked a simple explanation. She wasn't merely curious, and she WAS being trained. Unfortunately, she was being trained as a chaperone during intimate procedures. It would seem possible that this lady could, at times, be asked to fulfill that role.

Does this explanation mean that the doctor was not intentionally misleading? Not at all.

In fact, I think that it makes matters worse. By writing to this board, I have to believe that the author is not fond of chaperones. And so, he probably would have been even less likely to accept her presence, had he known the true nature of her "training".

Joel Sherman MD said...

This was received by email:

Hi Dr. Sherman:

Let me start by saying that I was not looking for information on patient privacy. I happened upon this by accident, as I found stories posted on various sites. Often, they reported treatment by medical professionals that surprised me. As I looked further, I found your blogs.

So, I have found your blogs only recently. However, I have found the topic to be both fascinating, and a bit infuriating!

In my searches, I also found other sites, with stories similar to those that you expose. But, for me, the most upsetting part of these stories is often not the tale itself, but the comments left, especially by those purporting to be in the medical field.

One such that I found concerns the use of female chaperons, by female doctors, when examining male patients. I know that you have covered this topic in the past, but this one post, on another site, raised questions that I am not sure that you have covered. Again, since I am new to your blogs, I may simply have missed this.

The post, in question, is contained here:

It is the third comment from the bottom, written by a nurse calling herself "Betsy":

"Our practice has contracts with companies to do pre-employment and insurance physicals, so the nurse practitioners do them. Recently I average 16 a week, usually 10 of them men. Even our younger assistants have seen several hundred men, & they're well past the gawk stage. Suppose a secretary has to help chaperon her female doctor, twice a day; that's 10 a week, and 500 in her first year. No way she's going to gawk over every exposed male."

My initial shock, of course, was this nurse's complete disregard for the men being examined. You can find more of that in her comments throughout the post, as she writes quite often. Worse, she blithely mentions that a secretary is used to seing naked men, because she sees up to 500 a year at this practice! A secretary? And that's OK with a nurse? It seems to be that she has just documented 500 cases of sexual abuse a year, and seems unconcerned about it!

But, even that isn't the topic that I think that needs to be considered. Nor is the obvious lack of either an ethics policy, or the enforcement thereof, at this practice.

Not mentioned is whether these men gave their consent to this treatment. But, more than that, CAN a man, undergoing a pre-employment physical, be considered to have freely given consent to such treatment? Or, is the threat of the loss of his employment opportunity, if he complains, sufficient to constitute coercion?

I know that you often advise men to complain when such treatment occurs, and I concur. However, I also know that a man in need of employment will arrive at such a practice, and, likely with no warning, be examined in the presence of a chaperon, such as a secretary. Few enough men complain, even if this is done at their own doctor's office. But, how many men will raise their voices, if they believe it might cause the job offer to be rescinded? Also, at least in the case of their doctor, they chose that office. What choice does a man at a pre-employment physical have?

I'm sure that you see my point. I'm curious as to whether such a scenario violates the ethics code of a decent medical practice, or any medical association. I'm also curious if this violates any laws, since it is part of the employment process.

If you would consider addressing this topic in your blog, I would be very appreciative.


Thank You, StayingFit

Joel Sherman MD said...

Your comment covers a lot of questions, StayingFit. I also have no idea if the comment you quoted is real, embellished or pure fetish. The practice described is certainly not a common one. It costs a practice money to have lots of chaperones doing nothing but standing around.
It is certainly not recommended that medical practices use secretaries or any untrained personnel as chaperones. However it is not considered illegal or unethical unless perhaps they are falsely introduced as medical personnel.
At least 90% of men prefer not to have chaperones present during exams, but few will complain. Do they feel coerced? Probably no more than anyone else when put in a disadvantaged position. If they complained, most practices would accommodate them. I doubt that their jobs would be at risk if they objected, but for many it would not be worth the hassle of speaking up. Most pre-employment exams are done by contracted providers who don't directly work for the company sending the applicants. If a significant percentage of men complained, the practice would stop.

Joel Sherman MD said...

Here's a recently released (4/25/2011) statement of policy by the American Academy of Pediatrics on guidelines for chaperone usage.
The guidelines are pretty good to my surprise. They do allow for consideration of same gender chaperones and permit refusal of chaperones if not available or if not desired.
I'm pleased to see this. Can't take any credit for it, but the views expressed here do seem to be taking hold.

Joel Sherman MD said...

Here's a recent article in the New York Times blog, a woman physician's view of the need for chaperones.
It's pretty much in conformance with the views I have been expressing for several years and a good addition to the literature. Once again, I'm pleased to see greater recognition of the fact that the use of chaperones is a two edged sword to only be used in conjunction with patients' wishes.
I note the article is followed by over 100 comments.

Doug Capra said...

It's a good article, Joel, but a few comments just go to show how clueless the profession is about this issue: For example:
-- "In general, the rule is to have a “chaperon” present to protect patients against possible sexual misconduct, and to make them feel more secure during intimate examinations."
That may be the "rule," but we all know it's really about protecting the doctor.
-- "What’s more, it is not clear that having a chaperon in the room actually makes patients feel more comfortable, either."
Oh, really? Basic observations would make this clear. So would asking patients how they feel about it.
-- "For many patients, it turns out, a chaperon can make them feel uncomfortable."
So, that's how it "turns out?" The profession is just noticing this?
-- "So then we have to wonder whether chaperon policies are protecting the patient or protecting the doctor."
We really have to wonder about this? Seems quite clear to most patients, esp. when they are not even asked their preference.
-- "What probably makes the most sense is for male and female doctors to ask all patients whether they’d like another person present during an intimate exam."
So, asking "probably" makes sense?
Please excuse my cynical, even sarcastic tone. But, though it's good to see this issue written about and confronted, it's also astonishing to see how obtuse some professionals can be about these kinds of patient modesty issues.
MER/Doug

Joel Sherman MD said...

The American Academy of Physicians Assistants has published online guidelines for the use of chaperones. My article on the companion blog is specifically mentioned in the context of giving a male patient's point of view.
On the whole the article is well thought out and researched. The author recognizes that chaperones should be agreed to by the patient and be voluntary. That is a big improvement over the AMA guidelines for example. The author recognizes that nearly all men prefer not to have them. She says the discussion should be gender neutral. I'm not sure what she means by this, probably just that chaperones should be offered to all patients irregardless of the genders involved. My only major disagreement with her views is that she states that chaperones should be introduced as assistants, not chaperones. That to my mind is misleading to the point of being unethical. Patients understand an assistant is needed for medical reasons, not legal reasons.
She also states that patients should be offered a 'trained' chaperone but doesn't define what she means by this. Does a secretary qualify? What training would make her appropriate for use as a chaperone? The problems are always in the details.

Anonymous said...

I work for a large health care organization at which I also receive medical care. Every two years, I endure a PAP smear, pelvic exam and breast exam. Yesterday, I went in for my first exam with a new doctor- my previous doctor having left the company. The OB/GYN was a woman. We chatted a bit, with me undressed and in their fabric cape plus paper drape. As she asked me to lay back to begin the exam portion, the LPN reappeared and started to put on gloves. I stopped and asked whey she was present. The doctor indicated that our organization now requires them to be present for all female exams done by either men or women. I told her I would rather the woman not be there. The doctor indicated she was present to protect both of us. I was highly offended because essentially she was telling me the patient was not trustworthy.

But that wasn't my first reaction. I started to cry. I was so uncomfortable. I told her that if this was a requirement henceforth, I would never be coming back for another PAP smear. Here I am, in a room unclothed, and meeting a strange woman for the first time. That stranger will shortly be poking around in my nether-regions. That's bad enough. Then to be told that a second stranger was required to stand there and watch the first stranger work- that was terribly uncomfortable. I can't begin to tell you how uncomfortable. To lose the control over the situation, made things worse.

My background is in legal, risk management and compliance. I understand why they might have made the requirement. I get that. I might have made the same recommendation. At the same time, as much as I want to be helpful and realistic, and make the doctor comfortable, this is my body and my emotions we're talking about. At this particular point in time, when I am feeling incredibly vulnerable and having to share personal details with one stranger, I cannot deal with a second stranger in the room. In this situation, I care more about myself than the doctor. How can you create trust on both sides if you are saying, right from the beginning, that one of you is not trustworthy?

The doctor did allow the nurse to leave, and I did allow the exam to continue, but I am still very uncomfortable about this situation. The idea that the chaperone protects both the patient and the doctor is not true. I felt very unprotected. I felt like I was not trusted and I was extremely vulnerable both physically and emotionally.

I wonder if the best thing to do is to ask all patients (male or female) being treated by male or female physicians, if they would like to have a chaperone present? Whichever way they respond, respect it.

Joel Sherman MD said...

Anon, you're not alone. Many women prefer not to have chaperones present during a pelvic exam no matter what the gender of the doctor is. You can find references if you read thru these 2 threads. Might be easier to start with my article on the subject. Your reaction is certainly much stronger than typical though.
When a male doctor uses a chaperone for this, most would say they have no choice in the matter, though a few are willing to forgo them, especially with established patients. A women doctor practically needs no protection at all, and I'd disagree with a rigid clinic policy. It certainly does imply that the physician doesn't trust the patient. You'd probably be better off leaving this clinic and seeing an Ob-Gyn in a small practice.
I'm a strong proponent of always asking the patient's permission before using a chaperone, but it's not done very often.

Joel Sherman MD said...

This column appeared yesterday in Annies mailbox (successor to Ann Landers).
A man states that his doctor uses a nurse chaperone for all patients (because he can't remember things). But he has a new nurse who is best friends with his wife. The man doesn't want to be examined in front of her. The columnists give mixed advice, but most commenters ( including me) encourage the man to insist upon a private exam or find another doctor.

Anonymous said...

I had an ultrasound biopsy of my prostate a while back.

They toldme there was no option but to have it undertaken by a female specialist nurse, supported by another female nurse.

I refused absolutely.

Amazingly, it was possible to have it done by 2 males after all, they just "didnt think it was that important".

I am sure they thought i was very strange for standing my ground, i just felt so much more relaxed about the (VERY painful) procedure.

Just as well they relented really, my biopsy was positive, I have since had brachytherapy for the cancer, again by an all male team. Amazing what they can do if pushed.

Joel Sherman MD said...

I will repost this on the gender preferences in health care part 2 thread where it is more on topic.
Thanks for the post.

Anonymous said...

I am female and have had negative experiences with both male and female medical providers (MDs and nurses/techs alike). I don't have a gender preference, but I strongly object to having more than one person in the room. In fact, having another unknown female in the room makes things worse. I hate feeling out of control of what happens to me, and I have never had a medical experience where that was not the case. Probably why I've sworn off "regular primary care." Care? Yeah, right.

Joel Sherman MD said...

I note with interest that Uptodate, a bible of current information in medicine has this sentence in a section under the heading the pediatric exam, the perineum:

The use of a chaperone for the examination of the anorectal and genital areas of adolescent patients should be a shared decision between the patient and the clinician after the clinician has explained the reason for the examination and described how the examination will proceed. The sex of the chaperone should be determined by the patient’s wishes and comfort (if possible). If a patient is offered the use of a chaperone and declines, this should be documented in the chart.

I suspect this is new, but don't know when it was amended.

Joel Sherman MD said...

Here's a Canadian article from an assistant who was trained to be a chaperone. She only mentions being used for women's exams. Her description of her training is interesting. In her area a formal course is available which is rare in the US.

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